Comparing fibrin sealant with staples for mesh fixation in laparoscopic transabdominal hernia repair: A case control-study

Department of General, Vascular and Mininvasive Surgery, Spoleto Hospital, Spoleto, PG, Italy.
Surgical Endoscopy (Impact Factor: 3.26). 04/2008; 22(3):668-73. DOI: 10.1007/s00464-007-9458-7
Source: PubMed


Laparoscopic hernia repair is not as popular as cholecystectomy. We have performed more than 3,000 laparoscopic herniorrhaphies using the trans-abdominal (TAPP) technique. To prevent recurrences we fix the polypropylene mesh with staples. The use of fibrin glue for graft fixation is a possible alternative.
We have performed 3,130 laparoscopic hernia repairs over 14 years. For mesh fixation we used titanium clips and observed a small number of complications. In July 2003 we started using fibrin glue (Tissucol(R)). The purpose of this retrospective longitudinal study was to evaluate if the use of fibrin sealant was as safe and effective as conventional stapling and if there were differences in post-operative pain, complications and recurrences.
From July 2003 to June 2006 we performed 823 laparoscopic herniorrhaphies. Fibrin glue (Tissucol(R)) was used in 88 cases. Two homogeneous groups of 68 patients (83 cases) treated with fibrin glue and 68 patients (87 cases) where the mesh was fixed with staples, were compared. Patients with relevant associated diseases or large inguino-scrotal hernias were excluded. Operative times were longer in the group treated with fibrin glue with a mean of 35 minutes (range 22-65 mins) compared to the group treated with staples (25 minutes, range 14-50 mins). The time of hospital stay was the same (24 hours). Post-operative complications, that were more frequent in the stapled group, included trocar site pain, hematomas, intra-operative bleedings and incisional hernias. No significant difference was observed concerning seromas, chronic pain and recurrence rate.
Less post-operative pain, and a faster return to usual activities are the main advantages of laparoscopic repair compared to the traditional approach. The use of fibrin sealant reduces in our experience the risk of post- and intra-operative complications such as bleeding and incisional hernia; recurrence rates are similar, but the operative time is longer.

