A comparison of a bovine albumin/glutaraldehyde glue versus fibrin sealant for hernia mesh fixation in experimental onlay and IPOM repair in rats

Bridging wounds: tissue adhesives' essential mechanisms, synthesis and characterization, bioinspired adhesives and future perspectives

Bioadhesives act as a bridge in wound closure by forming an effective interface to protect against liquid and gas leakage and aid the stoppage of bleeding. To their credit, tissue adhesives have made an indelible impact on almost all wound-related surgeries. Their unique properties include minimal damage to tissues, low chance of infection, ease of use and short wound-closure time. In contrast, classic closures, like suturing and stapling, exhibit potential additional complications with long operation times and undesirable inflammatory responses. Although tremendous progress has been made in the development of tissue adhesives, they are not yet ideal. Therefore, highlighting and summarizing existing adhesive designs and synthesis, and comparing the different products will contribute to future development. This review first provides a summary of current commercial traditional tissue adhesives. Then, based on adhesion interaction mechanisms, the tissue adhesives are categorized into three main types: adhesive patches that bind molecularly with tissue, tissue-stitching adhesives based on pre-polymer or precursor solutions, and bioinspired or biomimetic tissue adhesives. Their specific adhesion mechanisms, properties and related applications are discussed. The adhesion mechanisms of commercial traditional adhesives as well as their limitations and shortcomings are also reviewed. Finally, we also discuss the future perspectives of tissue adhesives.

Agentes hemostáticos tópicos em cirurgia: revisão e perspectivas

RESUMO A hemostasia tem papel crítico e importância fundamental em todos os procedimentos cirúrgicos. Seu manejo possui diversos pontos chaves, que se iniciam por boa técnica operatória e adequado suporte anestésico. Determinadas situações, como hemorragias graves resultantes de trauma penetrante, por exemplo, não dependem exclusivamente do controle da equipe cirúrgica e necessitam do apoio de novas soluções que diminuam ou controlem a hemorragia. Desde os tempos antigos, um marco da medicina é atuar no controle da hemorragia e, mais recentemente, na facilitação da hemostasia pela aplicação de agentes tópicos, seja por compressão manual ou agentes modernos. Na última década, o número de diferentes agentes hemostáticos tópicos cresceu drasticamente. Para que o cirurgião moderno escolha o agente correto no momento correto, é essencial que conheça o mecanismo de ação, entenda a eficácia e os possíveis efeitos adversos relacionados a cada agente. Assim, a grande variedade de hemostáticos tópicos, somada à ausência de um artigo de revisão na literatura nacional sobre este tópico, nos estimulou a elaborar este manuscrito. Aqui relatamos uma revisão detalhada sobre os agentes hemostáticos tópicos mais comumente utilizados nas especialidades cirúrgicas.

Emerging Trends in Abdominal Wall Reinforcement: Bringing Bio-Functionality to Meshes

Abdominal wall hernia is a recurrent issue world-wide and requires the implantation of over 1 million meshes per year. Because permanent meshes such as polypropylene and polyester are not free of complications after implantation, many mesh modifications and new functionalities have been investigated over the last decade. Indeed, mesh optimization is the focus of intense development and the biomaterials utilized are now envisioned as being bioactive substrates that trigger various physiological processes in order to prevent complications and to promote tissue integration. In this context, it is of paramount interest to review the most relevant bio-functionalities being brought to new meshes and to open new avenues for the innovative development of the next generation of meshes with enhanced properties for functional abdominal wall hernia repair.

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.

Small bowel lesion due to spiral tacks after laparoscopic intraperitoneal onlay mesh repair for incisional hernia

INTRODUCTION

Laparoscopic intraperitoneal onlay mesh (IPOM) repair has become a widely accepted operative technique for incisional hernias. However, tack fixation poses the risk of adhesions and injury to the intestine. We report the case of spiral tacks adherent to the small bowel after IPOM repair for incisional hernia.

PRESENTATION OF CASE

64 years old male patient who underwent laparoscopic IPOM repair for incisional hernia 1 year after open sigmoid resection. A laminated polypropylene mesh was fixed with titanium spiral tacks. 4 years later, elective open cholecystectomy was performed. Two spiral tacks integrated in the seromusular layer of the small bowel were encountered. Tacks were removed and bowel lesions oversewn with interrupted seromuscular stitches.

DISCUSSION

According to the current literature, complications related to metal spiral tacks in IPOM mesh repair such as intestinal perforation or strangulation ileus seem to be rare. To our knowledge, spiral tacks adherent to the intestine have not yet been published to date. Alternative techniques for mesh fixation are transfascial sutures with single stitches, continuous sutures or fibrin glue, as already used in TAPP and TEP procedures for inguinal hernia repair. The ideal and safest technique for mesh fixation in IPOM repair for incisional hernias remains controversial.

