Laparoscopic intraperitoneal mesh fixation with fibrin sealant (Tisseel®) vs. titanium tacks: a randomised controlled experimental study in pigs

Laparoscopic Intraperitoneal Onlay Mesh (IPOM) in the Treatment of Ventral Hernias: Technique Discussion Points

Incisional ventral hernias (IVH) are a common occurrence worldwide. The resolve is fundamentally surgical. In this regard, laparoscopic treatment has become the standard. This paper aims to review intraperitoneal onlay mesh (IPOM) as a surgical solution for IVH and to explore the limitations and advantages in relation to the technique of mesh fixation, defect suture, seroma formation, and recurrence in accordance with the data published. The article is structured as a narrative review and relies on the Scale for the Assessment of Narrative Review Articles (SANRA) convention. In the analysis, we included articles published in the literature regarding the surgical treatment of ventral hernias (umbilical and incisional) through the IPOM technique. We explored data regarding the mesh fixation technique on the anterior abdominal wall (tacks or sutures), indications and limitations of defect closure, incidence of seroma formation, and recurrence rate. Laparoscopic IPOM is a better option for IVH up to 10 cm than the open technique with regard to aesthetics, length of hospital stay, and postoperative pain. There is no difference in recurrence rates. Suturing of the defect should be done to decrease seroma formation and maintain the functionality of the abdominal wall. Ideally, the suture should be done intraperitoneally or laparoscopically. Regarding pain in mesh fixation, there seems to be an increase in the short-term postoperative pain in the suture groups, but at six months, when compared to the tacks groups, there is no difference. New methods are being developed that include different types of glue but require large prospective, randomized trials if they are to be included in the guidelines.

Synthesis and Evaluation of Metal Lipoate Adhesives

The development of new bioadhesives with integrated properties remains an unmet clinical need to replace staples or sutures. Current bioadhesives do not allow electronic activation, which would allow expansion into laparoscopic and robotic surgeries. To address this deficiency, voltage-activated adhesives have been developed on both carbene- and catechol-based chemical precursors. Herein, a third platform of voltage-activated adhesive is evaluated based on lipoic acid, a non-toxic dithiolane found in aerobic metabolism and capable of ring-opening polymerization. The electro-rheological and adhesive properties of lithium, sodium, and potassium salts of lipoic acid are applied for wet tissue adhesion. At ambient conditions, potassium lipoate displays higher storage modulus than lithium or sodium salt under similar conditions. Voltage stimulation significantly improves gelation kinetics to Na- and K-lipoates, while Li-lipoate is found to not require voltage stimulation for gelation. Lap shear adhesion strength on wetted collagen substrates reveals that the synthetic metal lipoates have comparable adhesion strength to fibrin sealants without viral or ethical risks.

Synthetic Pressure Sensitive Adhesives for Biomedical Applications

Pressure sensitive adhesives are components of everyday products found in homes, offices, industries, and hospitals. Serving the general purpose of fissure repair and object fixation, pressure sensitive adhesives indiscriminately bind surfaces, as long as contact pressure is administered at application. With that being said, the chemical and material properties of the adhesive formulation define the strength of a pressure sensitive adhesive to a particular surface. Given our increased understanding of the viscoelastic material requirements as well as the intermolecular interactions at the binding interface required for functional adhesives, pressure sensitive adhesives are now being explored for greater use. New polymer formulations impart functionality and degradability for both internal and external applications. This review highlights the structure-property relationships between polymer architecture and pressure sensitive adhesion, specifically for medicine. We discuss the rational, molecular-level design of synthetic polymers for durable, removable, and biocompatible adhesion to wet surfaces like tissue. Finally, we examine prevalent challenges in biomedical wound closure and the new, innovative strategies being employed to address them. We conclude by summarizing the progress of current research, identifying additional clinical opportunities, and discussing future prospects.

Multifunctional Dual Cross-Linked Bioadhesive Patch with Low Immunogenic Response and Wet Tissues Adhesion

The development of bioadhesives is an important, yet challenging task as seemingly mutually exclusive properties need to be combined in one material, that is, strong adhesion, water resistance, and high biocompatibility. Here, a biocompatible and biodegradable protein-based bioadhesive patch (PBP) with high adhesion strength and low immunogenic response is reported. PBP exists as a strong adhesion for biological surfaces, which is higher than some conventional bioadhesives (i.e., polyethylene glycol and fibrin). Robust adhesion and strength are realized through the removal of interfacial water and fast formation of multiple supramolecular interactions induced by metal ions. The PBP's high biocompatibility is evaluated and immunogenic response in vitro and in vivo is neglected. The strong adhesion on soft biological tissues qualifies the PBP as biomedical glue outperforming some commercial products for applications in hemostasis performance, accelerated wound healing, and sealing of defected organs, anticipating to be useful as a tissue adhesive and sealant.

Safety and efficacy of absorbable and non-absorbable fixation systems for intraperitoneal mesh fixation: an experimental study in swine

PURPOSE

Choice of the best possible fixation system in terms of safety and effectiveness for intraperitoneal mesh placement in hernia surgery remains controversial. The aim of the present study was to compare the performance of four fixation systems in a swine model of intraperitoneal mesh fixation.

