Adhesions to sutures, tackers, and glue for intraperitoneal mesh fixation: an experimental study

Minimally Invasive Extended Totally Extraperitoneal Versus Transabdominal Retromuscular Ventral Hernia Mesh Repair: Systematic Review and Meta-Analysis

Introduction: Minimally invasive surgery for ventral hernia repair (MIS-VHR) with mesh in retromuscular plane can be performed by either transabdominally (TA-RM) or via enhanced view totally extraperitoneal approach (eTEP). Although both techniques offer the mesh extension in the best anatomical space, closure of hernia defect, avoidance of traumatic fixation, the superiority of one approach over another is not established. This systematic review and meta-analysis were set up to analyze safety and efficacy of eTEP in comparison with TA-RM. Materials and Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) framework was used as guideline to conduct systematic search of literature. Studies that provided comparative data of MIS-VHR using eTEP versus TA-RM were identified. Primary outcomes were major complications. These were defined as grade III-IV according to Clavien-Dindo classification. Secondary outcomes included: surgical site infection (SSI) rates, seroma rates, surgical site occurrence requiring procedural intervention (SSOPI), minor complications (Clavien-Dindo grade I-II), intraoperative complications, recurrence rate, postoperative ileus, duration of surgery, postoperative pain. Random- and fixed-effects models of statistical analysis were used. Risk difference (RD) was computated for binary outcomes (major and minor complications, SSI, seroma, SSOPI, recurrence, ileus) with 95% confidence intervals. I2 test was used to assess statistical heterogeneity. Risk of bias assessment was performed using Newcastle-Ottawa framework. Results: There were 3 observational studies that enrolled 370 participants. In the eTEP group there were 166 patients and, in the TA-RM group there were 204 patients. There was no significant RD with regard to major complications (RD -0.02 [-0.06 to 0.02], test for overall effect: Z = 0.86 [P = .39]). There was no significant RD in occurrence of minor complications, SSI, seroma, SSOPI, recurrence, ileus. Conclusions: Both eTEP and TA-RM were found to have equal safety profile. Further high-quality studies evaluating patient reported outcomes and late recurrence may be useful. PROSPERO registration number: CRD42023429160.

THE USE OF SURGICAL ADHESIVE AND SUTURE FIXING MESHES TO THE ABDOMINAL WALL: AN EXPERIMENTAL STUDY IN RATS

AIM

Proper fixation of the surgical mesh determines the success of a herniorrhaphy. Understanding the inflammatory response and the mechanical properties of the mesh helps to define whether a fixation method is superior. This study aimed to evaluate the healing of defects in the abdominal wall of rats, comparing the repair of macroporous polypropylene meshes fixed with surgical glue and polypropylene thread.

METHODS

In 20 Wistar rats, a defect was produced in the abdominal wall, with the integrity of the parietal peritoneum. For correction, the meshes were fixed with surgical glue (2-octyl cyanoacrylate) (subgroup C1), or polypropylene suture (subgroup C2). The two subgroups of 10 animals were euthanized on the 90th postoperative day, and the fragments of the abdominal wall were submitted to macroscopic, histological, and tensiometric analysis.

RESULTS

Macroscopic analysis did not show any abnormalities. Tensiometry on the 90th postoperative day in subgroup C1 showed mean rupture tension of 28.47N and in subgroup C2 32.06N (p=0.773). The inflammatory process score revealed that both groups are in the subacute phase (p=0.380).

CONCLUSION

The fixation of a polypropylene macroporous mesh to repair an abdominal wall defect can be performed with surgical glue (2-octyl cyanoacrylate) or polypropylene suture, both methods being equally effective.

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 pectopexy: the learning curve and comparison with laparoscopic sacrocolpopexy

Introduction and hypothesis

In addition to laparoscopic sacrocolpopexy (LS), laparoscopic pectopexy (LP) is a novel surgical method for correcting apical prolapse. The descended cervix or vaginal vault is suspended with a synthetic mesh by fixing the bilateral mesh ends to the pectineal ligaments. This study was aimed at developing a learning curve for LP and to compare it with results with LS.

Methods

We started laparoscopic/robotic pectopexy in our department in August 2019. This retrospective study included the initial 18 consecutive women with apical prolapse receiving LP and another group undergoing LS (21 cases) performed by the same surgeon. The medical and video records were reviewed.

Results

The age was older in the LP group than in the LS group (65.2 vs 53.1 years). The operation time of LP group was significantly shorter than that of the LS group (182.9 ± 27.2 vs 256.2 ± 45.5 min, p < 0.001). The turning point of the LP learning curve was observed at the 12th case. No major complications such as bladder, ureteral, bowel injury or uncontrolled bleeding occurred in either group. Postoperative low back pain and defecation symptoms occurred exclusively in the LS group. During the follow-up period (mean 7.2 months in LP, 16.2 months in LS), none of the cases had recurrent apical prolapse.

Conclusions

Laparoscopic pectopexy is a feasible surgical method for apical prolapse, with a shorter operation time and less postoperative discomfort than LS. LP may overcome the steep learning curve of LS because the surgical field of LP is limited to the anterior pelvis and avoids encountering the critical organs.

