Randomized clinical trial of fibrin sealant versus titanium tacks for mesh fixation in laparoscopic umbilical hernia repair

UMBILICAL AND EPIGASTRIC HERNIA REPAIR: A SYSTEMATIC REVIEW

BACKGROUND

Umbilical and epigastric hernias are among the most common hernias of the abdominal wall; however, there is a lack of standardization for their treatment.

AIMS

To clarify the controversies regarding therapeutic possibilities, indications, and surgical techniques for umbilical and epigastric hernia repair.

METHODS

A systematic review and qualitative analysis of randomized clinical trials published in the last 20 years, involving adults (aged 18 years and over) with umbilical and/or epigastric hernias, was performed by systematically searching the PubMed/Medline, Cochrane, SciELO, and LILACS databases. The risk of bias in individual studies was assessed using the Cochrane Risk of Bias Tool.

RESULTS

Initially, 492 studies were selected and, subsequently, 15 randomized controlled clinical trials were chosen that met the inclusion criteria and underwent full reading and qualitative analysis, considering possible bias.

CONCLUSIONS

This review concluded that it is evident the superiority of the use of meshes in the repair of epigastric/primary umbilical hernias with a defect larger than 1 cm, even in certain emergency situations. However, suture repair is a good option for patients with a defect smaller than 1 cm. In the laparoscopic approach, recent evidence points towards possible superiority in fixation with fibrin sealant, and fascial defect closure is recommended. In addition, due to a scarcity of randomized controlled trials with low risk of bias, further studies are needed on types, positioning and fixation techniques, as well as the real role of video-assisted laparoscopic surgery in the correction of hernias, especially umbilical.

Evaluating mesh fixation techniques for ventral hernia repair: A systematic review and network meta-analysis of randomised control trials

INTRODUCTION

There is uncertainty regarding the optimal mesh fixation techniques for laparoscopic ventral and incisional hernia repair.

AIM

To perform a systematic review and network meta-analysis of randomised control trials (RCTs) to investigate the advantages and disadvantages associated with absorbable tacks, non-absorbable tacks, non-absorbable sutures, non-absorbable staples, absorbable synthetic glue, absorbable sutures and non-absorbable tacks, and non-absorbable sutures and non-absorbable tacks.

METHODS

A systematic review was performed as per PRISMA-NMA guidelines. Odds ratios (ORs) and mean differences (MDs) were extracted to compare the efficacy of the surgical approaches.

RESULTS

Nine RCTs were included with 707 patients. Short-term pain was significantly reduced in non-absorbable staples (MD; -1.56, confidence interval (CI); -2.93 to -0.19) and non-absorbable sutures (MD; -1.00, CI; -1.60 to -0.40) relative to absorbable tacks. Recurrence, length of stay, operative time, conversion to open surgery, seroma and haematoma formation were unaffected by mesh fixation technique.

CONCLUSION

Short-term post-operative pain maybe reduced by the use of non-absorbable sutures and non-absorbable staples. There is clinical equipoise between each modality in relation to recurrence, length of stay, and operative time.

An Evaluation of the Evidence Guiding Adult Midline Ventral Hernia Repair

Purpose:  Several guidelines have been published in recent years to guide the clinician in ventral hernia repair. This review distils this advice, critically assesses their evidence base, and proposes avenues for future study. Methods:  A PUBMED search identified four guidelines addressing midline ventral hernia repair published by major surgical societies between 2016 and 2020. The studies used to inform the advice have been critically appraised, including 20 systematic reviews/meta-analyses, 10 randomized controlled trials, 32 cohort studies, and 14 case series. Results:  Despite a lack of randomized controlled trials, case heterogeneity, and variation in outcome reporting, key themes have emerged. Preoperative computed tomography scan assesses defect size, loss of domain, and the likely need for component separation. Prehabilitation, frailty assessment, and risk stratification are beneficial in complex cases. Minimally invasive component separation techniques, Botox injection, and progressive pneumoperitoneum represent novel techniques to promote closure of large fascial defects. Rives-Stoppa sublay mesh repair has become the "gold" standard for open and minimally invasive repairs. Laparoscopic repair promotes early return to functional status. The enhanced-view totally extraperitoneal approach facilitates laparoscopic sublay mesh placement, avoiding mesh contact with viscera. Robotic techniques continue to evolve, although the evidence at present remains immature. Synthetic mesh is recommended for use in clean and clean-contaminated cases. However, optimism regarding the use of biologic and biosynthetic meshes in the contaminated setting has waned. Conclusions:  Surgical techniques in ventral hernia repair have advanced in recent years. High-quality data has struggled to keep pace; rigorous clinical trials are required to support the surgical innovation.

Comparative review of outcomes: single-incision laparoscopic total extra-peritoneal sub-lay (SIL-TES) mesh repair versus laparoscopic intraperitoneal onlay mesh (IPOM) repair for ventral hernia

To compare outcomes between single-incision laparoscopic totally extra-peritoneal sub-lay (SIL-TES) mesh repair and laparoscopic intraperitoneal onlay mesh (IPOM) repair of ventral hernia (VH). A retrospective selection of 104 patients who underwent VH repair (50 and 54 in the SIL-TES and IPOM groups, respectively) was made. Patient data were collected, and quality of life was evaluated using Carolinas Comfort Scale (CCS) 1 month and 3 months after surgery. There were no significant differences in sex, American Society of Anesthesiologists class, defect size, mesh area, estimated blood loss, and complication rate between the groups. Age was lower, body mass index was higher, prevalence of primary VH was significantly higher (p < 0.0001), and pain was less at 24 and 48 h post procedure (p < 0.0001) in the SIL-TES group. Drainage placement was more (p < 0.0001), operation time was shorter (p = 0.012), and hospitalization duration and total hospitalization cost were greater in the IPOM group than that in SIL-TES group (8.3 ± 0.3 vs 4.3 ± 0.4 days, p < 0.0001; $7126.9 ± 141.4 vs $2937.3 ± 58.3, p < 0.0001, respectively). Pain and movement limitation scores evaluated by CCS were significantly worse at 1 month (4.93 ± 0.28 vs 1.75 ± 0.28: p < 0.0001; 2.52 ± 0.24 vs 1.15 ± 0.18: p < 0.0001, respectively) and 3 months (4.32 ± 0.37 vs 0.9 ± 0.29: p < 0.0001; 2.06 ± 0.25 vs 0.69 ± 0.11: p < 0.0001, respectively) in IPOM group, compared with the according scores in SIL-TES group. There was no readmission within 30 days and no hernia recurrence at mean follow-up of 12 months. SIL-TES mesh repair is safe and effective and is superior to IPOM repair.