METHODS

Fourteen Landrace swine were utilized in the study. The experiment included two stages. Initially, four pieces of mesh (Ventralight ™ ST) sizing 10 × 5 cm were placed and fixed intraperitoneally to reinforce 4 small full thickness abdominal wall defects created with diathermy. These defects were repaired primarily with absorbable suture before mesh implantation. Each mesh was anchored with a different tack device between Absorbatack™, Protack™, Capsure™, or Optifix™. The second stage took place after 60 days and included euthanasia, laparoscopy, and laparotomy via U-shaped incision to obtain the measurements for the outcome parameters. The primary endpoint of the study was to compare the peel strength of the compound tack/mesh from the abdominal wall. Secondary parameters were the extent and quality of visceral adhesions to the mesh, the degree of mesh shrinkage and the histological response around the tacks.

RESULTS

Thirteen out of 14 animals survived the experiment and 10 were included in the final analysis. Capsure™ tacks had higher peel strength when compared to Absorbatack™ (p = 0.028); Protack™ (p = 0.043); and Optifix™ (p = 0.009). No significant differences were noted regarding the extent of visceral adhesions (Friedman's test p value 0.854), the adhesion quality (Friedman's test p value 0.506), or the mesh shrinkage (Friedman's test p value = 0.827). Four out of the ten animals developed no adhesions at all 2 months after implantation.

CONCLUSION

Capsure™ fixation system provided higher peel strength that the other tested devices in our swine model of intraperitoneal mesh fixation. Our findings generate the hypothesis that this type of fixation may be superior in a clinical setting. Clinical trials with long-term follow-up are required to assess the safety and efficacy of mesh fixation systems in hernia surgery.

Laparoscopic fixation of biological mesh at hiatus with glue and suture during hiatal hernia repair

BACKGROUND

Laparoscopic paraesophageal hernia repair is associated with higher recurrence rate. Mesh is used to reduce the recurrence rate. This retrospective study is to review our experience of biological mesh fixed with suture and medical glue in hiatal hernias repairs.

METHODS

A retrospective chart review was conducted for a consecutive series of patients undergoing laparoscopic hiatal herniorrhaphy between January 2018 and January 2019. After hiatus closure, a piece of biological prosthesis was fixed with medical glue and suture for reinforcement of the crural closure. Clinical outcomes were reviewed, and data were collected regarding operative details, complications, symptoms, and follow-up imaging. Radiological evidence of any size of hiatal hernia was considered to indicate a recurrence.

RESULTS

Thirty-six patients underwent surgery uneventfully without any serious complication. There was no mortality. The follow-up was, on average, 18.4 months, and there was no symptomatic recurrence. There was one anatomical recurrence without any related presentation. The method of mesh fixation with medical glue and suture took 12 min on average, and the handling was fairly easy.

CONCLUSIONS

Biological mesh fixed with suture and medical glue was safe and effective for repairing large hiatal hernias. Of course, a longer follow-up is still needed for determining long-term outcomes.

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.

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.

Multifunctional Biomedical Adhesives

Currently available biomedical adhesives are mainly engineered to have one function (i.e., providing mechanical support for the repaired tissue). To improve the performance of existing bioadhesives and broaden their applications in medicine, numerous multifunctional bioadhesives are reported in the literature. These adhesives can be categorized as passive or active by design. Passive multifunctional bioadhesives contain inherent compositions and structural designs that can carry out additional functions without added external influences. These adhesives exhibit new functionalities such as antimicrobial properties, self-healing abilities, the ability to promote cellular ingrowth, and the ability to be reshaped. Conversely, active multifunctional bioadhesives respond to environmental changes (e.g., pH, temperature, electricity, light, and biomolecule concentration), which initiate a change in the adhesive to release encapsulated drugs or to activate or deactivate the bioadhesive for interfacial binding. This review article highlights recent advances in multifunctional bioadhesives.

Absorbable versus non-absorbable tacks for mesh fixation in laparoscopic ventral hernia repair: A systematic review and meta-analysis

OBJECTIVES

To investigate the outcomes of absorbable versus non-absorbable tacks in patients undergoing laparoscopic ventral hernia repair.

METHODS

We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. We conducted a search of electronic information sources, including MEDLINE; EMBASE; CINAHL; the Cochrane Central Register of Controlled Trials (CENTRAL); the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; and ISRCTN Register, and bibliographic reference lists to identify all randomised controlled trials (RCTs) and observational studies investigating outcomes of absorbable versus non-absorbable tacks for mesh fixation in patients undergoing laparoscopic ventral hernia repair. We used the Cochrane risk of bias tool and the Newcastle-Ottawa scale to assess the risk of bias of RCTs and observational studies, respectively. Fixed-effect or random-effects models were applied to calculate pooled outcome data.

