Fibrin sealant versus mechanical stapling for mesh fixation during endoscopic extraperitoneal inguinal hernioplasty: a randomized prospective trial

Fibrin sealant (Tissucol) for the fixation of hiatal mesh in the repair of giant paraesophageal hernia: a case report

INTRODUCTION

The use of hiatal meshes for the repair of giant paraesophageal hernias (GPH) is associated with a significantly decreased rate of recurrences compared with mesh free techniques. Many surgeons refrain from mesh implantation at the gastroesophageal junction owing to reported complications, such as mesh migration, strictures, and risks of tack or suture placement. This case report presents the laparoscopic application of a titanium-coated mesh (TiSure, GfE, Germany) designated for hiatal repair, with fibrin sealant fixation (Tissucol, Baxter, Austria) in a patient with GPH.

METHODS

A patient (male, 59 y) presented at our outpatient department with a 3-year history of epigastric pain and decreasing lung capacity. A GPH with an intrathoracic upside-down stomach had already been radiologically diagnosed 3 years before admission. In elective laparoscopy, the stomach was repositioned and the crura of the diaphragm were approximated with nonresorbable sutures. The defect was reinforced with a preshaped titanium-coated mesh and fibrin sealant (2 mL) applied with a 45 degree angled tip laparoscopic spraying device. No perforating fixation device was used for mesh fixation itself. The patient was discharged on the seventeenth postoperative (postOP) day. The clinical follow-up included the assessment of postOP pain with a visual analog score and a confirmative computed tomography scan 6 months after surgery.

RESULTS

The patient has fully recovered, showing no recurrence or adverse effects 1 year postOP.

DISCUSSION

Based on previous good results from own experimental trials, the mesh sealing approach in hiatal hernia repair was performed clinically, yielding an excellent result in this case. Multicenter trials to assess the full impact of FS mesh fixation in combination with macroporous hiatal meshes seem mandatory.

European Hernia Society guidelines on the treatment of inguinal hernia in adult patients

The European Hernia Society (EHS) is proud to present the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS. They are evidence-based and, when necessary, a consensus was reached among all members. The Guidelines have been reviewed by a Steering Committee. Before finalisation, feedback from different national hernia societies was obtained. The Appraisal of Guidelines for REsearch and Evaluation (AGREE) instrument was used by the Cochrane Association to validate the Guidelines. The Guidelines can be used to adjust local protocols, for training purposes and quality control. They will be revised in 2012 in order to keep them updated. In between revisions, it is the intention of the Working Group to provide every year, during the EHS annual congress, a short update of new high-level evidence (randomised controlled trials [RCTs] and meta-analyses). Developing guidelines leads to questions that remain to be answered by specific research. Therefore, we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment. In addition, a short summary, specifically for the general practitioner, is given. In order to increase the practical use of the Guidelines by consultants and residents, more details on the most important surgical techniques, local infiltration anaesthesia and a patient information sheet is provided. The most important challenge now will be the implementation of the Guidelines in daily surgical practice. This remains an important task for the EHS. The establishment of an EHS school for teaching inguinal hernia repair surgical techniques, including tips and tricks from experts to overcome the learning curve (especially in endoscopic repair), will be the next step. Working together on this project was a great learning experience, and it was worthwhile and fun. Cultural differences between members were easily overcome by educating each other, respecting different views and always coming back to the principles of evidence-based medicine. The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project.

Fibrin sealant in inguinal hernioplasty: an observational multicentre study in 1,201 patients

Purpose

A prospective, multicentre, observational study was undertaken to assess Tisseel^® fibrin sealant for atraumatic mesh fixation in inguinal hernia repair throughout France.

Methods

Surgeons recorded data on patients undergoing tension-free inguinal hernioplasty with mesh fixation with Tisseel^®, regardless of the hernioplasty technique used. Assessments were made at 2 days and 1 month after surgery. Data on local complications, operation times and ease of product use were collected.

Results

In total, 1,201 patients were recruited (90% men, mean age 57 years), among which 526 procedures were performed using open techniques and 675 using laparoscopic repairs. Local complications occurred in 4.7% of patients: 3.0% haematoma, 1.4% seroma, 0.3% recurrence. The mean visual analogue scale (VAS)-rated pain scores were 3.2 pre-operatively, 2.3 immediately after surgery and 1.8 at 1 month. Surgeons rated the product as very easy to use.

Conclusions

Tisseel^® fibrin sealant appears to be a well-tolerated and easy-to-use alternative to traditional, tissue-penetrating devices for mesh fixation in hernia repair techniques.