Self-adhesive hydrogel meshes reduce tissue incorporation and mechanical behavior versus microgrips self-fixation: a preclinical study

Purpose

Atraumatic mesh fixation for abdominal hernia repair has been developed to avoid the disadvantages of classical fixation with sutures, which is considered a cause of chronic pain and discomfort. This study was designed to analyze, in the short and medium term, the biological and mechanical behavior of two self-fixing meshes compared to that of a polypropylene (PP) mesh fixed with a cyanoacrylate (CA) tissue adhesive.

Methods

Partial abdominal wall defects (6 × 4 cm) were created in New Zealand rabbits (n = 36) and repaired using a self-adhesive hydrogel mesh (Adhesix™), a self-gripping mesh (ProGrip™) or a PP mesh fixed with CA (Surgipro™ CA). After 14 and 90 days, the host tissue incorporation, macrophage response and biomechanical strength were examined.

Results

At 14 and 90 days, the ProGrip and Surgipro CA meshes showed good host tissue incorporation; however, the Adhesix implants presented poor integration, seroma formation and a higher degree of shrinkage. The Adhesix hydrogel was completely reabsorbed at 14 days, whereas ProGrip microhooks were observed at all study times. The macrophage response was higher in the ProGrip and Surgipro CA groups at 14 and 90 days, respectively, and decreased over time. At 90 days, the ProGrip implants showed the highest tensile strength values and the Adhesix implants showed the highest failure stretch.

Conclusion

Meshes with mechanical microgrip self-fixation (ProGrip) show better biological and mechanical behavior than those with adhesive hydrogel (Adhesix) in a preclinical model of abdominal hernia repair in rabbits.

Mesh fixation techniques in primary ventral or incisional hernia repair

BACKGROUND

The use of a mesh in primary ventral or incisional hernia repair lowers the recurrence rate  and is the accepted standard of care for larger defects. In laparoscopic primary ventral or incisional hernia repair the insertion of a mesh is indispensable. Different mesh fixation techniques have been used and refined over the years. The type of fixation technique is claimed to have a major impact on recurrence rates, chronic pain, health-related quality of life (HRQOL) and complication rates.

OBJECTIVES

To determine the impact of different mesh fixation techniques for primary and incisional ventral hernia repair on hernia recurrence, chronic pain, HRQOL and complications.

SEARCH METHODS

On 2 October 2020 we searched CENTRAL, MEDLINE (Ovid MEDLINE(R)) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R)), Ovid Embase, and two trials registries. We also performed handsearches, and contacted experts from the European Hernia Society (EHS).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) including adults with primary ventral or incisional hernia that compared different types of mesh fixation techniques (absorbable/nonabsorbable sutures, absorbable/nonabsorbable tacks, fibrin glue, and combinations of these techniques).

DATA COLLECTION AND ANALYSIS

We extracted data in standardised piloted tables, or if necessary, directly into Review Manager 5. We assessed risks of bias with the Cochrane 'Risk of bias' tool. Two review authors independently selected the publications, and extracted data on results. We calculated risk ratios (RRs) for binary outcomes and mean differences (MDs) for continuous outcomes. For pooling we used an inverse-variance random-effects meta-analysis or the Peto method in the case of rare events. We prepared GRADE 'Summary of findings' tables. For laparoscopic repair we considered absorbable tacks compared to nonabsorbable tacks, and nonabsorbable tacks compared to nonabsorbable sutures as key comparisons.

MAIN RESULTS

We included 10 trials with a total of 787 participants. The number of randomised participants ranged from 40 to 199 per comparison. Eight studies included participants with both primary and incisional ventral hernia. One study included only participants with umbilical hernia, and another only participants with incisional hernia. Hernia size varied between studies. We judged the risk of bias as moderate to high. Absorbable tacks compared to nonabsorbable tacks Recurrence rates in the groups were similar (RR 0.74, 95% confidence interval (CI) 0.17 to 3.22; 2 studies, 101 participants). It is uncertain whether there is a difference between absorbable tacks and nonabsorbable tacks in recurrence because the certainty of evidence was very low. Evidence suggests that the difference between groups in early postoperative, late follow-up, chronic pain and HRQOL is negligible. Nonabsorbable tacks compared to nonabsorbable sutures At six months there was one recurrence in each group (RR 1.00, 95% CI 0.07 to 14.79; 1 study, 36 participants). It is uncertain whether there is a difference between nonabsorbable tacks and nonabsorbable sutures in recurrence because the certainty of evidence was very low. Evidence suggests that the difference between groups in early postoperative, late follow-up and chronic pain is negligible. We found no study that assessed HRQOL. Absorbable tacks compared to absorbable sutures No recurrence was observed at one year (very low certainty of evidence). Early postoperative pain was higher in the tacks group (VAS 0 - 10: MD -2.70, 95% CI -6.67 to 1.27; 1 study, 48 participants). It is uncertain whether there is a difference between absorbable tacks compared to absorbable sutures in early postoperative pain because the certainty of evidence was very low. The MD for late follow-up pain was -0.30 (95% CI -0.74 to 0.14; 1 study, 48 participants). We found no study that assessed HRQOL. Combination of different fixation types (tacks and sutures) or materials (absorbable and nonabsorbable) There were mostly negligible or only small differences between combinations (e.g. tacks plus sutures) compared to a single technique (e.g. sutures only), as well as combinations compared to other combinations (e.g. absorbable sutures combined with nonabsorbable sutures compared to absorbable tacks combined with nonabsorbable tacks) in all outcomes. It is uncertain whether there is an advantage for combining different fixation types or materials for recurrence, chronic pain, HRQOL and complications, because the evidence certainty was very low or low, or we found no study on important outcomes. Nonabsorbable tacks compared to fibrin sealant The two studies showed different directions of effects: one showed higher rates for nonabsorbable tacks, and the other showed higher rates for fibrin sealant. Low-certainty evidence suggests that the difference between groups in early postoperative, late follow-up, chronic pain and HRQOL is negligible. Absorbable tacks compared to fibrin sealant One recurrence in the tacks group and none in the fibrin sealant group were noted after one year (low certainty of evidence). Early postoperative pain might be slightly lower using tacks (VAS 0 - 100; MD -12.40, 95% CI -27.60 to, 2.80;1 study, 50 participants; low-certainty evidence). The pattern of pain and HRQOL course over time (up to 1 year) was similar in the groups (low certainty of evidence).

AUTHORS' CONCLUSIONS

Currently none of the techniques can be considered superior to any other, because the certainty of evidence was low or very low for all outcomes.

Chinese expert consensus on adult ventral abdominal wall defect repair and reconstruction

BACKGROUND

Surgical management of patients with ventral abdominal wall defects, especially complex abdominal wall defects, remains a challenging problem for abdominal wall reconstructive surgeons. Effective surgical treatment requires appropriate preoperative assessment, surgical planning, and correct operative procedure in order to improve postoperative clinical outcomes and minimize complications. Although substantial advances have been made in surgical techniques and prosthetic technologies, there is still insufficient high-level evidence favoring a specific technique. Broad variability in existing practice patterns, including clinical pre-operative evaluation, surgical techniques and surgical procedure selection, are still common.