RESULTS

We identified three RCTs and two observational studies enrolling a total of 1149 patients. The included patients were comparable in terms of age [Mean difference (MD) 0.28, 95% confidence intervals (CI) -1.45-2, P = 0.75], male gender (MD 0.81, 95% CI 0.63-1.04, P = 0.10), body mass index (MD -041, 95% CI -1.28-0.46, P = 0.36) and hernia defect size (MD 0.12, 95% CI -0.26-0.49, P = 0.54). The mean and median follow-up period was 30 months and 13 months, respectively There was no difference between the two mesh fixation techniques in terms of recurrence [Risk difference (RD) 0.03, 95% CI -0.04, 0.09, P = 0.47], chronic pain [Odds ratio (OR) 0.91, 95% CI 0.62-1.33, P = 0.64], seroma (OR 0.98, 95% CI 0.37-2.60, P = 0.96), haematoma (RD -0.00, 95% CI -0.04- 0.04, P = 0.99), prolonged ileus (OR 0.99, 95% CI 0.24-4.03, P = 0.99), length of hospital stay (MD 0.10, 95% CI -0.36-0.56, P = 0.68) and port-site hernia (OR 0.98, 95% CI 0.13-7.16, P = 0.98). The operative time was longer in absorbable tack group (MD 7.53, 95% CI 1.49-13.58, P = 0.01). The results remain consistent when randomised trials were analysed separately.

CONCLUSIONS

We found no difference in clinical outcomes between absorbable and non-absorbable tacks for mesh fixation in patients undergoing laparoscopic ventral hernia repair. The quality of the available evidence is moderate with a possibility of type 2 error. High quality RCTs with adequate statistical power are required to provide more robust basis for definite conclusions. Considering the similarity of both techniques in terms of clinical outcomes, the cost-effectiveness of each technique would be an important outcome determining which technique should be used; this needs to be considered as an outcome of interest in future studies.

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.

Surgical treatment of large incisional hernias with intraperitoneal composite mesh: a cohort study

PURPOSE

Patients with large incisional hernias have significant morbidity and their management is a challenge for the surgical team because of the large abdominal wall involvement. The choice of surgical technique is still controversial. The purpose of this study is to analyze the predictive factors for recurrence after intraperitoneal mesh repair in patients with large incisional hernias.

METHODS

A retrospective cohort observational study with a prospectively collected database was performed in the Hospital Clinico San Carlos (Madrid, Spain). All consecutive patients operated on from January 2009 to December 2014 with incisional hernia of 10 or more centimeters in its transverse diameter were included. An intraperitoneal repair with a composite mesh fixed with discontinuous absorbable suture and fibrin sealant was performed. Demographic data, comorbidities, and early and long term outcomes were analyzed. The primary outcome was the presence of recurrence.

RESULTS

One hundred and twenty patients were included. Mean age was 63.3 years (SD 12.9) and sex ratio was 1.4:1. Seventy-two patients (60%) were ASA III-IV. Forty-five patients (37.5%) had recurrent ventral hernias. Mean defect size was 14.7 cm (SD 3.21) of width. Overall postoperative morbidity rate was 25%. Median hospital stay was 6 days (IQR 4-8). Recurrence rate was 8.3%, after a median follow-up of 16 months (IQR 10-25). Multivariate analysis showed significant association between ASA III-IV, use of Composix Kugel™ mesh, superficial surgical site infection, and the presence of recurrence.

CONCLUSIONS

The recurrence rate after intraperitoneal mesh repair in patients with large incisional hernias might be associated with ASA III-IV, use of Composix Kugel™ mesh, and superficial surgical site infection.

Parietex™ Composite mesh versus DynaMesh®-IPOM for laparoscopic incisional and ventral hernia repair: a retrospective cohort study

INTRODUCTION Laparoscopic incisional and ventral hernia repair (LIVHR) is widely accepted and safe but the type of mesh used is still debated. We retrospectively compared postoperative outcomes with two different meshes commonly used in LIVHR. METHODS This is a retrospective study of patients who underwent incisional hernia repair between January 2008 and December 2010. Two meshes were used: Parietex™ Composite (Covidien, New Haven, CT, USA) and the DynaMesh®-IPOM (FEG Textiltechnik mbH, Aachen, Germany). The two groups were compared with respect to recurrence rates, incidence of seroma and intestinal obstruction. RESULTS Among the 88 patients who underwent LIVHR, 75 patients (85.2%) presented with primary incisional hernia, 10 (11.4%) presented with a first recurrence and 3 (3.4%) presented with a second recurrence. Median follow-up was 53.6 months (range 40-61 months). 12.9% of patients had recurrence in the Parietex™ Composite mesh group (n=62) in comparison to 3.8% in the DynaMesh®-IPOM mesh group (n=26; P=0.20). DynaMesh®-IPOM was associated with a significantly higher incidence of intestinal obstruction secondary to adhesions (11.5% vs. 0%, P=0.006) and lower incidence of seroma and haematoma formation compared to Parietex™ composite mesh group (0% vs. 6.4% of patients; P=0.185). CONCLUSIONS LIVHR is a safe and feasible technique. Dynamesh®-IPOM is associated with a significantly higher incidence of adhesion related bowel obstruction, albeit with a lower incidence of recurrence, seroma and haematoma formation compared with Parietex™ Composite mesh. However, there is a need for further well-designed, multicentre randomised controlled studies to investigate the use of these meshes.