Fibrin sealant (Tisseel) for hiatal mesh fixation in an experimental model in pigs

BACKGROUND

This study was designed to assess the efficacy of the fibrin sealant fixation of titanized polypropylene mesh in experimental hiatal mesh closure in pigs. Prosthetic hiatal closure is recommended for the repair of large hiatal/paraesophageal hernias as well as for antireflux surgery. However, only limited data exist on the favorable choice of meshes and fixation devices. Migration of the implant and trauma to neighboring organs due to perforating devices, such as sutures or tacks, present potentially lethal complications. In this study, we propose the fixation of titanized polypropylene meshes (TS) specifically developed for hiatal closure (TISure; GfE Medizintechnik GmbH, Nuremberg, Germany) with human fibrin sealant (FS, Tisseel; Baxter Biosciences, Vienna, Austria).

MATERIALS AND METHODS

A laparotomy was carried out in 7 mini-pigs (27-30 kg bodyweight) under general anaesthesia, and a TS was implanted after precise dissection of the right and left crura and the crural commissure. The key hole of the TS was placed around the esophagus at the gastroesophageal junction. One mL of FS was applied with the Easy Spray system (Baxter Biosciences, Vienna, Austria) for circular and three dimensional mesh fixation onto the diaphragm. Due to the lack of accepted gold standards of hiatal mesh reinforcement, no control group was used. Animals were sacrificed after 4 wk, and meshes were explanted after macroscopical assessment of the correct position and tissue integration. Histology was performed.

RESULTS

All meshes showed excellent tissue integration and no signs of migration or dislocation. FS was completely degraded and replaced by well vascularized fibroblastic tissue.

CONCLUSIONS

Titanized polypropylene mesh with FS fixation was found to be a safe and efficient combination for reinforcement of the hiatal closure in this preliminary experimental model.

Fixation of mesh to the peritoneum using a fibrin glue: investigations with a biomechanical model and an experimental laparoscopic porcine model

BACKGROUND

In recent years, the use of fibrin glue has become an established practice in several areas of surgical treatment. For example, fibrin glue is used increasingly as an alternative method for mesh fixation in hernia surgery, significantly helping to reduce the incidence of chronic pain. The experiments in this study were aimed at elucidating the extent to which tack- or suture-based permanent fixation can be replaced by fixation with fibrin glue for laparoscopic intraperitoneal repair of abdominal wall hernias.

METHODS

In an initial series of experiments conducted with a biomechanical model, the strength of the fibrin glue for fixation of lightweight mesh (TiMesh light) to muscle tissue was compared with its strength of fixation to the peritoneum. In a second series of experiments, mesh was laparoscopically implanted in an established porcine model. Fibrin glue was used for mesh fixation in six animals. Laparoscopic exploration and explantation of the meshes were conducted after 4 months. Planimetric analysis was performed to investigate adhesion and shrinkage of the mesh surface.

RESULTS

The strength of fibrin glue for fixation of mesh to the peritoneum was significantly less than for its fixation to muscle tissue (11.86 N vs. 47.88 N; p = 0.001). Three of the implanted meshes were not completely integrated, and two of these were dislocated. On the average, adhesions were seen on 16% of the mesh surfaces. The mesh shrinkage rate was 24.2%.

CONCLUSION

Mesh fixation alone to the undamaged peritoneum in the intraperitoneal region cannot be recommended because of the risk for dislocation. Additional fixation using sutures, tacks, or both is needed until the mesh material is completely integrated.

Mesh fixation with fibrin glue (Tissucol/Tisseel) in hernia repair dependent on the mesh structure--is there an optimum fibrin-mesh combination?--investigations on a biomechanical model

BACKGROUND

Because of its hemostatic and adhesive properties, fibrin glue has been used in many areas of surgical treatment in recent years. One example is hernia repair, where fibrin gluing has become increasingly established as an alternative method for mesh fixation. Clinically, fixation with fibrin glue shows a reduced postoperative complication rate compared to other fixation methods (staples, sutures), particularly with regard to pain.

MATERIALS AND METHODS

Six different lightweight meshes were tested: TiMesh light, TiMesh extralight, Parietene light, Ultrapro, Optilene LP, and BARD Soft Mesh. Two millimeters Tissucol was used for fixation. Five meshes from each group were tested on muscular tissue with and without fibrin glue. The defined defect was 4.5 cm in diameter. The biomechanical measurements were taken in a standardized way using a materials testing machine. The minimum fixation strength required was 32 N, calculated from a corresponding model.