DATA SOURCES

With the purpose of providing a best practice algorithm, a comprehensive search was conducted in Medline and PubMed. Sixty-four surgeons considered as experts on abdominal wall defect repair and reconstruction in China were solicited to develop a Chinese consensus and give recommendations to help surgeons standardize their techniques and improve clinical results.

CONCLUSIONS

This consensus serves as a starting point to provide recommendations for adult ventral abdominal wall repair and reconstruction in China and may help build opportunities for international cooperation to refine AWR practice.

Two Polyurethane Adhesives for PVDF Fixation Show Superior Biocompatibility in a Rat Model

BACKGROUND

The current standard for open and laparoscopic repair of incisional hernia consist of an abdominal wall augmentation by mesh implantation. However, the ideal fixation method of the prothesis material remains under discussion, due to potential complications of conventional fixation methods such as chronic abdominal pain or intestinal obstruction. As the use of adhesive based mesh fixation is an option of growing interest, the aim of this experimental study was to investigate the strength and biocompatibility of two newly developed polyurethane-based adhesives in comparison to a cyanoacrylatic adhesive, which is currently in clinical use.

METHODS

Two experimental polyurethane/urea-based adhesives (Adhesive-A and Adhesive-B) were compared to a conventional cyanoacrylatic adhesive and an untreated control group. Biomechanical testing was carried out using a pull-out test in uniaxial tensile mode, while biocompatibility assessment was performed in a rat model with 40 Sprague-Dawley rats receiving a subcutaneous implanted PVDF mesh fixed by the corresponding adhesive. Histological and immunohistochemical analysis by a Tissue FAXS system examined the tissue integration of the mesh/adhesive combination and characterized the foreign body reaction.

RESULTS

Biomechanical testing of the mesh/adhesive combinations showed a minimal strength of 15.08 N without a significant difference between the groups. Cellular penetration into the mesh/adhesive interface was significantly improved after application of polyurethane adhesives and Adhesive-A showed a significantly lower migration of CD68 positive cells to the adhesive sites compared to cyanoacrylate after 7 days.

CONCLUSION

The developed polyurethane-based adhesives are a promising alternative with sufficient adhesive strength and superior short-term biocompatibility to cyanoacrylate.

Laparoscopic intraperitoneal onlay mesh (IPOM) repair using n-butyl-2-cyanoacrylate (Liquiband Fix8™) for mesh fixation: learning experience and short-medium term results

AIM

The purpose of this study was to evaluate a novel hernia repair glue fixation device (LiquibandFix8™) in laparoscopic IPOM repair for incisional hernias.

METHODS

All ventral incisional hernia patients requiring laparoscopic IPOM repair were included in the study. A retrospective review of the data was performed.

RESULTS

137 patients underwent 138 laparoscopic IPOM repairs for incisional hernias using n-butyl-2-cyanoacrylate (LiquibandFix8™) for mesh fixation over a 40-month period by a single experienced laparoscopic surgeon. There were 70 males and 67 females, median age 54 years (range 23-80 years). Defects were predominantly midline n = 123/138 (89%) and were closed by transfascial sutures in 126/138 (91%) prior to IPOM repair (IPOM plus). Mesh fixation was successful in all 138 repairs. Synthetic meshes (Symbotex™ [polyester/collagen composite, Medtronic] n = 80, and Dynamesh^® [polypropylene/PVDF composite, FEG Textiltechnik mbH] n = 5) and biologic meshes (Surgimend^® [bovine collagen dermal matrix, Integra] n = 53) were used. Median follow-up was 32 months (range 12-48 months). There were 16 adverse events in 12 patients (9%): conversion to open surgery (inadvertent enterotomy) 2 (1.5%), bladder perforation 1, intraperitoneal bleeding 2, port-site haematoma 2, port site wound infection 1, post-op ileus 2, chest infection 1, seroma 1 (1%), hernia recurrence 3 (2%) and chronic pain 2 (1.5%).

CONCLUSION

This retrospective study shows that mesh fixation in laparoscopic IPOM using cyanoacrylate glue with the Liquiband Fix8™ device is feasible, safe, easy to learn, and is associated with a low risk of seroma, hernia recurrence and chronic pain with short-medium term follow-up.

Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society

BACKGROUND

Umbilical and epigastric hernia repairs are frequently performed surgical procedures with an expected low complication rate. Nevertheless, the optimal method of repair with best short- and long-term outcomes remains debatable. The aim was to develop guidelines for the treatment of umbilical and epigastric hernias.

METHODS

The guideline group consisted of surgeons from Europe and North America including members from the European Hernia Society and the Americas Hernia Society. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, the Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done on 1 May 2018, and updated on 1 February 2019.

RESULTS

Literature reporting specifically on umbilical and epigastric hernias was limited in quantity and quality, resulting in a majority of the recommendations being graded as weak, based on low-quality evidence. The main recommendation was to use mesh for repair of umbilical and epigastric hernias to reduce the recurrence rate. Most umbilical and epigastric hernias may be repaired by an open approach with a preperitoneal flat mesh. A laparoscopic approach may be considered if the hernia defect is large, or if the patient has an increased risk of wound morbidity.

CONCLUSION

This is the first European and American guideline on the treatment of umbilical and epigastric hernias. It is recommended that symptomatic umbilical and epigastric hernias are repaired by an open approach with a preperitoneal flat mesh.

Atraumatic laparoscopic intraperitoneal mesh fixation using a new laparoscopic device: an animal experimental study

PURPOSE

Laparoscopic ventral and incisional hernia repair (LVIHR) has become a common procedure because of its feasibility and safety, but it is not free of complications. Acute and chronic post-operative pain and bleeding caused by traumatic fixation of the mesh are frequently prolonging the hospital stay. The aim of this study was to analyze the behavior of n-butyl-cyanoacrylate (GLUBRAN^® 2) as only mesh fixation METHODS: Ten female pigs were involved in the study and were divided into two groups of five (A and B). Animals in each group underwent a laparoscopic procedure in which two meshes were placed intraperitoneally and fixed with the same synthetic glue only. Animals in group A were sacrificed after 3 weeks, and those in group B were sacrificed after 12 weeks. We studied the morphological, biomechanical, and histological characteristics of the intraperitoneal mesh-tissue interface RESULTS: No disruption, migration or folding was observed in any of the pigs. In group A, the mean tensile strength was 1.4 N/cm (± 0.2) while in group B, the mean tensile strength was 2.5 N/cm (± 0.8). Histological analyses, in areas where mesh was fixed using the glue, showed a chronic lymphocytic inflammatory reaction with a granulomatous component and a marked desmoplastic reaction made up of immature collagen and numerous fibroblasts acquiring myofibroblastic characteristics. In some areas corresponding to fixation, the desmoplastic reaction originated from mature lamellar bone tissue with osteocytes and osteoblasts.