Staple Line Coverage with a Polyglycolic Acid Patch and Fibrin Glue without Pleural Abrasion after Thoracoscopic Bullectomy for Primary Spontaneous Pneumothorax

Background

This study was conducted to determine the efficacy of staple line coverage using a polyglycolic acid patch and fibrin glue without pleural abrasion to prevent recurrent postoperative pneumothorax.

Methods

A retrospective analysis was carried out of 116 operations performed between January 2011 and April 2013. During this period, staple lines were covered with a polyglycolic acid patch and fibrin glue in 58 cases (group A), while 58 cases underwent thoracoscopic bullectomy only (group B).

Results

The median follow-up period was 33 months (range, 22 to 55 months). The duration of chest tube drainage was shorter in group A (group A 2.7±1.2 day vs. group B 3.9±2.3 day, p=0.001). Prolonged postoperative air leakage occurred more frequently in group B than in group A (43% vs. 19%, p=0.005). The postoperative recurrence rate of pneumothorax was significantly lower in group A (8.6%) than in group B (24.1%) (p=0.043). The total cost of treatment during the follow-up period, including the cost for the treatment of postoperative recurrent pneumothorax, was not significantly different between the two groups (p=0.43).

Conclusion

Without pleural abrasion, staple line coverage with a medium-sized polyglycolic acid patch and fibrin glue after thoracoscopic bullectomy for primary spontaneous pneumothorax is a useful technique that can reduce the duration of postoperative pleural drainage and the postoperative recurrence rate of pneumothorax.

Radical-Mediated Enzymatic Polymerizations

Polymerization reactions are commonly effected by exposing monomer formulations to some initiation stimulus such as elevated temperature, light, or a chemical reactant. Increasingly, these polymerization reactions are mediated by enzymes--catalytic proteins--owing to their reaction efficiency under mild conditions as well as their environmental friendliness. The utilization of enzymes, particularly oxidases and peroxidases, for generating radicals via reduction-oxidation mechanisms is especially common for initiating radical-mediated polymerization reactions, including vinyl chain-growth polymerization, atom transfer radical polymerization, thiol-ene step-growth polymerization, and polymerization via oxidative coupling. While enzyme-mediated polymerization is useful for the production of materials intended for subsequent use, it is especially well-suited for in situ polymerizations, where the polymer is formed in the place where it will be utilized. Such polymerizations are especially useful for biomedical adhesives and for sensing applications.

Titanium versus absorbable tacks comparative study (TACS): a multicenter, non-inferiority prospective evaluation during laparoscopic repair of ventral and incisional hernia: study protocol for randomized controlled trial

BACKGROUND

Laparoscopic repair of ventral and incisional hernias has gained popularity since many studies have reported encouraging results in terms of outcomee and recurrence. Choice of mesh and fixation methods are considered crucial issues in preventing recurrences and complications. Lightweight meshes are considered the first choice due to their biomechanical properties and the ability to integrate into the abdominal wall. Titanium helicoidal tacks still represent the "gold standard" for mesh fixation, even if they have been suggested to be involved in the genesis of post-operative pain and complications. Recently, absorbable tacks have been introduced, under the hypothesis that there will be no need to maintain a permanent fixation device after mesh integration. Nevertheless, there is no evidence that absorbable tacks may guarantee the same results as titanium tacks in terms of strength of fixation and recurrence rates. The primary end point of the present trial is to test the hypothesis that absorbable tacks are non-inferior to titanium tacks in laparoscopic incisional and ventral hernia repair (LIVHR) by lightweight polypropylene mesh, in terms of recurrence rates at 3-year follow-up. Surgical complications, post-operative stay, comfort and pain are secondary end points to be assessed.

METHODS/DESIGN

Two hundred and twenty patients with ventral hernia will be randomized into 2 groups: Group A (110) patients will be submitted to LIVHR by lightweight polypropylene mesh fixed by titanium tacks; Group B (110) patients will be submitted to LIVHR by lightweight polypropylene mesh fixed by absorbable tacks.

DISCUSSION

A few retrospective studies have reported similar results when comparing absorbable versus non-absorbable tacks in terms of intraoperative and early post-operative outcomes. These studies have the pitfalls to be retrospective evaluation of small series of patients, and the reported results still need to be validated by larger series and prospective studies. The aim of the present trial is to investigate and test the non-inferiority of absorbable versus non-absorbable tacks in terms of hernia recurrence rates, in order to assess whether the use of absorbable tacks may achieve the same results as non-absorbable tacks in mid-term and long-term settings.

TRIAL REGISTRATION NUMBER

NCT02076984: 5 June 2014 (ClinicalTrials.gov).

Recurrence rate after absorbable tack fixation of mesh in laparoscopic incisional hernia repair

Background

The mesh fixation technique in laparoscopic incisional hernia repair may influence the rates of hernia recurrence and chronic pain. This study investigated the long-term risk of recurrence and chronic pain in patients undergoing laparoscopic incisional hernia repair with either absorbable or non-absorbable tacks for mesh fixation.