RESULTS

The fixation strength measurements without fibrin glue gave a mean value for all 30 meshes of 2.98 N with a SD of 0.92 N. This was far below the 32 N required. With fibrin glue, the mean of all the measurements (30 meshes) was 61.86 +/- 23.0 N (min 34.9 N, max 97.3 N). The lowest value was recorded for Ultrapro (34.9 +/- 12.5 N). All the other meshes had a significantly higher fixation strength when fixed with fibrin glue than Ultrapro (p = 0.001). The best results were found for Optilene LP, and this was significantly better than all the other meshes (97.3 +/- 8.9 N; p < 0.001).

CONCLUSION

Given the adequate stability and superior biocompatibility of lightweight large pore monofilament polypropylene meshes, heavyweight polypropylene meshes should no longer be used. It is possible to achieve adequate fixation of the meshes using fibrin glue. However, careful consideration should be given to the particular structure of the mesh in each case. Not every mesh is equally suitable for this purpose.

Laparoscopic management of large hiatus hernia with mesh cruroplasty

PURPOSE

Laparoscopy has become the standard surgical approach to surgery for gastrooesophageal reflux disease (GERD) and hiatal hernia repair with excellent long-term results and high patient satisfaction. However several studies have shown that hiatal hernia repair, especially large hiatus are associated with high recurrence rate. Mesh reinforcement has been proposed for repair of large hiatus hernia. The objective of this study was to evaluate the role of mesh cruroplasty in management of large hiatus hernia (> 5 cm).

METHODS

Between February 2002 to December 2007, 73 patients (28 men and 45 women) who underwent laparoscopic hiatal hernia repair with mesh cruroplasty were included in our study. Mesh reinforcement (cruroplasty) was used for repair of large hiatus hernia (>5 cms hernial defect). Mean age was 50.4 years (range 30-72 years). Follow up included barium swallow of patients at 3 months and yearly thereafter.

RESULTS

Seventy-three patients underwent mesh cruroplasty for large hiatus hernia. We were able to adequately mobilise the oesophagus to achieve an intra-abdominal length of at least 3 cm in all patients. Intraoperative complication rate was 8.21% (6/73), intraoperative complications included pleural tear, bleeding from splenic capsule laceration and short gastric vessels. Postoperative complication rate was 4.1% (3/73), which included complete dyspahgia, atelactasis and pneumonia. Mean duration of hospitalisation was 3.5 days (range 3-9 days). Five patients (5/73) were lost to follow up. Four patients (5.8%) developed recurrence on routine follow up. No mesh related complications were noted on long-term follow up period. Mean follow up period was 3.2 years (range 5 months-6 years).

CONCLUSION

Our data supports the use of mesh in hiatal hernia repair, especially in large hiatus hernia as it leads to low recurrence rates. Longer follow up and more randomised controlled trials are needed to establish laparoscopic mesh cruroplasty as standard technique for large hiatal hernia repair.

Inguinal hernia: state of the art

A review of the history of inguinal hernia repair from the far surgical approach performed by Celso, trought the physiological reconstruction of inguinal canal by Bassini and the introduction of the concept of tensionfree repair, to the newest find in this specialist surgery. Nowadays in addition to the choice of approach (open vs laparoscopic, anterior vs preperitoneal), the plane where placing the mesh (in front of the trasversalis fascia vs preperitoneal space), and the fixation device (suture vs sutureless vs glue), surgeons can select among a wide range of prosthesis. Choosing the proper biomaterial can determine the success of an operation and prevent biomaterial-related complications. Indepth knowledge and understanding of the physical properties of the prosthesis, porosity, and pore size in particular are required. Modern advances in hernia repair are credited with reduced recurrence rate, so surgeons' attention is shifted from preventing recurrence to the new topic of chronic pain after surgery.

Hemostatic agents injected directly into hepatic injury sites for liver trauma hemorrhage under the guidance of contrast-enhanced ultrasound: an animal experiment

We investigated whether direct injection of hemostatic agents into injury sites under the guidance of contrast-enhanced ultrasound (CEUS) can decrease blood loss from liver trauma. Twelve adult healthy dogs underwent laparotomy, and a hepatic wound (6.0 x 4.5 cm) was created in each dog. All animals were divided randomly into two groups: the treatment group and the control group. In the treatment group, hemocoagulase Atrox (Solco Basle Ltd., Birsfelden, Switzerland) and absorbable cyanoacrylate were injected directly into the liver injury sites, and 0.9% normal saline was injected into the injury sites in the control group. Resuscitation volume in the treatment group was less than that in the control group (55 +/- 12 mL vs. 105 +/- 23 mL, p < 0.001). The control group presented bleeding from liver injury sites. Times of bleeding at the injury site in the treatment groups were 6 +/- 1 s. Both groups presented an-echo and/or hypo-echo contrast regions, with contrast material pooling in the injury sites before the therapy. After the injection, the contrast material pooling disappeared in the treatment group observed by CEUS. Gross examination of liver tissue revealed that the injury site that had been treated was covered by clot and glue membrane. Histopathologic examination showed that there was hemostitic glue embolizing the microvessels and inflammatory cell infiltration among hepatocytes. Direct injection of hemocoagulase Atrox and cyanoacrylate into the liver injury sites guided by CEUS can effectively reduce blood loss from liver trauma within a short time. This experimental study may suggest a possible treatment for liver trauma hemorrhage and provide an experimental evidence for treating blunt abdominal parenchyma organs trauma under the guidance of CEUS.

