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
Department of General, Visceral and Oncological Surgery, Wilhelminenspital, Vienna, Austria. Surgical Endoscopy
(Impact Factor: 3.26).
08/2011; 26(1):249-54. DOI: 10.1007/s00464-011-1862-3
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.
Available from: Ferdinand Köckerling
- "In another prospective randomized controlled trial by Fortelny et al. , 87 patients with 110 inguinal hernias were operated on with the TAPP technique. TiMesh extralight (16 g/m2) was used for lateral hernias and TiMesh light (35 g/m2) for medial hernias. "
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ABSTRACT: Despite the vast selection of brands available, nearly all synthetic meshes for hernia surgery continue to use one or other of three basic materials: polypropylene, polyester and ePTFE. These are used in combination with each other or with a range of additional materials such as titanium, omega 3, monocryl, PVDF and hyaluronate. This systematic review of all experimental and clinical studies is aimed at investigating whether titanized meshes confer advantages over other synthetic meshes in hernia surgery.
A search of the medical literature from 2002 to 2012, as indexed by Medline, was performed, using the PubMed search engine ( http://www.pubmed.gov ). The search terms were: hernia mesh, titanium coating, lightweight mesh, TiMesh, mesh complications. All papers were graded according to the Oxford hierarchy of evidence.
Patients operated on with the Lichtenstein technique performed using the lightweight titanium-coated mesh have a shorter convalescence than those with the heavy-weight mesh Prolene. For inguinal hernias operated on with the TAPP technique and using a lightweight titanium-coated mesh in comparison to a heavy-weight Prolene mesh, the early postoperative convalescence seems to improve. Titanized meshes do exhibit a negative effect on sperm motility 1 year after a TEP operation, but not after 3 years. The laparoscopic IPOM technique with a titanium-coated polypropylene mesh was associated with less postoperative pain in the short term, lower analgesic consumption and a quicker return to everyday activities compared with the Parietex composite mesh.
In clinical studies, the titanium-coated polypropylene mesh shows in inguinal hernia repair certain benefits compared with the use of older heavy-weight meshes.
- "We first used polypropylene high-weight meshes  fixed with absorbable clips, then we started to use polypropylene low-weight meshes fixed with fibrin glue [4,13] and finally we started to use self-locking Polyester meshes : currently 30 TAPP (6 in elderly) were performed using this mesh, in these cases without any fixation device. "
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Aim of this study is to present our standardized laparoscopic transabdominal preperitoneal hernia repair (TAPP) technique, and to study our experience in the elderly as far as concerns preoperative and postoperative variables.
We described our standardized TAPP technique according with Stuttgart technique , and we evalutated our team's experience in TAPP inguinal hernia repair in elderly (> 65 yrs) and in young patients (< 65 yrs).
We retrospectively reviewed our Surgery Division's experience about TAPP; we included in our study 185 patients. The sample was subdivided in two groups: TAPP Group (< 65 years patients) and TAPPe Group (> 65 years patients). TAPP Group was composed by 154 patients and TAPPe Group of 31 patients. According with literature, in this subgroup recurrence rate (3,2%), early and delayed complications and mean operative time (86 min). There were no major vascular or intestinal complications. At the moment follow-up is 31 months. There were no incisional hernias on umbilical trocar. Mean satisfaction rate was excellent also in elderly patients.
According with literature, in our experience TAPP technique is a safe and feasible procedure, even in elderly patients.
Available from: Marcello Donati
- "The TIMELI trial has shown a reduced risk of post chronic pain by using fibrin sealant as a fixation method of mesh instead of common stitches , this was also confirmed in a recent metanalysis . Even the approach (open or laparoscopic) has been advocated as a risk factor for chronic pain [26,27], however, there are same data in contrast with this assumption  especially in laparoscopic techniques, mesh fixation methods seem to be of capital importance [29,30]. Our technique does not fix the mesh to the abdominal wall as it is self-adhesive, this could explain the low incidence of post-operative chronic pain . "
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Chronic pain after prosthetic inguinal hernioplasty is one of the most important current issues in the current literature debate. Mechanisms related to pain development are only partially known. Influence of age as well as other factors is still unclear. The aim of this work was to evaluate whether development of chronic pain after open prosthetic plug and mesh inguinal hernioplasty is influenced by age.
Analysis was retrospectively conducted, dividing our cohort of patients (2,902) who had undergone prosthetic open plug&mesh inguinal hernioplasty from Jannuary 1994 to May 2012, following only the age criterion (cut-off 65 yrs.), into two groups (Gr.A<65 yrs, Gr.B>65 yrs.). All patients were routinely submitted to a postoperative questionnaire. Complications such as analgesic assumption were registered in both groups. Pain intensity was classified following the Visual Analogic Scale (VAS). Incidence of chronic pain, discomfort, and numbness, was assessed in both groups. Statistical significance was assessed by X2-test.
Only 0.2% of patients suffered from a recurrence in our cohort. Postoperative chronic pain was observed in Gr. A in 0.12% of patients vs Gr.B 0.09% (p>0.05). Incidence of other postoperative symptoms such as discomfort or numbness were slightly prevalent on young patients (respectively p = 0.0286 and p = 0.01), while for hyperesthesia and sensation of foreign body no statistically significant difference of incidence between groups was observed.
Real chronic pain after inguinal hernioplasty is a rare clinical entity. Other causes of chronic pain should be accurately researched and excluded. In young patients psychological factors seem to show a slight influence. There was no influence of age on chronic postoperative pain incidence after inguinal hernioplasty.
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