Methods

This was a nationwide consecutive cohort study based on data collected prospectively concerning perioperative information and clinical follow-up. Patients undergoing primary, elective, laparoscopic incisional hernia repair with absorbable or non-absorbable tack fixation during a 4-year interval were included. Follow-up was by a structured questionnaire regarding recurrence and chronic pain, supplemented by clinical examination, and CT when indicated. Recurrence was defined as either reoperation for recurrence or clinical/radiological recurrence.

Results

Of 1037 eligible patients, 84·9 per cent responded to the questionnaire, and 816 were included for analysis. The median observation time for the cohort was 40 (range 0–72) months. The cumulative recurrence-free survival rate was 71·5 and 82·0 per cent after absorbable and non-absorbable tack fixation respectively (P = 0·007). In multivariable analysis, the use of absorbable tacks was an independent risk factor for recurrence (hazard ratio 1·53, 95 per cent c.i. 1·11 to 2·09; P = 0·008). The rate of moderate or severe chronic pain was 15·3 and 16·1 per cent after absorbable and non-absorbable tack fixation respectively (P = 0·765).

Conclusion

Absorbable tack fixation of the mesh was associated with a higher risk of recurrence than non-absorbable tacks for laparoscopic mesh repair of incisional hernia, but did not influence chronic pain.

Injectable dopamine-modified poly(ethylene glycol) nanocomposite hydrogel with enhanced adhesive property and bioactivity

A synthetic mimic of mussel adhesive protein, dopamine-modified four-armed poly(ethylene glycol) (PEG-D4), was combined with a synthetic nanosilicate, Laponite (Na(0.7+)(Mg5.5Li0.3Si8)O20(OH)4)(0.7-)), to form an injectable naoncomposite tissue adhesive hydrogel. Incorporation of up to 2 wt % Laponite significantly reduced the cure time while enhancing the bulk mechanical and adhesive properties of the adhesive due to strong interfacial binding between dopamine and Laponite. The addition of Laponite did not alter the degradation rate and cytocompatibility of PEG-D4 adhesive. On the basis of subcutaneous implantation in rat, PEG-D4 nanocomposite hydrogels elicited minimal inflammatory response and exhibited an enhanced level of cellular infiltration as compared to Laponite-free samples. The addition of Laponite is potentially a simple and effective method for promoting bioactivity in a bioinert, synthetic PEG-based adhesive while simultaneously enhancing its mechanical and adhesive properties.

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.

Oxygen-Mediated Enzymatic Polymerization of Thiol-Ene Hydrogels

Materials that solidify in response to an initiation stimulus are currently utilized in several biomedical and surgical applications; however, their clinical adoption would be more widespread with improved physical properties and biocompatibility. One chemistry that is particularly promising is based on the thiol-ene addition reaction, a radical-mediated step-growth polymerization that is resistant to oxygen inhibition and thus is an excellent candidate for materials that polymerize upon exposure to aerobic conditions. Here, thiol-ene-based hydrogels are polymerized by exposing aqueous solutions of multi-functional thiol and allyl ether PEG monomers, in combination with enzymatic radical initiating systems, to air. An initiating system based on glucose oxidase, glucose, and Fe²⁺ is initially investigated where, in the presence of glucose, the glucose oxidase reduces oxygen to hydrogen peroxide which is then further reduced by Fe²⁺ to yield hydroxyl radicals capable of initiating thiol-ene polymerization. While this system is shown to effectively initiate polymerization after exposure to oxygen, the polymerization rate does not monotonically increase with raised Fe²⁺ concentration owing to inhibitory reactions that retard polymerization at higher Fe²⁺ concentrations. Conversely, replacing the Fe²⁺ with horseradish peroxidase affords an initiating system is that is not subject to the iron-mediated inhibitory reactions and enables increased polymerization rates to be attained.

Physical and mathematical modelling of implant-fascia system in order to improve laparoscopic repair of ventral hernia

BACKGROUND

This paper describes an investigation of biomechanical behaviour of hernia repair, which is focused on the selection of safe linking of certain type of implant with fascia in laparoscopic operation. The strength of various fixations of the implant to the fascia is analysed.

METHODS

The research is based on experimental observations of operated hernia model behaviour during a dynamic impulse load corresponding to post-operative cough. Fifty seven different types of models of implanted mesh are considered. Five types of implants and five types of connectors are used. Mechanical properties of the implants as well as limit tearing forces of joints are identified in uni-axial tensile tests. Mathematical model of implanted mesh based on finite element method is proposed. The identified mechanical properties of the materials are applied and the model is calibrated using quantities measured during experiments.

FINDINGS

The presented results point at trans-abdominal sutures and ProTacks (connectors) and at DynaMesh (implant) as the most reliable materials used in ventral hernia operation, in the tested materials group. Desired properties of implants seem to be: elastic properties similar to the properties of tissues and high local strength, as fixation have a local character. The proposed mathematical model can be applied to simulate real behaviour of an implant with appropriate accuracy and to estimate the number of tacks for the implantation of hernia meshes.