Pain, quality of life and recovery after laparoscopic ventral hernia repair

BACKGROUND

Laparoscopic ventral hernia repair (LVHR) is a well established procedure in the treatment of ventral hernias. It is our clinical experience that patients suffer intense postoperative pain, but this issue and other recovery parameters have not been studied in detail.

METHODS

Thirty-five patients with hernias >3 cm prospectively underwent LVHR using "double-crown" titanium tack mesh fixation. Pre- and postoperative pain was measured on a 0-100-mm visual analogue scale (VAS) and health-related quality of life was measured using the Short Form 36 questionnaire (SF-36). Several other recovery parameters were measured systematically in the 6 months follow-up period.

RESULTS

We observed no recurrences or severe complications in the follow-up period (n = 31 at day 30 and n = 28 after 6 months). The median in-hospital stay was 2 days (range 0-5). Patients reported significantly more pain during activity than at rest at all times (p < 0.05). The median VAS-pain score during activity vs. at rest at discharge was 60 and 31, respectively. The median VAS-pain score during activity on the day of operation (day 0) was 78; it returned to baseline values at day 30 (p = 0.148) and, after 6 months, it was below the preoperative score (p = 0.01). The scores for general well-being and fatigue returned to baseline values at days 3 and 30, respectively, and at 6 months, they had both significantly improved compared with preoperative values (p = 0.005). The SF-36 scores were significantly worse in three domains at day 30 (p < 0.005). After 6 months, the bodily pain score had increased significantly compared with preoperative values (p < 0.005) and all eight scales were comparable to the Danish reference population scores. Patients resumed normal daily activities after a median of 14 days (range 1-38). Smokers and patients with hard physical demands at work took a significantly longer amount of time to resume work compared with non-smokers (30 vs. 9 days, p < 0.005) and patients with light work demands (29 vs. 9 days, p < 0.05), respectively. VAS-pain scores were strongly correlated to general well-being (r = -0.8, p < 0.001), patient satisfaction (r = -0.67, p < 0.001) and quality of life (r = -0.63, p < 0.001). We found no significant correlation between the number of tacks used (median 59) and postoperative pain.

CONCLUSION

LVHR was associated with considerable postoperative pain and fatigue in the first postoperative month, prolonging the time of convalescence and significantly affecting patients' quality of life up to 6 months postoperatively. Mesh fixation with fibrin glue or other non-invasive/degradable products seems promising for reducing pain and it should be investigated in future randomised trials.

Biomechanical analyses of mesh fixation in TAPP and TEP hernia repair

BACKGROUND

Reliable laparoscopic fixation of meshes prior to their fibrous incorporation is intended to minimize recurrences following transabdominal preperitoneal hernia repair (TAPP) and totally extraperitoneal repair (TEP) repair of inguinal hernias. However, suture-, tack- and staple-based fixation systems are associated with postoperative chronic inguinal pain. Initial fixation with fibrin sealant offers an atraumatic alternative, but there is little data demonstrating directly whether fibrin-based mesh adhesion provides adequate biomechanical stability for repair of inguinal hernia by TAPP and TEP.

METHODS

Using a newly developed, standardized simulation model for abdominal wall hernias, sublay repairs were performed with six different types of commercially available hernia mesh. The biomechanical stability achieved, and the protection afforded by the mesh-hernia overlap, were compared for three different techniques: nonfixation, point-by-point suture fixation, and fibrin sealant fixation.

RESULTS

Mesh dislocation from the repaired hernia defect was consistently seen with nonfixation. This was reliably prevented with all six mesh types when fixed using either sutures or fibrin sealant. The highest stress resistance across the whole abdominal wall was found following superficial fixation with fibrin sealant across the mesh types. There was a highly statistically significant improvement in fixation stability with fibrin sealant versus fixation using eight single sutures (p = 0.008), as assessed by the range of achievable peak pressure stress up to 200 mmHg.

CONCLUSIONS

To ensure long-term freedom from recurrence, intraoperative mesh-hernia overlap must be retained. This can be achieved with fibrin sealant up to the incorporation of the mesh - without trauma and with biomechanical stability.