CONCLUSION

Laparoscopic mesh fixation with only the synthetic comonomer glue GLUBRAN^® 2 is feasible, effective, and safe in intraperitoneal incisional/ventral hernia repair in this animal model.

Modified laparoscopic Sugarbaker repair of parastomal hernia with a three-point anchoring technique

AIM

To retrospectively evaluate the safety and feasibility of a new modified laparoscopic Sugarbaker repair in patients with parastomal hernias.

METHODS

A retrospective study was performed to analyze eight patients who underwent parastomal hernia repair between June 2016 and January 2018. All of these patients received modified laparoscopic Sugarbaker hernia repair treatment. This modified technique included an innovative three-point anchoring and complete suturing technique to fix the mesh. All procedures were performed by a skilled hernia surgeon. Demographic data and perioperative outcomes were collected to evaluate the safety and efficacy of this modified technique.

RESULTS

Of these eight patients, two had concomitant incisional hernias. All the hernias were repaired by the modified laparoscopic Sugarbaker technique with no conversion to laparotomy. Three patients had in-situ reconstruction of intestinal stoma. The median mesh size was 300 cm², and the mean operative time was 205.6 min. The mean postoperative hospitalization time was 10.4 d, with a median pain score of 1 (visual analog scale method) at postoperative day 1. Two patients developed postoperative complications. One patient had a pocket of effusion surrounding the biologic mesh, and one patient experienced an infection around the reconstructed stoma. Both patients recovered after conservative management. There was no recurrence during the follow-up period (6-22 mo, average 13 mo).

CONCLUSION

The modified laparoscopic Sugarbaker repair could fix the mesh reliably with mild postoperative pain and a low recurrence rate. The technique is safe and feasible for parastomal hernias.

Cost comparison of fibrin sealant versus tack screws for mesh fixation in laparoscopic repair of inguinal hernia

OBJECTIVES

Inguinal hernias of the abdominal wall are common accounting for 75% of all hernia defects. They can be treated with laparoscopic surgery using a transabdominal preperitoneal (TAPP) approach. However, in surgery there is some contention on how to conclude the hernia repair, as there are alternatives of using fibrin sealant (FS) or tack screws for fixation of a mesh implant over the defect in the abdominal wall. In this study, we evaluate the economic consequences of using FS vs. tacks for mesh fixation in TAPP inguinal hernia repair for the UK from a hospital perspective.

METHODS

The model was populated with clinical inputs (theater time, hospitalization days, occurrence of seroma, and neuralgia) from a previously conducted study comparing FS and tack screws in patients who had undergone TAPP hernia repair, and cost inputs from official government sources. One-way sensitivity analyses were also conducted to evaluate key drivers of cost analyses.

RESULTS

The average cost per case treated with FS 2 mL Tisseel® and tack screws (ProTack^TM) was £1,098 and £1,348, respectively, for resource expenses paid by the healthcare system. This would suggest a potential savings achieved of £249 per surgery using FS for mesh fixation. The sensitivity analysis showed that the key drivers for the cost difference were a variation in time to complete the surgery, followed by hospitalization days, and lower adverse outcomes such as seroma and neuralgia in the two cohorts.

CONCLUSION

Using FS resulted in cost savings in hospitals based on reduced time to complete surgery, hospitalization time post-op, and lower adverse outcomes. Indirect cost savings were also found in favor of FS when comparing the two alternatives from a societal perspective, as patients were able to return to work more promptly in the FS group versus the tack screws group.

The use of fibrin sealant during non-emergency surgery: a systematic review of evidence of benefits and harms

BACKGROUND

Fibrin sealants are used in different types of surgery to prevent the accumulation of post-operative fluid (seroma) or blood (haematoma) or to arrest haemorrhage (bleeding). However, there is uncertainty around the benefits and harms of fibrin sealant use.

OBJECTIVES

To systematically review the evidence on the benefits and harms of fibrin sealants in non-emergency surgery in adults.

DATA SOURCES

Electronic databases [MEDLINE, EMBASE and The Cochrane Library (including the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment database and the Cochrane Central Register of Controlled Trials)] were searched from inception to May 2015. The websites of regulatory bodies (the Medicines and Healthcare products Regulatory Agency, the European Medicines Agency and the Food and Drug Administration) were also searched to identify evidence of harms.

REVIEW METHODS

This review included randomised controlled trials (RCTs) and observational studies using any type of fibrin sealant compared with standard care in non-emergency surgery in adults. The primary outcome was risk of developing seroma and haematoma. Only RCTs were used to inform clinical effectiveness and both RCTs and observational studies were used for the assessment of harms related to the use of fibrin sealant. Two reviewers independently screened all titles and abstracts to identify potentially relevant studies. Data extraction was undertaken by one reviewer and validated by a second. The quality of included studies was assessed independently by two reviewers using the Cochrane Collaboration risk-of-bias tool for RCTs and the Centre for Reviews and Dissemination guidance for adverse events for observational studies. A fixed-effects model was used for meta-analysis.

RESULTS

We included 186 RCTs and eight observational studies across 14 surgical specialties and five reports from the regulatory bodies. Most RCTs were judged to be at an unclear risk of bias. Adverse events were inappropriately reported in observational studies. Meta-analysis across non-emergency surgical specialties did not show a statistically significant difference in the risk of seroma for fibrin sealants versus standard care in 32 RCTs analysed [n = 3472, odds ratio (OR) 0.84, 95% confidence interval (CI) 0.68 to 1.04; p = 0.13; I² = 12.7%], but a statistically significant benefit was found on haematoma development in 24 RCTs (n = 2403, OR 0.62, 95% CI 0.44 to 0.86; p = 0.01; I² = 0%). Adverse events related to fibrin sealant use were reported in 10 RCTs and eight observational studies across surgical specialties, and 22 RCTs explicitly stated that there were no adverse events. One RCT reported a single death but no other study reported mortality or any serious adverse events. Five regulatory body reports noted death from air emboli associated with fibrin sprays.

LIMITATIONS

It was not possible to provide a detailed evaluation of individual RCTs in their specific contexts because of the limited resources that were available for this research. In addition, the number of RCTs that were identified made it impractical to conduct independent data extraction by two reviewers in the time available.