INTERPRETATION

The presented results may help in the deeper understanding of the fascia-mesh system behaviour, and thus may lead to improve the fixation methods.

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 systematic review of randomised control trials assessing mesh fixation in open inguinal hernia repair

PURPOSE

The technique for fixation of mesh has been attributed to adverse patient and surgical outcomes. Although this has been the subject of vigorous debate in laparoscopic hernia repair, the several methods of fixation in open, anterior inguinal hernia repair have seldom been reviewed. The aim of this systematic review was to determine whether there is any difference in patient-based (recurrence, post-operative pain, SSI, quality of life) or surgical outcomes (operative time, length of operative stay) with different fixation methods in open anterior inguinal hernioplasty.

METHODS

A literature search was performed in PubMed, EMBASE and the Cochrane Library databases. Randomised clinical trials assessing more than one method of mesh fixation (or fixation versus no fixation) of mesh in adults (>18 years) in open, anterior inguinal hernia repair, with a minimum of 6-month follow-up and including at least one of the primary outcome measures (recurrence, chronic pain, surgical site infection) were included in the review. Secondary outcomes analysed included post-operative pain (within the first week), quality of life, operative time and length of hospital stay.

RESULTS

Twelve randomised clinical trials, which included 1,992 primary inguinal hernia repairs, were eligible for inclusion. Four studies compared n-butyl-2 cyanoacrylate (NB2C) glues to sutures, two compared self-fixing meshes to sutures, four compared fibrin sealant to sutures, one compared tacks to sutures, and one compared absorbable sutures to non-absorbable sutures. The majority of the trials were rated as low or very low-quality studies. There was no significant difference in recurrence or surgical site infection rates between fixation methods. There was significant heterogeneity in the measurement of chronic pain. Three trials reported significantly lower rates of chronic pain with fibrin sealant or glue fixation compared to sutures. A further three studies reported lower pain rates within the first week with non-suture fixation techniques compared to suture fixation. A significant reduction in operative time, ranging form 6 to 17.9 min with non-suture fixation, was reported in five of the studies. Although infrequently measured, there were no significant differences in length of hospital stay or quality of life between fixation methods.

CONCLUSIONS

There is insufficient evidence to promote fibrin sealant, self-fixing meshes or NB2C glues ahead of suture fixation. However, these products have been shown to be at least substantially equivalent, and moderate-quality RCTs have suggested that both fibrin sealant and NB2C glues may have a beneficial effect on reducing immediate post-operative pain and chronic pain in at-risk populations, such as younger active patients. It will ultimately be up to surgeons and health-care policy makers to decide whether based on the limited evidence these products represent a worthwhile cost for their patients.

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.

May titanium spiral tacks contribute to intra-abdominal adhesion formation?

PURPOSE

To verify if titanium spiral tacks may contribute to intra-abdominal adhesion formation in rabbits.

METHODS

Ten New Zealand white rabbits were used. Through videolaparoscopic surgery two titanium spiral tacks (ProTack(®), Covidien(®)) were applied in the right flank. After 30 days the animals were submitted to evaluate peritoneal cavity by videolaparoscopy.

RESULTS

No adhesion was found where the titanium spiral tacks were placed.

CONCLUSION

Titanium spiral tacks for fixation do not cause adhesions in rabbits.

Bioadhesion: a review of concepts and applications

Bioadhesion refers to the phenomenon where natural and synthetic materials adhere to biological surfaces. An understanding of the fundamental mechanisms that govern bioadhesion is of great interest for various researchers who aim to develop new biomaterials, therapies and technological applications such as biosensors. This review paper will first describe various examples of the manifestation of bioadhesion along with the underlying mechanisms. This will be followed by a discussion of some of the methods for the optimization of bioadhesion. Finally, nanoscale and macroscale characterization techniques for the efficacy of bioadhesion and the analysis of failure surfaces are described.

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.

Laparoscopic fixation of biologic mesh at the hiatus with fibrin or polyethylene glycol sealant in a porcine model

BACKGROUND

The objective of this study was to determine the acute and chronic fixation strengths achieved by fibrin or polyethylene glycol (PEG) sealants to secure biologic mesh at the esophageal hiatus in a porcine model.

METHODS

For this study, 32 female domestic pigs were divided into four groups of 8 each. The four groups respectively received acute fibrin sealant, acute PEG sealant, chronic fibrin sealant, and chronic PEG sealant. Laparoscopically, a 5.5 × 8.5-cm piece of Biodesign Surgisis Hiatal Hernia Graft (porcine small intestine submucosa) was oriented with the U-shaped cutout around the gastroesophageal junction and the short axis in the craniocaudal direction to simulate hiatal reinforcement with a biologic mesh. The mesh then was secured with 2 ml of either fibrin sealant or PEG sealant. The pigs in the acute groups were maintained alive for 2 h to allow for complete polymerization of the sealants, and the pigs in the chronic group were maintained alive for 14 days. After the pigs were euthanized, specimens of the mesh-tissue interface were subjected to lap shear testing to determine fixation strength, and hematoxylin and eosin (H&E) stained slides were evaluated for evidence of remodeling.