The assessment of quality of life in a trial on lightweight mesh fixation with fibrin sealant in transabdominal preperitoneal hernia repair

BACKGROUND

Chronic pain is a major concern in open and laparoscopic hernia repair. Study groups have adopted a variety of tools to assess postoperative (postOP) pain and quality of life (QoL). Unfortunately, modifications of existing tests and self-designed questionnaires are common, yielding unvalidated results and making comparison of data difficult. The aim of this study was to assess the QoL in transabdominal preperitoneal mesh repair (TAPP) with fibrin sealant (FS) for lightweight mesh fixation, applying the standardised Short Form 36 (SF36) questionnaire in its unmodified design. The SF36 has already been validated and implemented in a large number of studies. In this trial the physical-health-component summary measure (PHM), summarising the physical health-related scales, served as the primary outcome parameter.

MATERIALS AND METHODS

After informed written consent was obtained, TAPP with fibrin mesh sealing was performed in 11 non-selected consecutive patients by a single surgeon. A direct control group (e.g. TAPP with staples) was not enrolled, because a favourable change in the QoL in patients subjected to the mesh sealing approach was the tested hypothesis and not the comparison of techniques. The macroporous mesh (TI-Mesh, GfE, Germany) was fixed with 1 ml of FS (FS, Tisseel, Tissucol, Baxter Biosciences, Austria), and the QoL and pain were assessed preoperatively and 1 year postOP using the SF36 survey and the visual analogue score (VAS).

RESULTS

After 12 months, recurrences or complications were observed. The analysis of the unmodifed SF36 revealed a highly significant improvement in the PHM, based on significant changes of all physical-health-related scales. The scale 'social functioning' (SOCIAL), which belongs to the mental-health-related scale, had also significantly improved. The VAS was significantly reduced after 1 year.

CONCLUSIONS

Despite a small number of patients (n = 11), a strikingly significant improvement in physical health and reduction of pain was detected with the unmodified SF36 and the VAS 1 year after TAPP repair with fibrin-sealed lightweight meshes. We suggest the use of the unmodified SF36 for QoL in hernia repair in order to assess all aspects of recovery (physical and mental) and to facilitate comparison of data.

Do various mesh placement techniques affect the outcome in totally extraperitoneal hernia repair? What is the role of the surgeon?

BACKGROUND

Various modifications of mesh placement are currently used in total extraperitoneal (TEP) groin hernia repair. The aim of this study was to compare three different variants of mesh placement with respect to rate of complications and clinical outcome.

METHODS

A series of 397 consecutive patients with a total of 534 preperitoneal groin hernia TEP repairs performed by four surgeons at a single institution between 1999 and 2003 were retrospectively analyzed. The mean follow-up was 19.7 +/- 7.5 months. A single-mesh technique was used in cases of hernial orifice <1.5 cm. Larger hernial defects were closed either in a double-mesh or a modified double-mesh placement technique. The three placement techniques were compared with respect to hospital stay, operative time, early and late complications, return-to-work time, and recurrence rate.

RESULTS

The modified double-mesh technique was associated with the longest hospital stay, the longest operative time, the slowest return to work, and significantly higher rates of early (5.6% vs. 4.6% vs. 2.9%) and late (19.1% vs. 11.3% vs. 7.9%) postoperative complications, when compared to double-and single-mesh placement. Overall recurrence rate was 1.3% after a mean follow-up of 19.7 months. The larger the experience of a surgeon with his preferred technique, the shorter the operative time and hospital stay were.

CONCLUSIONS

Mesh placement techniques appeared to have a direct impact on clinical outcome and hospital stay. The modified double-mesh technique showed the worst postoperative results, independent of the surgeon's experience. Which mesh placement technique is most appropriate for complex hernias remains to be answered by further randomized, controlled trials.

Laparoscopic inguinal hernia repair without mesh fixation, early results of a large randomised clinical trial

BACKGROUND

A new persistent groin pain is reported by a significant number of patients following laparoscopic totally extraperitoneal hernia repair (TEP). Mesh fixation has been implicated as a possible cause, but is widely considered essential for mesh stabilization and early recurrence prevention. This study investigates whether any association exists between mesh fixation by metal tacks and the incidence of new groin pain or early hernia recurrence.

METHODS

A prospective multicenter double-blinded randomised trial was conducted between December 2004 and January 2006. Standardized TEP repair was performed with a rectangular 10 x 15cm polypropylene mesh. Hernia were randomized to either mesh fixation by metal tacks or left entirely unfixated. Clinical review by physical examination was performed by a separate blinded surgeon after a minimum of six months, with another review planned after two years. The incidence of new groin pain and recurrence were compared.