CONCLUSIONS

The effectiveness of fibrin sealants does not appear to vary according to surgical procedures with regard to reducing the risk of seroma or haematoma. Surgeons should note the potential risk of gas embolism if spray application of fibrin sealants is used and not to exceed the recommended pressure and spraying distance. Future research should be carried out in surgery specialties for which only limited data were found, including neurological, gynaecological, oral and maxillofacial, urology, colorectal and orthopaedics surgery (for any outcome); breast surgery and upper gastrointestinal (development of haematoma); and cardiothoracic heart or lung surgery (reoperation rates). In addition, studies need to use adequate sample sizes, to blind participants and outcome assessors, and to follow reporting guidelines.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015020710.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A systematic methodological review of reported perioperative variables, postoperative outcomes and hernia recurrence from randomised controlled trials of elective ventral hernia repair: clear definitions and standardised datasets are needed

BACKGROUND

This systematic review assesses the perioperative variables and post-operative outcomes reported by randomised controlled trials (RCTs) of VH repair. This review focuses particularly on definitions of hernia recurrence and techniques used for detection.

OBJECTIVE

Our aim is to identify and quantify the inconsistencies in perioperative variable and postoperative outcome reporting, so as to justify future development of clear definitions of hernia recurrence and a standardised dataset of such variables.

METHODS

The PubMed database was searched for elective VH repair RCTs reported January 1995 to March 2016 inclusive. Three independent reviewers performed article screening, and two reviewers independently extracted data. Hernia recurrence, recurrence rate, timing and definitions of recurrence, and techniques used to detect recurrence were extracted. We also assessed reported post-operative complications, standardised operative outcomes, patient reported outcomes, pre-operative CT scan hernia dimensions, intra-operative variables, patient co-morbidity, and hernia morphology.

RESULTS

31 RCTs (3367 patients) were identified. Only 6 (19.3%) defined hernia recurrence and methods to detect recurrence were inconsistent. Sixty-four different clinical outcomes were reported across the RCTs, with wound infection (30 trials, 96.7%), hernia recurrence (30, 96.7%), seroma (29, 93.5%), length of hospital stay (22, 71%) and haematoma (21, 67.7%) reported most frequently. Fourteen (45%), 11 (35%) and 0 trials reported CT measurements of hernia defect area, width and loss of domain, respectively. No trial graded hernias using generally accepted scales.

CONCLUSION

VH RCTs report peri- and post-operative variables inconsistently, and with poor definitions. A standardised minimum dataset, including definitions of recurrence, is required.

Systematic review and network meta-analysis of methods of mesh fixation during laparoscopic ventral hernia repair

BACKGROUND

Ventral hernia repairs are common and have high recurrence rates. They are usually repaired laparoscopically with an intraperitoneal mesh, which can be fixed in various ways. The aim was to evaluate the recurrence rates for the different fixation techniques.

METHODS

This systematic review included studies with human adults with a ventral hernia repaired with an intraperitoneal onlay mesh. The outcome was recurrence at least 6 months after operation. Cohort studies with 50 or more participants and all RCTs were included. PubMed, Embase and the Cochrane Library were searched on 22 September 2016. RCTs were assessed with the Cochrane risk-of-bias assessment tool and cohort studies with the Newcastle-Ottawa scale. Studies comparing fixation techniques were included in a network meta-analysis, which allowed comparison of more than two fixation techniques.

RESULTS

Fifty-one studies with a total of 6553 participants were included. The overall crude recurrence rates with the various fixation techniques were: absorbable tacks, 17·5 per cent (2 treatment groups); absorbable tacks with sutures, 0·7 per cent (3); permanent tacks, 7·7 per cent (20); permanent tacks with sutures, 6·0 per cent (25); and sutures, 1·5 per cent (6). Six studies were included in a network meta-analysis, which favoured fixation with sutures. Although statistical significance was not achieved, there was a 93 per cent chance of sutures being better than one of the other methods.

CONCLUSION

Both crude recurrence rates and the network meta-analysis favoured fixation with sutures during laparoscopic ventral hernia repair.

Long-term follow-up results of umbilical hernia repair

Introduction

Multiple suture techniques and various mesh repairs are used in open or laparoscopic umbilical hernia (UH) surgery.

Aim

To compare long-term follow-up results of UH repair in different hernia surgery groups and to identify risk factors for UH recurrence.

Material and methods

A retrospective analysis of 216 patients who underwent elective surgery for UH during a 10-year period was performed. The patients were divided into three groups according to surgery technique (suture, mesh and laparoscopic repair). Early and long-term follow-up results including hospital stay, postoperative general and wound complications, recurrence rate and postoperative patient complaints were reviewed. Risk factors for recurrence were also analyzed.

Results

One hundred and forty-six patients were operated on using suture repair, 52 using open mesh and 18 using laparoscopic repair technique. 77.8% of patients underwent long-term follow-up. The postoperative wound complication rate and long-term postoperative complaints were significantly higher in the open mesh repair group. The overall hernia recurrence rate was 13.1%. Only 2 (1.7%) patients with small hernias (< 2 cm) had a recurrence in the suture repair group. Logistic regression analysis showed that body mass index (BMI) > 30 kg/m², diabetes and wound infection were independent risk factors for umbilical hernia recurrence.

Conclusions

The overall umbilical hernia recurrence rate was 13.1%. Body mass index > 30 kg/m², diabetes and wound infection were independent risk factors for UH recurrence. According to our study results, laparoscopic medium and large umbilical hernia repair has slight advantages over open mesh repair concerning early postoperative complications, long-term postoperative pain and recurrence.

Superiority of Roeder’s Knot for Fascial Mesh Fixation in a Cadaveric Model

Objective. This study compares the use of Roeder’s knot (1:3:1, 1 hitch, 3 winds, and 1 locking hitch) to the surgeon’s knot regarding the security of the knot and predictability of its position. Method. A polypropylene mesh was secured to the undersurface of the abdominal wall of a fresh frozen cadaver using tacks. Eight standardized transfascial sutures were performed. Four of them were secured with surgeon’s knot and the remaining 4 were tied with Roeder’s knot. A Mosquito hemostat was placed between the mesh and the stitch loop and the distance between its jaws was measured. We then created subcutaneous flap and measured the vertical distance between the knot and the anterior sheath. Results. When surgeon’s knot was used, the distance between the mesh and the stitch loop ranged between 4 and 6 mm. This distance could not be measured when Roeder’s knot was used due to inability to place hemostat between the mesh and the stitch loop. The vertical length between the anterior sheath and the surgeon knot ranged between 3 and 13 mm while remaining consistent at 2 mm when Roeder’s knot was applied. Conclusions. This study shows that Roeder’s knot is superior to the regular sliding knot in securing the mesh to the abdominal wall. It can be tightened appropriately and leads to less variation when used properly. It has many other applications that stem from its ability to be advanced with different degrees of tightness based on body habitus and the operative requirements.