RESULTS

No significant differences were observed between the acute and chronic fixation strengths or the remodeling characteristics of the two sealants. However, fixation strength increased significantly over time for both types of sealant. Evidence of remodeling also was significantly more pronounced in the chronic specimens than in the acute specimens.

CONCLUSIONS

This study demonstrated the feasibility of using fibrin or PEG sealants to secure biologic mesh at the hiatus in a porcine model.

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

BACKGROUND

The use of tacks for mesh fixation may induce pain after surgery for ventral hernia. The aim of this study was to compare postoperative pain after laparoscopic ventral hernia repair (LVHR) with conventional mesh fixation using titanium tacks versus fibrin sealant (FS).

METHODS

This randomized clinical trial included patients with an umbilical hernia defect ranging from 1·5 to 5 cm at three Danish hernia centres. Participants were assigned randomly to FS or titanium tack fixation. The primary outcome was acute pain, defined as the mean pain score on days 0-2 after surgery, measured on a 0-100-mm visual analogue scale (VAS).

RESULTS

Forty patients were included, of whom 38 were available for intention-to-treat analysis after 1 month. Patients in the FS group reported less pain than those in the tack group on days 0-2, both at rest (median 19 versus 47 mm; P = 0·025) and during activity (38 versus 60 mm; P = 0·014). The absolute difference in pain score between groups was 19 (95 per cent confidence interval 3 to 34) and 20 (4 to 35) mm at rest and during activity respectively. Patients in the FS group resumed normal daily activity earlier (after median 7 versus 18 days; P = 0·027) and reported significantly less discomfort. No recurrences were observed.

CONCLUSION

Mesh fixation with FS in LVHR was associated with less acute postoperative pain, discomfort and a shorter convalescence than tack fixation. Long-term follow-up is needed to show whether the effect of FS fixation persists in terms of chronic pain and recurrence.

REGISTRATION NUMBER

NCT00842842 (http://www.clinicaltrials.gov).

Systematic review of the use of fibrin sealant in abdominal-wall repair surgery

PURPOSE

Our objective was to analyze the advantages and inconveniences associated with the use of fibrin sealant compared with mechanical means for mesh fixation following abdominal-wall surgery.

METHODS

Literature search was conducted in MedLine, EMBASE, and Cochrane Library Plus databases. Articles were randomized clinical trials, nonrandomized comparative studies, and case series containing at least ten patients.

RESULTS

The fibrin sealant was shown to be biocompatible with the surrounding tissue. In patients treated with fibrin sealant, lower prevalence of acute and chronic postoperative pain was observed, and less hemorrhagic complications occurred. There are no data on the influence of fibrin sealant on seroma decrease. Efficiency in experimental models was similar to that observed for mechanical methods of fixation. Also, adhesions with fibrin sealant were less than that for mechanical methods.

CONCLUSIONS

Compared with mechanical methods, fibrin sealant is an efficacious alternative for mesh fixation postsurgery of the abdominal wall.

Comparison of three separate antiadhesive barriers for intraperitoneal onlay mesh hernia repair in an experimental model

Background

Adhesion formation is a common adverse effect in intraperitoneal onlay mesh (IPOM) surgery. Different methods of adhesion prevention have been developed, including coated meshes and separate antiadhesive barriers (SABs). In this study one type of mesh was tested with different SABs, which were fixed to the sutured mesh using fibrin sealant. The primary aim was to compare adhesion prevention between different SABs. Secondary aims were the assessment of tissue integration and evaluation of SAB fixation with fibrin sealant.

Methods

Thirty-two rats were randomized to one of three treatment groups (SurgiWrap®, Prevadh® and Seprafilm®) or a control group (no SAB). Animals were operated on with an open IPOM technique (8 per group). One macroporous polypropylene mesh per animal (2 × 2 cm) was fixed with four non-absorbable sutures. An antiadhesive barrier of 2·5 × 2·5 cm was fixed with fibrin sealant. After 30 days, adhesion formation, tissue integration, seroma formation, inflammation and vascularization were evaluated macroscopically and by histology.

Results

Prevadh® and Seprafilm® groups showed a significant reduction in adhesion formation compared with the control group. Tissue integration of the mesh was reduced in these groups. Fibrin sealant fixed the SAB to the mesh securely in all groups.

Conclusion

Prevadh® and Seprafilm® are potent materials for the reduction of adhesion formation. A potential relationship between effective adhesion prevention and impaired tissue integration of the implant was observed. Fibrin sealant proved an excellent agent for SAB fixation.

Adhesive performance of biomimetic adhesive-coated biologic scaffolds

Surgical repair of a discontinuity in traumatized or degenerated soft tissues is traditionally accomplished using sutures. A current trend is to reinforce this primary repair with surgical grafts, meshes, or patches secured with perforating mechanical devices (i.e., sutures, staples, or tacks). These fixation methods frequently lead to chronic pain and mesh detachment. We developed a series of biodegradable adhesive polymers that are synthetic mimics of mussel adhesive proteins (MAPs), composed of 3,4-dihydroxyphenylalanine (DOPA)-derivatives, polyethylene glycol (PEG), and polycaprolactone (PCL). These polymers can be cast into films, and their mechanical properties, extent of swelling, and degradation rate can be tailored through the composition of the polymers as well as blending with additives. When coated onto a biologic mesh used for hernia repair, these adhesive constructs demonstrated adhesive strengths significantly higher than fibrin glue. With further development, a precoated bioadhesive mesh may represent a new surgical option for soft tissue repair.