RESULTS

Five hundred herniae in 360 patients were entered into the study. At the first wave of clinical follow-up (median eight, range 6-13 postoperative months) a new pain was reported by 38 versus 23% (p = 0.003), occurring at least once a week in 22 versus 15% (p = 0.049), or several times per week in 16 versus 8% (p = 0.009) for fixated versus unfixated repairs, respectively. Patients with bilateral repairs were five times more likely to report the unfixated side being more comfortable (p = 0.006). There was one recurrence in the fixated group (1/247) whilst none have yet occurred in the unfixated group. Fixation increased operative costs by approximately 375 AUD.

CONCLUSION

Mesh fixation in TEP is associated with increased operative cost and chronic pain but no difference in the risk of hernia recurrence at six months was observed.

Tissue resistance of the tension-free procedure: What about healing?

The aim of our work was to objectify and quantify the mechanical benefits of healing with regards to tearing meshes off of tissues and maximal resistance after cicatrization. In vivo, we tested the mechanical gain in resistance by healing after implantation of a Prolene mesh. We measured the value of forces when traction was exerted until mobilization at different stages of cicatrization. Resistance increased progressively at the beginning of tissue inclusion. A maximal plateau was reached around the 25th day. It is important to understand the role of sustaining and reinforcement we hope tissue integration of the mesh will play. We can thus adapt procedures to have the best kinetics and maximal resistance of montages. Study of the kinetics and maximal plateau allows us to make the best clinical recommendations.

Transinguinal preperitoneal repair with the Polysoft patch: prospective evaluation of recurrence and chronic pain

OBJECTIVE

The Polysoft patch was conceived to facilitate performance of the transinguinal preperitoneal patch method and combine the advantages of patch placement in the preperitoneal space and the open inguinal approach. The aim of this prospective study was to evaluate the rate of recurrence and chronic pain at midterm follow-up.

METHODS

In a cohort of 200 hernia repairs involved in a prospective evaluation, midterm results of 171 cases operated on from 1 July 2004 to 31 December 2005 were assessed. The anesthesia was spinal in 136 (79.5%) cases, local in 26 (15.2%), and general in nine (5.3%). A questionnaire was sent to patients on 30 November 2006 asking about recurrence, chronic groin pain, and satisfaction.

RESULTS

With a median follow-up of 21.9 months (11.6-29.4), 167 (97.7%) patients were evaluated, two were dead, and two were lost to follow-up. There were two (1.2%) recurrences that were reoperated on; both consisted of an indirect sac that protruded between the branches of the split patch. Eleven (6.6%) patients alleged the feeling of a foreign body, and 12 (7.2%) reported pain that occurred occasionally or upon effort but did not prevent activity. In one case, the pain present before operation was unchanged, and in three cases, the pain could clearly be attributed to an origin other than the hernia repair. No case of pain that impaired activity was observed. With regard to results, 98.2% of patients were satisfied and 97.6% declared that they would adopt the same method in case they had to be operated on for another hernia.

CONCLUSION

These results suggest that the technique provides a low rate of recurrence and a low percentage of chronic pain that did not impair activity.

Chronic pain after mesh repair of inguinal hernia: a systematic review

BACKGROUND

Chronic pain is a severe complication of mesh-based inguinal hernia repair. Its perceived risk varies widely in the literature. The current objectives are to review the incidence, severity, and consequences of chronic pain and its etiologies.

DATA SOURCES

A multi-database systematic search was conducted for prospective trials on mesh-based inguinal hernia repair reporting the measurement and outcome of pain at least 3 months postoperatively with a minimum follow-up of 80%.

CONCLUSIONS

After mesh-based inguinal hernia repair, 11% of patients suffer chronic pain. More than a quarter of these patients have moderate to severe pain, mostly with a neuropathic origin. As a consequence of chronic pain, almost one third of patients have limitations in daily leisure activities. Chronic pain is less frequent after endoscopic repair and with the use of a light-weighted mesh.

Quantification of pain in laparoscopic transabdominal preperitoneal (TAPP) inguinal hernioplasty identifies marked differences between prosthesis fixation systems

BACKGROUND

Various systems exist for prosthesis fixation in hernia repair. These techniques vary in terms of postoperative complications and pain. This study compares prosthesis fixation techniques employed in laparoscopic transabdominal preperitoneal (TAPP) hernioplasty using a visual analog scale (VAS) to quantify postoperative pain.