Systematic review of intervention design and delivery in pragmatic and explanatory surgical randomized clinical trials

BACKGROUND

Surgical interventions are complex, with multiple components that require consideration in trial reporting. This review examines the reporting of details of surgical interventions in randomized clinical trials (RCTs) within the context of explanatory and pragmatic study designs.

METHODS

Systematic searches identified RCTs of surgical interventions published in 2010 and 2011. Included studies were categorized as predominantly explanatory or pragmatic. The extent of intervention details in the reports were compared with the CONSORT statement for reporting trials of non-pharmacological treatments (CONSORT-NPT). CONSORT-NPT recommends reporting the descriptions of surgical interventions, whether they were standardized and adhered to (items 4a, 4b and 4c). Reporting of the context of intervention delivery (items 3 and 15) and operator expertise (item 15) were assessed.

RESULTS

Of 4541 abstracts and 131 full-text articles, 80 were included (of which 39 were classified as predominantly pragmatic), reporting 160 interventions. Descriptions of 129 interventions (80.6 per cent) were provided. Standardization was mentioned for 47 (29.4 per cent) of the 160 interventions, and 22 articles (28 per cent) reported measurement of adherence to at least one aspect of the intervention. Seventy-one papers (89 per cent) provided some information about context. For one-third of interventions (55, 34.4 per cent), some data were provided regarding the expertise of personnel involved. Reporting standards were similar in trials classified as pragmatic or explanatory.

CONCLUSION

The lack of detail in trial reports about surgical interventions creates difficulties in understanding which operations were actually evaluated. Methods for designing and reporting surgical interventions in RCTs, contributing to the quality of the overall study design, are required. This should allow better implementation of trial results into practice.

Patient-centered outcomes following laparoscopic ventral hernia repair: a systematic review of the current literature

BACKGROUND

The purpose of this study was to systematically review patients who underwent laparoscopic ventral hernia repair (LVHR) and assess quality of life, pain, functionality, and patient satisfaction.

DATA SOURCES

MEDLINE, PubMed, and Cochrane database search identified 880 relevant articles. After the limits were applied, 14 articles were accepted for review. The analysis included health-related quality of life (HRQoL) measures including quality of life, pain, function, satisfaction, and mental and emotional well-being.

CONCLUSIONS

Fourteen studies were reviewed. Mean study size was 92.6 subjects (24 to 306) and mean defect size was 71.7 cm(2). LVHR improved the overall HRQoL in 6 of the 8 studies. Thirteen studies assessing pain demonstrated improved pain scores relative to preoperative levels and long-term follow up. LVHR was not associated with long-term pain. Functionality improved in 12 studies. Return to work ranged from 6 to 18 days postoperatively in 50% of studies and physical function scores improved in the remaining 50% of the studies. Patient satisfaction improved after LVHR in all studies assessing patient satisfaction. Fixation methods did not influence HRQoL. Laparoscopic repair was associated with improving mental and emotional well-being in 6 of the 7 studies.

Laparoscopic ventral hernia repair: is there an optimal mesh fixation technique? A systematic review

PURPOSE

The purpose of this study is to distinguish the optimal mesh fixation technique used in laparoscopic ventral hernia repair (LVHR). A particular fixation technique of the mesh to the abdominal wall is required, which should be strong enough to prevent migration of the mesh and, at the same time, keep injury to the abdominal wall minimal to prevent postoperative discomfort and pain.

METHODS

An extensive literature search was performed in the PubMed database from its onset until November 2012. All series of at least 30 patients operated by laparoscopy for a ventral hernia, with the use of a standardized surgical technique well-defined in the “Methods” section, and with a follow-up of at least 12 months were included. The series were categorized according to the technique of mesh fixation described: “tacks and sutures,” “tacks only,” and “sutures only.” For each treatment group, the recurrence rate was adjusted to the number of patients treated and the 95 % confidence interval was calculated. No overlap between two intervals was defined as a significant difference in recurrence rate.

RESULTS

A total of 25 series were included for statistical evaluation. Thirteen trials used both tacks and sutures, ten used only tacks, and two used only sutures. Overall recurrence rate was 2.7 % (95 % CI [1.9–3.4 %]).

CONCLUSION

None of the currently available mesh fixation techniques used for LVHR was found to be superior in preventing hernia recurrence as well as in reducing abdominal wall pain. The pain reported was remarkably high with all different fixation devices. Further research to develop solid and atraumatic fixation devices is warranted.

Fibrin sealants: surgical hemostat, sealant and adhesive

INTRODUCTION

Fibrin sealants (FS) have been approved for use in the United States since 1998. Since approval, they have been used in a wide variety of clinical settings and new products continue to be introduced.

AREAS COVERED

This review covers the literature supporting the USA FDA-approved indications for FS products produced by Baxter Corp. Literature review of PubMed, the Cochrane Library, FDA approval documents and product websites yielded information contained in this article. Mechanism of action, efficacy and safety of these products are covered.

EXPERT OPINION

FS are generally safe, popular and are used for a wide variety of off-label indications. Their use appears to be expanding rapidly. For many uses, including approved ones, large well-controlled trials are still needed. Additionally, cost-effectiveness data for these products would be a great benefit in guiding their future use.

Ultrasound biomicroscopy (UBM) and scanning acoustic microscopy (SAM) for the assessment of hernia mesh integration: a comparison to standard histology in an experimental model

BACKGROUND

Mesh integration is a key parameter for reliable and safe hernia repair. So far, its assessment is based on histology obtained from rare second-look operations or experimental research. Therefore, non-invasive high-resolution imaging techniques would be of great value. Ultrasound biomicroscopy (UBM) and scanning acoustic microscopy (SAM) have shown potential in the imaging of hard and soft tissues. This experimental study compared the detection of mesh integration, foreign body reaction and scar formation in UBM/SAM with standard histology.

MATERIALS AND METHODS

Ten titanized polypropylene meshes were implanted in rats in a model of onlay repair. 17 days postoperative animals were killed and samples were paraffin embedded for histology (H&E, Cresyl violet) or processed for postmortem UBM/SAM. The observation period was uneventful and meshes appeared well integrated.

RESULTS

Relocation of neighboring cross-sectional levels could easily be achieved with the 40-MHz UBM and granulation tissue could be distinguished from adjacent muscle tissue layers. The spatial resolution of approximately 8 μm of the 200-MHz UBM system images was comparable to standard histology (2.5-5× magnification) and allowed a clear identification of mesh fibers and different tissue types, e.g., scar, fat, granulation, and muscle tissues, as well as vessels, abscedations, and foreign body giant cell clusters.

CONCLUSION

This pilot study demonstrates the potential of high-frequency ultrasound to assess hernia mesh integration non-invasively. Although the methods lack cell-specific information, tissue integration could reliably be assessed. The possibility of conducting UBM in vivo advocates this method as a guidance tool for the indication of second-look operations and subsequent elaborate histological analyses.