CONCLUSION

Spiral tacks used for intraperitoneal mesh fixation can lead to adhesions and bowel lesions. Sutures, absorbable tacks or fibrin glue are alternatives for mesh fixation. Further clinical trials are needed to evaluate the safest technique of laparoscopic IPOM incisional hernia repair.

Biomechanical properties of (semi-) synthetic glues for mesh fixation in endoscopic inguinal hernia repair

PURPOSE

In endoscopic inguinal hernia repair, the use of fibrin glues for mesh fixation instead of staples and sutures can demonstrably reduce postoperative morbidity without increasing the recurrence rate. Various fibrin glues differ in terms of their mesh fixation strength. As an alternative to fibrin glue, there is an increasing trend toward using synthetic glues for mesh fixation in both open and endoscopic inguinal hernia surgery. To date, no studies have been conducted comparing the fixation strength of (semi-) synthetic glues with that of fibrin glues. Here, using a biomechanical model, we compared the adhesive strength of two glues (BioGlue and Glubran) used in surgery with a fibrin glue.

METHODS

We used light-weight polypropylene meshes (TiMesh light). In each case, the biomechanical stability of five meshes in each group was tested with 2 ml fibrin glue (Evicel), 2 ml BioGlue or 2 ml Glubran (cyanoacrylate). The defect in the muscle tissue used was 4.5 cm in diameter for a mesh size of 10 × 15 cm. Measurements were taken using a standardized stamp penetration test while aiming not to remain under a minimum fixation strength of 32 N.

RESULTS

Using Evicel for mesh fixation, an adhesive strength of 64.3 N was achieved. This was significantly greater than that obtained in the absence of fixation (2.9 N, p < 0.001) and higher than the requisite value of 32 N. Using Glubran, it was possible once again to significantly improve the adhesive strength (105.4 N, p = 0.008). The use of BioGlue improved the adhesive strength to 131.7 N, but not significantly so compared with Glubran (p = 0.110).

CONCLUSIONS

In terms of adhesive strength, (semi-) synthetic glues can be used for mesh fixation instead of fibrin glue and even achieve significantly better adhesive strength than fibrin glue. However, further clinical studies are needed to identify the role of (semi-) synthetic glues compared with fibrin glues in endoscopic inguinal hernia surgery.

Novel technique of overlaying a poly-L: -lactic acid nanosheet for adhesion prophylaxis and fixation of intraperitoneal onlay polypropylene mesh in a rabbit model

BACKGROUND

One problem with polypropylene mesh (PPM) used to repair abdominal wall hernias is dense adhesions to the visceral surface. The authors developed the biocompatible poly-L: -lactic acid (PLLA) nanosheet (thickness < 100 nm), which has the unique ability to adhere tightly to tissues but not to opposing tissues. This study investigated the antiadhesive and fixative characteristics of the PLLA nanosheet after placement of intraperitoneal onlay PPM (IPOM) overlaid with a PLLA nanosheet on intact peritoneum.

METHODS

The PLLA nanosheet was fabricated by the spin-coating method and peeling technique with polyvinyl alcohol (PVA) as a supporting film. Two 1.5-cm-square pieces of mesh were implanted on each peritoneal side of the midline incision. The mesh was fixed to the peritoneum with a suture and then overlaid with a 4-cm-square piece of Seprafilm or nanosheet. To examine the fixative property, mesh was overlaid with Seprafilm or nanosheet without a fixed suture. After 4 weeks, mesh adhesion, inflammatory reaction, fixation, and dislocation of mesh were evaluated.

RESULTS

Nanosheet-overlaid meshes were flexible and fit over the peritoneum. Adhesion was observed in 10% of the nanosheet-overlaid meshes and in 50% of the Seprafilm-overlaid meshes. The adhesion tenacity grade was significantly lower with the nanosheet-overlaid meshes (0.1 ± 0.1) than with the Seprafilm-overlaid meshes (1.0 ± 0.4) (p = 0.029), and the percentage of the adhesion area also was lower with the nanosheet-overlaid meshes (1.0 ± 1.0% vs 8.5 ± 3.2%; p = 0.037). The mean inflammatory cell counts were lower with the nanosheet-overlaid meshes (p = 0.0023). Regarding the fixative property, 37.5% of the nanosheet-overlaid meshes were fixated on the peritoneum, but no Seprafilm-overlaid mesh was fixated.

CONCLUSION

Overlaying of a PLLA nanosheet was effective for adhesion prophylaxis of intraperitoneal mesh. It also may have a possible beneficial effect on fixation of mesh.