METHODS

Patients (n = 600) underwent TAPP inguinal hernia repair in a randomized prospective study. Prostheses were fixed with Protak (Tyco, Norwalk, Conn), (Group A; n = 150), EndoANCHOR (Ethicon Endo-Surgery, Inc., Cincinnati, Ohio) (Group B; n = 150), EMS (Ethicon Endo-Surgery, Inc.) (Group C; n = 150), or Tissucol (Baxter Healthcare, Milan, Italy) (Group D; n = 150). Patients were interviewed up to 1 month post-intervention. Post-operative pain was evaluated on a 0- to 10-point VAS (0 = no pain, 10 = maximum pain). Morbidity, length of stay, return to work and recurrence were also assessed.

RESULTS

Overall, 803 hernias were treated: 397 patients (66.2%) had unilateral hernias and 203 (33.8%) had bilateral hernias. In total, 96 (12%) hernias were recurrences and 707 (88%) were primary. Postoperative pain ranged from VAS1 to VAS2 (mild pain) between 12 hours and 72 hours with Tissucol (Group D), and it was higher in Groups A-C: Maxima ranged from VAS4 (moderate pain) with EMS to VAS7 (severe pain) with Protak at 48-hour follow-up. Significant differences in length of stay occurred, no recurrence or conversion rates were observed among groups, and morbidity was generally lower with Tissucol. Patients in Group D (Tissucol) also returned to work sooner than did Groups A-C (Protak, EndoANCHOR, and EMS).

CONCLUSIONS

We found differences in postoperative pain among different laparoscopic TAPP prosthesis fixation methods. The use of the biocompatible fibrin sealant Tissucol seems to reduce significantly postoperative pain, complications, and resumption to work times compared with other systems.

Discomfort five years after laparoscopic and Shouldice inguinal hernia repair: a randomised trial with 867 patients. A report from the SMIL study group

BACKGROUND

In recent years long-term discomfort after inguinal hernia surgery has become an issue of great concern to hernia surgeons. Long-term results on discomfort from large randomised studies are sparse.

METHODS

One-thousand one-hundred and eighty-three patients were randomised in a multicentre trial with the primary aim of comparing recurrence rates after laparoscopic TAPP and Shouldice repair. Evaluating late discomfort and its possible risk factors were secondary objectives, and are reported here. The patients were clinically examined after 1 and 5 years, and answered questionnaires 2 and 3 years postoperation.

RESULTS

Of 1,068 operated patients, 867 were eligible for analysis after 5 years (81.2%). The percentage of patients experiencing discomfort of any kind were 8.5% in the TAPP group and 11.4% (p = 0.156) in the Shouldice group. Although discomfort was usually mild it was severe for 0.2 and 0.7%, respectively. Severe pain the first postoperative week was a risk factor for late discomfort in the Shouldice group (OR 2.25, P = 0.022) but not in the TAPP group. No other risk factor for late discomfort was found.

CONCLUSION

There was no difference between late discomfort at five-year follow-up after laparoscopic TAPP and Shouldice repair. Discomfort was mostly mild and pain during the first postoperative week was a prognostic variable for late discomfort in Shouldice patients.

Management of herniated retroperitoneal adipose tissue during endoscopic extraperitoneal inguinal hernioplasty

BACKGROUND

Herniation of retroperitoneal adipose tissue into the inguinal canal, traditionally called cord lipoma, is frequently encountered during endoscopic totally extraperitoneal inguinal hernioplasty (TEP). Failure to recognize and manage the cord lipoma accounted for 30%-50% of recurrent hernia after TEP. The present study was undertaken to evaluate the incidence, risk factors, and management of herniated retroperitoneal adipose tissue during TEP.

METHODS

Between December 2002 and November 2005 all patients who underwent TEP were prospectively evaluated for the presence of cord lipoma. Clinical outcomes of patients who were treated for their cord lipoma were compared with those without cord lipoma. Risk factors for the occurrence of cord lipoma were also examined.

RESULTS

A total of 498 patients underwent unilateral (n = 386) or bilateral (n = 112) TEP. The overall incidence of cord lipoma was 26.5% (n = 132). A higher body weight, a higher body mass index, and a larger hernial defect were significantly associated with the presence of cord lipoma. Most of the cord lipoma cases (n = 119) were reduced to pelvic peritoneal reflection line after division of the feeding vessels from surrounding structures, while the rest (n = 13) were resected. Early postoperative outcomes, including pain score, morbidities, and other recovery variables, showed no significant difference between the two groups. No recurrence occurred in the present series.

CONCLUSIONS

Herniation of retroperitoneal adipose tissue into the inguinal canal occurred in more than one-fifth of the patients with inguinal hernia. Awareness and appropriate treatment of the cord lipoma helped to reduce the risk of recurrence. During TEP, the internal inguinal ring and inguinal canal should always be cleared of any herniated adipose tissue by either reduction or resection. This clearing posed no adverse effects on postoperative outcome.