Laparoscopic versus open elective repair of primary umbilical hernias: short-term outcomes from the American College of Surgeons National Surgery Quality Improvement Program

BACKGROUND

Approximately 175,000 umbilical hernia repairs are performed annually in the US. Controversy exists regarding the optimal approach for the elective repair of primary umbilical hernias.

OBJECTIVE

The objective of this study was to compare 30-day outcomes of elective primary open (OHR) and laparoscopic (LHR) umbilical hernia repairs, using a prospectively collected dataset.

METHODS

We performed a retrospective cohort study using the American College of Surgeons National Surgery Quality Improvement Program Participant Use Files during 2009 and 2010. Current Procedural Terminology and post-operative International Classification of Diseases, Ninth Revision diagnostic codes were used to identify primary umbilical hernia repairs. Primary outcomes included composite endpoints of 30-day mortality, and major and overall complications. Univariate analyses and multivariate logistic regression were performed controlling for relevant patient characteristics. Secondary outcomes included operative time and hospital length of stay (LOS).

RESULTS

Overall, 14,652 patients were identified-13,109 (89.5 %) OHR and 1543 (10.5 %) LHR. Univariate analyses of primary outcomes demonstrated similar 30-day morbidity and mortality between groups. In our multivariate model, however, after controlling for body mass index, gender, American Society of Anesthesiologists class, and chronic obstructive pulmonary disease, the odds ratio (OR) for overall complications favored LHR (OR 0.60; p = 0.01). This difference was driven primarily by the reduced wound complication rate in the LHR group [OR 0.41 (0.20, 0.78); p = 0.005]. LHR was associated with significantly longer operative time [57.7 min (SD 32.6) vs. 38.3 min (SD 22.9); p < 0.001], longer LOS [0.29 days (SD 0.68) vs. 0.17 days (SD 1.47); p = 0.001], and an increased rate of respiratory (0.52 vs. 0.10 %; p < 0.001) and cardiac (0.26 vs. 0.05 %; p = 0.005) complications.

CONCLUSIONS

This study identified potential decreased total and wound morbidity associated with LHR for elective primary umbilical hernia repairs at the expense of increased operative time, LOS, and respiratory and cardiac complications. These results should be considered within the context of a retrospective study with its inherent risks of bias and limitations.

A totally recombinant human fibrin sealant

BACKGROUND

Applications of plasma-derived human fibrin sealants (pdhFS) have been limited because of cost, limited supply of pathogen-screened plasma, the need for bioengineering improvements, and regulatory issues associated with federal approval. We describe a totally recombinant human fibrin sealant (rhFS), which may engender an abundant, safe, and cost-effective supply of efficacious fibrin sealant.

MATERIALS AND METHODS

A first-generation rhFS made from recombinant human fibrinogen (rhFI; produced in the milk of transgenic cows), activated recombinant human factor XIII (rhFXIIIa; produced in yeast), and recombinant human thrombin (rhFIIa; purchased, made in animal cell culture) was formulated using thromboelastography (TEG). The hemostatic efficacy of rhFS versus commercial pdhFS was compared in a nonlethal porcine hepatic wedge excision model.

RESULTS

The maximal clot strength of rhFS measured in vitro by TEG was not statistically different than that of pdhFS. TEG analysis also showed that the rhFS gained strength more quickly as reflected by a steeper α angle; however, the rhFS achieved this clot strength with a 5-fold lower factor I content than the pdhFS. When these fibrin sealants were studied in a porcine hepatic wedge excision model, the hemostatic scores of the rhFS were equivalent or better than that of the pdhFS.

CONCLUSIONS

The bioengineered rhFS had equivalent or better hemostatic efficacy than the pdhFS in a nonlethal hemorrhage model, despite the factor I concentration in the rhFS being about one-fifth that in the pdhFS. Because the rhFS is amenable to large-scale production, the rhFS has the potential to be more economical and abundant than the pdhFS, while having a decreased risk of blood-borne pathogen transmission.

Fibrin sealant for mesh fixation in laparoscopic umbilical hernia repair: 1-year results of a randomized controlled double-blinded study

PURPOSE

Fibrin sealant for mesh fixation has significant positive effects on early outcome after laparoscopic ventral hernia repair (LVHR) compared with titanium tacks. Whether fibrin sealant fixation also results in better long-term outcome is unknown.

METHODS

We performed a randomized controlled trial including patients with umbilical hernia defects from 1.5 to 5 cm at three Danish hernia centres. We used a 12 cm circular mesh. Participants were randomized to fibrin sealant or titanium tack fixation. Patients were seen in the outpatient clinic at 1 and 12 months follow-up.

RESULTS

Forty patients were included of whom 34 were available for intention to treat analysis after 1 year. There were no significant differences in pain, discomfort, fatigue, satisfaction or quality of life between the two groups at the 1-year follow-up. Five patients (26 %) in the fibrin sealant group and one (6 %) in the tack group were diagnosed with a recurrence at the 1-year follow-up (p = 0.182) (overall recurrence rate 17 %). Hernia defects in patients with recurrence were significantly larger than in those without recurrence (median 4.0 vs. 2.8 cm, p = 0.009).

CONCLUSION

Patients with larger hernia defects and fibrin sealant mesh fixation had higher recurrence rates than expected, although the study was not powered for assessment of recurrence. There was no significant difference between groups in any parameters after the 1-year follow-up. The beneficial effects of mesh fixation with fibrin sealant on early outcome warrant further studies on optimization of the surgical technique to prevent recurrence.

A Collective Review on Mesh-Based Repair of Umbilical and Epigastric Hernias

In accordance with the tension-free principles for other hernias, umbilical and epigastric hernia repair should probably be mesh-based. The number of randomized studies is increasing, most of them showing significantly less recurrences with the use of a mesh. Different devices are available and are applicable by several approaches. The objective of this review was to evaluate recent literature for the different types of mesh for umbilical and epigastric hernia repair and recurrences after mesh repair. A multi-database search was conducted to reveal relevant studies since 2001 reporting mesh-based repair of primary umbilical/epigastric hernia and their outcomes in adult patients. A total of 20 studies were included, 15 of them solely involved umbilical hernias, whereas the remaining studies included epigastric hernias as well. A median of 124 patients (range, 17-384) was investigated per study. Three quarters of the included studies had a follow-up of at least 2 years. Six studies described the results of laparoscopic approach, of which one reported a recurrence rate of 2.7 %; in the remaining studies, no recurrences occurred. Two comparative studies reported a lower incidence of complications and postoperative pain after laparoscopic repair compared to open repair. Seventeen studies reported results of open techniques, of which seven studies showed no recurrence. Other studies reported recurrence rates up to 3.1 %. A wide range of complication rates were reported (0-33 %). This collective review showed acceptable recurrence rates for mesh-based umbilical and epigastric hernia repair. A wide range of devices was investigated. A tendency toward more complications after laparoscopic repair was found compared to open repair.