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Available from: Alberto Patriti, Jul 04, 2015
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    • "In a recent review, mesh fixation with glue was compared to mesh fixation with staples for an endoscopic inguinal hernia repair [18]. For the TAPP repair, two randomized controlled trials [19,20], one non-randomized trial [21], and two case series [22,23] were reviewed. The authors of the review found less postoperative pain and more rapid recovery after glue fixation than after staple fixation, without any significant difference in the recurrence rate. "
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    ABSTRACT: Inguinal hernia repair is one of the most common surgical procedures worldwide. This procedure is increasingly performed with endoscopic techniques (laparoscopy). Many surgeons prefer to cover the hernia gap with a mesh to prevent recurrence. The mesh must be fixed tightly, but without tension. During laparoscopic surgery, the mesh is generally fixed with staples or tissue glue. However, staples often cause pain at the staple sites, and they can cause scarring of the abdominal wall, which can lead to chronic pain. We designed a trial that aims to determine whether mesh fixation with glue might cause less postoperative pain than fixation with staples during a transabdominal preperitoneal patch plastic repair. The TISTA trial is a prospective, randomized, controlled, single-center trial with a two-by-two parallel design. All patients and outcome-assessors will be blinded to treatment allocations. For eligibility, patients must be male, >=18 years old, and scheduled for laparoscopic repair of a primary inguinal hernia. One group comprises patients with a unilateral inguinal hernia that will be randomized to receive mesh fixation with either tissue glue or staples. The second group comprises patients with bilateral inguinal hernias. They will be randomized to receive mesh fixation with tissue glue either on the right or the left side and with staples on the other side. The primary endpoint will be pain under physical stress, measured at 24 h after surgery. Pain will be rated by the patient based on a numeric rating scale from 0 to 10, where 10 equals the worst pain imaginable. A total of 82 patients will be recruited (58 patients with unilateral inguinal hernias and 24 patients with bilateral hernias). This number is estimated to provide 90% power for detecting a pain reduction of one point on a numeric rating scale, with a standard deviation of one. Patients with bilateral hernias will receive two meshes, one fixed with glue, and the other fixed with staples. This design will eliminate the inter-individual bias inherent in comparing pain measurements between two groups of patients.Trial registration: NCT01641718.
    Full-text · Article · Apr 2014 · BMC Surgery
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    ABSTRACT: Die sehr guten Ergebnisse endoskopischer Leistenhernienchirurgie hierzulande, besonders vertreten von Bittner und Köckerling, wurden durch die Multicenterstudie von Neumayer Anfang 2004 in Frage gestellt. Daraus resultierte der Anspruch der vorliegenden Studie, durch möglichst lückenlose und konsequente Verlaufsbeobachtung, die zurzeit am häufigsten angewandten Verfahren zur Leistenhernienversorgung in einem Regelkrankenhaus, aus der Sicht der Patienten, ergänzend durch objektive Untersuchung der Problemfälle, zu vergleichen. Im Rahmen einer prospektiven Beobachtungsstudie wurden die Patienten zur Leistenbruchoperation eines Jahrganges mittels selbst entworfener Fragebögen prä-, 2 Tage postoperativ, nach 3 Monaten, 1 und 2 Jahren evaluiert. Präferiertes OP-Verfahren war die transabdominelle präperitoneale Netzplastik (TAPP) ohne Netzfixierung. Auf Patientenwunsch oder medizinisch erforderlich erfolgte die Lichtenstein-OP (LS) bzw. eine Shouldice-Reparation (Naht). Anhand einer visuellen Analogskala von 0 bis 10 wurde nach präoperativen Beschwerden, Präferenz der Narkose- und Eingriffstechnik sowie postoperativen Schmerzen, Missempfinden, Belastbarkeit und Zufriedenheit gefragt. Vom 01.04.2004 bis 31.03.2005 wurden in unserer Chirurgischen Klinik des Bethlehem-Krankenhauses insgesamt 127 erwachsene Patienten ein- oder beidseitig am Leistenbruch operiert. Bei davon 109 evaluierten Fällen erfolgte 74-mal eine TAPP, 25-mal Lichtenstein und 10-mal bloße Nahttechnik. Zwei Tage postoperativ gaben die TAPP-Patienten im Vergleich zu den LS-Patienten mit einem Median von 1 zu 4 (p<0,01) signifikant weniger Schmerzen an, wünschten einen mit 3 zu 5 Tagen (p=0,027) signifikant kürzeren Krankenhausaufenthalt, verbrauchten mit von 0 zu 5 (p<0,01) kaum Schmerzmittel. Auf der Basis einer Nachbeobachtungsquote von 108/109 (99%) nach 3 Monaten, 1 und 2 Jahren postoperativ verwischten diese Unterschiede, sodass nur das Taubheitsgefühl (p=0,022) von den LS-Patienten signifikant häufiger beklagt wurde. Die körperliche Belastbarkeit der operierten Leiste und die globale Zufriedenheit der Patienten in beiden OP-Gruppen waren zu jedem postoperativen Befragungszeitpunkt mit einem Median von 10 sehr hoch. Nach TAPP traten drei Rezidive bei zwei Patienten (4%) und nach Lichtenstein ein Rückfall (4%) auf. Die hier vorgelegte prospektive Beobachtungsstudie eines leistenhernienoperierten Patientengutes am Regelkrankenhaus stellt die TAPP-Technik als ein exzellentes Versorgungsangebot dar, das bei den operierten Patienten eine hohe Akzeptanz vor allem unmittelbar postoperativ genießt. Die Rezidivrate ist im Gegensatz zur Neumayer-Studie 2004 niedrig. Gleichzeitig bleibt die LS-Operation eine jederzeit tragfähige Alternative bei Risiko- oder für TAPP nicht geeigneten Patienten. In early 2004, the multi-center study by Neumayer put in question very good results of laparoscopic repair of inguinal hernia, which were achieved in Germany, especially those presented by Bittner and Köckerling. Hence, the idea of this study: we wanted to provide comparative analysis of all current methods available for treatment of inguinal hernias in hospital setting. We aimed to achieve maximum possible coverage to produce reliable patient-centered results, resorting to further investigation in uncertain cases. In this prospective cohort study, we followed patients with inguinal hernia for two years after the surgery, presenting them with self-designed questionnaires just before the surgery, and 2 days, 3 months, 1 year and 2 years after the surgery. The questionnaire contained gradation on a scale from 1 to 10 for the following items: patient preoperative complaints, preferred methods of anesthesia and surgical techniques, intensity of postoperative pain, paraesthesia, physical capacity and general satisfaction with the surgery. The surgical procedure of choice was laparascopic transabdomial pre-peritoneal (TAPP) hernioplasty without mesh fixation. Based on patient’s wishes and medical necessity we also used either Lichtenstein repair (LS) or Shouldice repair (SR). In our Surgical Clinic of the Bethlehem Hospital we operated on 127 adult patients with both uni- and bilateral inguinal hernias between April 2004 and March 2005. 109 patients were enrolled in the study. Out of 109, TAPP were used in 74 cases, Lichtenstein repair in 25 cases, and Shouldice repair in 10 cases. Two days post-op the TAPP group experienced significantly less pain (median of 1 on the pain scale compared to 4 in LS-patients, p < 0.01) than the LS group, requested significantly shorter hospital stay (3 days compared to 5, p = 0.027), and required almost no analgetics (median 0 compared to 5, p < 0.01). 3 month, 1 year and 2 years follow-ups of 108 out 109 patients (99%) revealed no differences between TAPP and LS patients on all the scales but one – numbness was noticed in LS patients more often (p=0.022). Overall physical capacity and satisfaction by surgery was equally high in both groups in all post-op stages (10 on average). Among TAPP patients there were 3 recurrences of hernia (4%), and one among LS-patients (4%). TAPP technique is an excellent procedure, favoured by patients in the immediate post-operative period. The hernia recurrence rates are low in both cases, especially compared to the 2004 Neumayer study. At the same time, the LS-operation remains an important alternative for high-risk patients, or patients not suitable for the TAPP procedure.
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    ABSTRACT: Fibrin sealants are complex plasma-derived products, biocompatible and biodegradable, which are used with increasing frequency in a variety of surgical fields for their unique haemostatic and adhesive properties. They mimic the last step of the coagulation cascade and take place independently of the patient's coagulation status. This review summarizes the components, mechanism of action and clinical effectiveness of fibrin glues in modern surgical care, emphasis given to surgical outcomes: they reduce perioperative and postoperative complications by reducing perioperative hemorrhage and controlling blood loss; by decreasing fluid or air leakage, and by preventing anastomosis dehiscence and fistula formation or sealing it endoscopically. Finally, with rapid advances in tissue engineering their potential uses are expanded exponentially as either delivery systems of stem cells in regenerative medicine or as drug delivery systems to different tissues.
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