Preliminary Experience Using Fibrin Glue for Mesh Fixation in 250 Patients Undergoing Minilaparoscopic Transabdominal Preperitoneal Hernia Repair

PURPOSE

Fibrin glue for mesh fixation has been proposed to prevent the risk of nerve injury in inguinal hernia repair. We retrospectively evaluated a series of 250 patients who underwent minilaparoscopic transabdominal preperitorneal (miniTAPP) hernioplasty (using trocars, optics, and instruments <10 mm in diameter) in whom mesh fixation was achieved using 2 mL of fibrin glue. We considered the feasibility of the technique and the incidence of complications, especially those possibly related to mesh fixation. We also compared the results with an earlier series of 245 patients in whom tacks were used to fix the mesh.

MATERIALS AND METHODS

Between April 2004 and November 2005, 250 patients underwent bilateral or unilateral miniTAPP hernioplasty with instruments, optics, and trocars smaller than 10 mm and meshes fixed by fibrin glue.

RESULTS

The mean overall operative time was 52.25 +/- 15.2 min. All the procedures were done as day surgeries. We registered one intraoperative bladder lesion and 15 cases of seroma. There were no relapses, prosthesis rejection, or infection. The mean follow-up was 13.2 +/- 6.1 months (range, 5-24 months).

CONCLUSION

On the basis of our initial experience, miniTAPP hernioplasty with a fibrin glue is feasible, effective, and easy to perform in experienced hands, with good results without higher risk of recurrence. In addition, the fibrin fixation method seems to decrease postoperative neuralgia and reduced the incidence of postoperative seromas and hematomas.

Fibrin sealant for mesh fixation in Lichtenstein repair: biomechanical analysis of different techniques

BACKGROUND

Mesh fixation using sealants is becoming increasingly popular in hernia surgery. Fibrin sealant is an atraumatic alternative to suture or stapler fixation and is currently the most frequently used sealant. There are currently no biomechanical data available for evaluation of the quality of adhesion achieved with fibrin sealant during Lichtenstein hernia repair.

METHODS

Five different suture and sealant techniques were evaluated and compared during simulated Lichtenstein hernia repair in an established, standardised biomechanical model for abdominal wall hernias.

RESULTS

Significantly greater stability was achieved with fibrin sealant fixation of meshes than with point-by-point suture fixation. Fibrin adhesion protected meshes from dislocation at least as well as suture fixation with additional running-suture closure of the hernia orifice. Fibrin mesh fixation combined with additional support from running-suture hernia closure was significantly (P < or = 0.002) superior to all other methods.

CONCLUSIONS

On the basis of these favourable biomechanical properties, mesh fixation using fibrin sealant can be recommended for use in onlay repair of transinguinal hernias.

Less chronic pain following mesh fixation using a fibrin sealant in TEP inguinal hernia repair

Endoscopic hernia repair methods have become increasingly popular over the past 15 years. The postulated main advantages of the endoscopic technique are less postoperative pain, early recovery and lower recurrence rates. Fixation of the endoscopic mesh seems to be necessary to minimize the risk of recurrence. Stapling has been implicated to cause chronic inguinal pain syndromes. We performed a retrospective study on male patients who were endoscopically operated on primary inguinal hernias. Our aim was to clarify whether mesh fixation using a fibrin sealant is as safe and reliable as conventional stapling. Additionally, we compared the prevalence of chronic inguinal pain. A standardized population of 133 male patients (mean age 55.9 years) with 186 (80 unilateral; 53 bilateral) consecutive primary laparoscopic total extraperitoneal inguinal hernia repairs was assigned to two groups, depending on whether stapling or a fibrin sealant had been used for mesh fixation. A retrospective case control study was performed to conduct statistical analysis based on the following parameters: recurrence, complications, chronic inguinal pain, foreign body sensation and numbness. Hernia repairs numbering 173 (staples n=87; fibrin n=86) were followed up for a mean duration of 23.7 (11-47) months. The prevalence of chronic inguinal pain was significantly (P=0.002; Fisher exact test) higher in the stapled group-20.7% than in the fibrin sealant group with a prevalence of 4.7%. In terms of recurrence rate, complications and foreign body sensation, fewer patients were affected in the fibrin group than in the reference population, although the differences were not statistically significant. There were no major complications in either of the groups. The mean postoperative stay in hospital was 1.4 days. Fibrin sealing is as effective as stapling in providing secure mesh fixation. The fibrin group displayed a statistically significant lower prevalence of chronic pain syndromes. Mesh sealing provides adequate fixation and reduces the risk of chronic inguinal pain as a complication of the intervention.