Randomized clinical trial of mesh fixation with "double crown" versus "sutures and tackers" in laparoscopic ventral hernia repair

BACKGROUND

Although laparoscopic intra-peritoneal mesh repair (LVHR) is a well-established treatment option to repair ventral and incisional hernias, no consensus in the literature can be found on the best method of fixation of the mesh to the abdominal wall.

METHODS

Between December 2004 and July 2008, 76 patients undergoing a LVHR were randomized between mesh fixation using a double row of spiral tackers (DC) (n = 33) and mesh fixation with transfascial sutures combined with one row of spiral tackers (S&T) (n = 43), in the WoW trial (with or without sutures). Patients were clinically examined and evaluated using a visual analog scale for pain (VAS) in rest and after coughing 4 h post-operatively, after 4 weeks and 3 months after surgery. Primary endpoint of the study was abdominal wall pain, defined as a VAS score of at least 1.0 cm, at 3 months post-operative. Quality of life was quantified with the SF-36 questionnaire preoperatively and after 3 months. Secondary endpoint was the recurrence rate at 24-month follow-up.

RESULTS

The DC and S&T group were comparable in age, gender, ASA score, BMI, indication, hernia, and mesh variables. The DC group had a significant shorter operating time compared with the S&T group (74 vs 96 min; p = 0.014) and a significant lower mean VAS score 4 h post-operatively (in rest; p = 0.028/coughing; p = 0.013). At 3 months, there were significant more patients in the S&T group with VAS score ≥1.0 cm (31.4 vs 8.3 %; p = 0.036). Clinical follow-up at 24 months was obtained in 63 patients (82.9 %). The recurrence rate at 24 months was 7.9 % overall (5/63). There were more recurrences in the S&T group (4/36) than in the DC group (1/27), but this difference was not significant (11.1 vs 3.7 %; p = 0.381).

CONCLUSION

We found that double-crown fixation of intra-peritoneal mesh during laparoscopic ventral hernia repair was quicker, was less painful immediately post-operative and after 3 months, and did not increase the recurrence rate at 24 months. In hernias at a distance from the bony borders of the abdomen, transfascial sutures can be omitted if a double crown of tackers is placed.

Laparoscopic treatment of incisional hernia. State of the art in 2012

OBJECTIVE

The objective of this review is to evaluate the results of laparoscopic treatment of ventral hernias using intra-peritoneal prosthetic mesh through a review of published surgical series.

METHODS

All large series of patients treated for an incisional hernia by laparoscopy and published between 2002 and 2011 were identified. The results of controlled randomized series comparing this technique with open surgical repair were analyzed.

RESULTS

Twenty-two series with a total of 7057 patients were analyzed (range 51-1242); the mean Body Mass Index (BMI) was 32 (range: 28.5-46), and the mean size of the hernia defect was 10.6 cm (range: 6-14.9 cm). The mean rate of conversion to open surgical repair was 2.7%. Mean operative duration was 90 ± 33 minutes. Mortality was 0.8%, usually due to an unrecognized intestinal injury (1.6%), which occurred more frequently with second or iterative hernia repairs. Hospital stay averaged 2.5 days. The infection rate was 0.3% and the rate of hernia recurrence was 4.6% (with a mean follow-up of 36 months). No statistically significant differences were found in terms of post-operative complications or hernia recurrence in the randomized studies comparing laparoscopic to open anterior abdominal surgical repair. However, duration of hospital stay was shorter after laparoscopy in some studies.

CONCLUSION

Laparoscopic repair of ventral incisional hernia is technically feasible and reliable for large hernia defects, even in obese patients. This approach should be reserved for patients with no history of previous hernia repair in order to avoid the risk of intestinal injury. It appears to allow for a shortened duration of hospitalization.

Ventral hernia mesh tack causes liver hemorrhage

INTRODUCTION

The laparoscopic approach is an increasingly popular option for ventral hernia repair. In the wake of this new technology, unexpected complications have been reported.

CASE PRESENTATION

We present the case of a patient who developed a liver laceration and hemorrhage after a mesh tacking device partially dislodged subsequent to ventral hernia repair. The patient underwent exploratory laparotomy, liver hemostasis and removal of the offending tack.

DISCUSSION

Our patient partially dislodged a mesh tacking device likely after violent coughing during a bout of pneumonia. The exposed blade caused a liver laceration and hemorrhage. Few other unexpected complications of the use of mesh tacking devices have been noted in the literature. Tackless hernia repair has also been described.

CONCLUSION

Laparoscopic ventral hernia repair with tacks may have unexpected complications of which the surgeon should be aware and advise patients. Our patient developed a liver laceration and symptomatic hemorrhage after partially dislodging a hernia mesh tack. Further research into tackless hernia repair may be beneficial. A low long-term recurrence rate would demonstrate if tackless hernia repair is a viable option.

Evaluation of fibrin sealant for biologic mesh fixation at the hiatus in a porcine model

BACKGROUND

The ideal method to secure biologic mesh during laparoscopic hiatal hernia repair remains uncertain. Suture or tack fixation can be technically difficult, and serious cardiovascular complications have been reported. Fibrin sealant (FS) offers a potential solution to this problem. We hypothesized that FS provides comparable mesh fixation to suture repair during laparoscopic mesh hiatoplasty.

STUDY DESIGN

Using a porcine model, laparoscopic hiatal hernia repair was performed with suture reapproximation of the crura and reinforcement with an acellular porcine dermal matrix. Prior to repair, animals were randomized to mesh fixation with sutures (S) or FS. After 30-day survival, an esophagram was performed, the diaphragm harvested, and mesh position, fixation, and incorporation were evaluated histologically and biomechanically using a T-peel test.

RESULTS

Twenty (10 S and 10 FS) laparoscopic hiatal hernia repairs were performed. Total operative time was significantly less in the FS group (74.7 versus 127.0 min, p < 0.01). There were no instances of mesh migration in any animal. Mean peel force did not differ significantly between the S and FS groups (0.21 vs. 0.18 N/mm, respectively; p = 0.49). There was no significant difference in cellular repopularization or inflammatory changes around the mesh.

CONCLUSIONS

Fibrin sealant offers a reasonable alternative to suturing biologic mesh during laparoscopic hiatal hernia repair with equivalent mesh fixation. At 30 days it provides adhesive strength similar to suture fixation, while significantly reducing operative time.

Use of fibrin sealant (Tisseel/Tissucol) in hernia repair: a systematic review

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.