Evaluation of intraperitoneal placement of absorbable and nonabsorbable barrier coated mesh secured with fibrin sealant in a New Zealand white rabbit model

BACKGROUND

This study aimed to evaluate the acute and chronic fixation strength of fibrin sealant (FS) as an alternative method of fixation for laparoscopic ventral hernia repair (LVHR).

METHODS

Representative mesh types for LVHR included one nonabsorbable barrier mesh (Composix) and three absorbable barrier meshes (Sepramesh, Proceed, and Parietex composite). Macroporous polypropylene mesh (Prolite Ultra) served as the control mesh. Three methods of fixation were used, namely, 0-polypropylene suture+FS (ARTISS 4 IU), FS alone (ARTISS), and tacks alone, to secure 3×4-cm pieces of mesh (10 of each combination) to the peritoneal surface of New Zealand white rabbit abdominal wall. After 2 h of incubation at 37 °C, specimens underwent acute testing. Subsequently, a chronic phase was completed using the aforementioned fixation methods (10 of each combination), in which two 4×4-cm pieces of mesh were secured intraperitoneally in each of 75 New Zealand white rabbits, which survived 8 weeks until they were sacrificed. A transparent grid overlay was used to measure the mesh and adhesion area. Adhesion tenacity was characterized using the Garrard adhesion scale. In both the acute and chronic samples, a 3×3-cm area of mesh-tissue interface underwent lap shear testing at a rate of 0.42 mm/s using a tensiometer (Instron 5542). The maximum load sustained by the mesh-tissue construct was recorded as the acute fixation strength in newtons (N). Data are given as means±standard error of the mean. Statistical significance (p<0.05) was determined using a one-way analysis of variance (ANOVA) with Fisher's least significant difference (LSD) posttest or a nonparametric Kruskal-Wallis test (adhesion scores).

RESULTS

The acute fixation strength was significantly greater for all the meshes secured with either suture+FS or tacks alone than for FS alone (p<0.001 for all comparisons). All the meshes except Proceed demonstrated greater acute fixation strength with suture+FS than with tacks alone (p≤0.016). Composix achieved greater acute fixation with suture+FS than all the other meshes (p≤0.022). Acute fixation with suture + FS was greater for Parietex Composite and ProLite Ultra than for Proceed (p≤0.015). When the animals were sacrificed, 48 of 50 meshes fixed with FS alone were insufficiently affixed to the abdominal wall, which may have resulted in hernia recurrence in a hernia model. The chronic fixation strength was greater for all the mesh types with either suture+FS or tacks only than with FS alone (p≤0.0005). The chronic fixation strength was greater with suture+FS than with tacks for Proceed and ProLite Ultra (p≤0.013). Neither mesh area nor adhesion tenacity differed significantly with any mesh/fixation method combination.

CONCLUSIONS

In a chronic rabbit model of LVHR, fixation strength with FS alone was inadequate for selected nonabsorbable and absorbable barrier-coated meshes. The acute and chronic fixation strengths of suture+FS were equivalent or superior to the fixation strength of tacks alone. Using a combination of suture and FS for mesh fixation in LVHR may provide adequate fixation while decreasing postoperative pain due to spiral titanium tacks. In this preclinical series, mesh secured to the peritoneal surface by FS alone may have led to early recurrence.

A comparative biomechanical evaluation of hernia mesh fixation by fibrin sealant

BACKGROUND

The atraumatic fixation of meshes by fibrin sealant (FS) has been established for both open and laparoscopic techniques of hernia repair. This study was performed to evaluate the use of FS in hernia mesh fixation with different polymerization speed (thrombin concentrations), using commercial hernia meshes, and in two techniques, transabdominal preperitoneal mesh placement (TAPP) and intraperitoneal mesh placement (IPOM).

MATERIALS AND METHODS

A median laparotomy was performed in a pig model and hernia meshes were placed in IPOM and TAPP techniques. After mesh fixation with FS using thrombin concentrations of 4 and 500 IU/mL, maximum shear force before failure was measured at 5, 60, and 120 min.

RESULTS

At both thrombin concentrations and in all meshes in which the technique was used, the TAPP method tended to show higher maximum force levels at failure than did the IPOM method. In both TAPP and IPOM techniques and in all meshes, the 4 IU/mL thrombin concentration FS was superior to the 500 IU/mL thrombin concentration sealant.

CONCLUSIONS

Although both thrombin concentrations are suitable for mesh fixation, lower concentrations allow slower polymerization and better sealant diffusion leading to higher maximum force levels at failure. The TAPP method was biomechanically superior to the IPOM method. There were no major differences between mesh products.