The impact of atraumatic fibrin sealant vs. staple mesh fixation in TAPP hernia repair on chronic pain and quality of life: results of a randomized controlled study
ABSTRACT Mesh reinforcement has become the standard of care in the open and laparoscopic repair of inguinal hernia. Chronic pain after inguinal hernia repair is often due to nerve injury by penetrating mesh fixation devices such as staples (ST), tacks, or sutures. In several studies on hernioplasty, atraumatic mesh fixation with fibrin sealant (FS) proved to be efficient in terms of fixation strength and elasticity. Unfortunately, most of these studies did not provide a standardized follow-up and assessment of the development of chronic pain (CP) and the quality of life (QoL). Therefore, a randomized controlled trial comparing CP and QoL after FS fixation of mesh with ST in transabdominal preperitoneal hernioplasty (TAPP) was performed at our department. The primary end point of our study was to assess the patient outcome by using a visual analog scale (VAS) and the short form 36 (SF-36). The evaluation of recurrence rates was the secondary aim.
According to the randomization, a macroporous mesh (TiMESH(®)) was fixed in group A (44 patients with 54 inguinal hernias) with FS (TISSEEL) or in group B (45 patients with 56 inguinal hernias) with ST (EMS(®) Stapler). The observation period was 1 year with regular clinical check ups and assessment of VAS and SF-36.
Patient characteristics expressed by BMI, ASA scores, and Schumpelick hernia classification were similar in both treatment groups. In each group there was one recurrence within 8 (FS) and 9 months (ST) postsurgery. The mean preoperative pain values scored by VAS were 1.7 (range = 0-7.5) in the FS group and 2.2 (range = 0-6) in the ST group. Postoperative mean VAS scores measured at 1 year postsurgery were 0.4 (range = 0-3) in the FS group and 0.9 (range = 0-7.5) in the ST group. One year postsurgery there was no significant difference between the two groups with respect to the parameter pain in the SF-36 and VAS.
Fibrin sealant fixation leads to a low rate of hernia recurrence and avoids tissue trauma. ST provide similar results in the hand of the expert but bear inherent risks of complications due to tissue perforation.
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ABSTRACT: BACKGROUND: As meshes markedly reduce recurrence rates following surgery for inguinal hernia, surgical methods employing meshes have become increasingly popular among surgeons. Innovations in laparoscopic surgery have enabled the surgeon to minimize the size of trocar incisions. This type of laparoscopy is therefore referred to as minimal incisional laparoscopic surgery (MILS). METHODS: All inguinal hernia patients who reported at our department during the last two years were included in a prospective observational study. In order to assess the feasibility of the MILS technique as well as its benefits for the patient, we investigated and compared the following intra- and postoperative parameters of two laparoscopic TAPP (transabdominal pre-peritoneal) techniques (MILS-TAPP versus conventional-TAPP): operating times, perioperative complications, postoperative and chronic pain, abdominal wall mobility, and recurrence rates. RESULTS: Of 462 patients aged 18 to 94 years (mean, 46 years), 559 inguinal hernias in 481 patients (86.1%) were treated by laparoscopic approach. The Lichtenstein technique was used to treat 65 hernias (11.6%). The mean operating time was 60 minutes for the conventional TAPP technique (n = 217) and 56 minutes for the MILS technique (n = 264). Postoperative abdominal wall mobility scored by Janda's method was significantly superior in the MILS group (4.6) than in the conventional laparoscopic group (3.7). Postoperative pain on the VAS scale was rated 1.3 in the MILS group versus 2.6 in the conventional TAPP group. Three (1.4%) recurrences occurred after the conventional TAPP technique, whereas no hernia recurrence occurred when a self-adhesive mesh was used. CONCLUSIONS: Minimization of trauma secondary to the trocar incision was able to reduce postoperative pain and improve abdominal wall mobility. The self-adhesive mesh may be inserted by the practiced laparoscopic surgeon with no delay, and optimizes incorporation in the groin by laminar mesh adhesion in the preperitoneal cavity.European Surgery 01/2012; 44(1). DOI:10.1007/s10353-011-0068-1 · 0.26 Impact Factor
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ABSTRACT: Abdominal wall and inguinal hernia repair are the most frequently performed surgical procedures in the United States and Europe. However, traditional methods of mesh fixation are associated with a number of problems including substantial risks of recurrence and of postoperative and chronic pain. The aim of this systematic review is to summarize the clinical safety and efficacy of Tisseel/Tissucol fibrin sealant for hernia mesh fixation. A PubMed title/abstract search was conducted using the following terms: (fibrin glue OR fibrin sealant OR Tisseel OR Tissucol) AND hernia repair. The bibliographies of the publications identified in the search were reviewed for additional references. There were 36 Tisseel/Tissucol studies included in this review involving 5,993 patients undergoing surgery for hernia. In open repair of inguinal hernias, Tisseel compared favorably with traditional methods of mesh fixation, being associated with shorter operative times and hospital stays and a lower incidence of chronic pain. Similarly, after laparoscopic/endoscopic inguinal hernia repair, Tisseel/Tissucol was associated with less use of postoperative analgesics and less acute and chronic postoperative pain than tissue-penetrating mesh-fixation methods. Other end points of concern to surgeons and patients are the risks of inguinal hernia recurrence and of complications such as hematoma formation and intraoperative bleeding. Comparative studies show that Tisseel/Tissucol does not increase the risk of these outcomes and may, in fact, decrease the risk compared with tissue-penetrating fixation methods. When used in the repair of incisional hernias, Tisseel/Tissucol significantly decreased both postoperative morbidity and duration of hospital stay. Clinical evidence published to date supports the use of Tisseel/Tissucol as an option for mesh fixation in open and laparoscopic/endoscopic repair of inguinal and incisional hernias. Guidelines of the International Endohernia Society recommend fibrin sealant mesh fixation, especially in inguinal hernia repair. Nonfixation is reserved for selected cases.Surgical Endoscopy 01/2012; 26(7):1803-12. DOI:10.1007/s00464-012-2156-0 · 3.31 Impact Factor
Chapter: The SAGES Manual of Hernia Repair[Show abstract] [Hide abstract]
ABSTRACT: The two most common techniques for laparoscopic inguinal hernia repair are the transabdominal preperitoneal (TAPP) technique and the totally extraperitoneal (TEP) technique. Although in the end both techniques are used to place mesh in the preperitoneal space to cover the entire myopectineal orifice, they differ in how access to that space is obtained, and slight differences between the two approaches exist. TAPP is quicker to learn and is associated with an overall low but higher risk of visceral injury and port-site herniation. TAPP has a slight operative time advantage with no difference in hernia recurrence rate. Pain may be more a function of mesh fixation during the operation rather than technique itself. This chapter discusses the risks and benefits of each technique and compares their surgical outcomes.The SAGES Manual of Hernia Repair, 01/2013: pages 197-202; , ISBN: 978-1-4614-4823-5