Strategies for Mesh Fixation in Abdominal Wall Reconstruction: Concepts and Techniques

SUMMARY

Ventral hernias have numerous causes, ranging from sequelae of surgical procedures to congenital deformities. Patients suffering from these hernias experience a reduced quality of life through pain, associated complications, and physical disfigurement. Therefore, it is important to provide these patients with a steadfast repair that restores functionality and native anatomy. To do this, techniques and materials for abdominal wall reconstruction have advanced throughout the decades, leading to durable surgical repairs. At the cornerstone of this lies the use of mesh. When providing abdominal wall reconstruction, a surgeon must make many decisions with regard to mesh use. Along with the type of mesh and plane of placement of mesh, a surgeon must decide on the method of mesh fixation. Fixation of mesh provides an equal distribution of tension and a more robust tissue-mesh interface, which promotes integration. There exist numerous modalities for mesh fixation, each with its own benefits and drawbacks. This Special Topic article aims to compare and contrast methods of mesh fixation in terms of strength of fixation, clinical outcomes, and cost-effectiveness. Methods included in this review are suture, tack, fibrin glue, mesh strip, and self-adhering modes of fixation.

Functionalized Strategies and Mechanisms of the Emerging Mesh for Abdominal Wall Repair and Regeneration

Meshes have been the overwhelmingly popular choice for the repair of abdominal wall defects to retrieve the bodily integrity of musculofascial layer. Broadly, they are classified into synthetic, biological and composite mesh based on their mechanical and biocompatible features. With the development of anatomical repair techniques and the increasing requirements of constructive remodeling, however, none of these options satisfactorily manages the conditional repair. In both preclinical and clinical studies, materials/agents equipped with distinct functions have been characterized and applied to improve mesh-aided repair, with the importance of mesh functionalization being highlighted. However, limited information exists on systemic comparisons of the underlying mechanisms with respect to functionalized strategies, which are fundamental throughout repair and regeneration. Herein, we address this topic and summarize the current literature by subdividing common functions of the mesh into biomechanics-matched, macrophage-mediated, integration-enhanced, anti-infective and antiadhesive characteristics for a comprehensive overview. In particular, we elaborate their effects separately with respect to host response and integration and discuss their respective advances, challenges and future directions toward a clinical alternative. From the vastly different approaches, we provide insight into the mechanisms involved and offer suggestions for personalized modifications of these emerging meshes.

Mesh fixation using novel bio-adhesive coating compared to tack fixation for IPOM hernia repair: in vivo evaluation in a porcine model

BACKGROUND

Mesh fixation in hernia repair is currently based on penetrating sutures or anchors, with proven early and late complications such as pain, adhesions, erosions, and anchor migration. In an attempt to reduce these complications, a bio-adhesive-based self-fixation system was developed. The purpose of this study was to assess the performance and safety of this novel self-adhesive mesh (LifeMesh™) by comparing it with standard tack fixation.

METHODS

A full-thickness abdominal wall defect was created bilaterally in 24 pigs. The defects were measured 14 days later, and laparoscopic intraperitoneal onlay mesh (IPOM) repairs were performed. In each animal, both LifeMesh and a titanium tack-fixed control, either uncoated polypropylene mesh (PP) or composite mesh (Symbotex™), were used. After 28 and 90 days, we performed macroscopic evaluation and analyzed the fixation strength, shrinkage, adhesion scores, and histopathology in all samples.

RESULTS

Measurements at both time points revealed that LifeMesh had fully conformed to the abdominal wall, and that its fixation strength was superior to that of the tack-fixated Symbotex and comparable to that of the tack-fixated PP. Shrinkage in all groups was similar. Adhesion scores with LifeMesh were lower than with PP and comparable with Symbotex at both time points. Histology demonstrated similar tissue responses in LifeMesh and Symbotex. Lack of necrosis, mineralization, or exuberant inflammatory reaction in all three groups pointed to their good progressive integration of the mesh to the abdominal wall. By 28 days the bio-adhesive layer in LifeMesh was substantially degraded, allowing a gradual tissue ingrowth that became the main fixation mode of this mesh to the abdominal wall.

CONCLUSIONS

The excellent incorporation of LifeMesh to the abdominal wall and its superior fixation strength, together with its low adhesion score, suggest that LifeMesh may become a preferred alternative for abdominal wall repair.

Postoperative Abdominal Adhesions: Clinical Significance and Advances in Prevention and Management

Postoperative adhesions remain one of the more challenging issues in surgical practice. Although peritoneal adhesions occur after every abdominal operation, the density, time interval to develop symptoms, and clinical presentation are highly variable with no predictable patterns. Numerous studies have investigated the pathophysiology of postoperative adhesions both in vitro and in vivo. Factors such as type and location of adhesions, as well as timing and recurrence of adhesive obstruction remain unpredictable and poorly understood. Although the majority of postoperative adhesions are clinically silent, the consequences of adhesion formation can represent a lifelong problem including chronic abdominal pain, recurrent intestinal obstruction requiring multiple hospitalizations, and infertility. Moreover, adhesive disease can become a chronic medical condition with significant morbidity and no effective therapy. Despite recent advances in surgical techniques, there is no reliable strategy to manage postoperative adhesions. We herein review the pathophysiology and clinical significance of postoperative adhesions while highlighting current techniques of prevention and treatment.

Evaluation of a novel permanent capped helical coil fastener in a porcine model of laparoscopic ventral hernia repair

Background

Existing permanent helical coil fasteners, although commonly employed for mesh fixation during laparoscopic hernia repair, are associated with peritoneal tissue attachment formation and resultant visceral complications. We evaluated attachment formation, fastener engagement, and mesh/tissue integration associated with laparoscopic fixation using a novel permanent capped helical coil fastener (HC-Capped) compared to permanent non-capped helical coil fasteners (HC-Non-Capped) in a porcine model.

Methods

Twelve female pigs underwent bilateral laparoscopic intraperitoneal fixation of Composix™ L/P Mesh (10 × 15 cm oval) with HC-Capped or HC-Non-Capped fasteners. Thirty-two fasteners were used to secure each mesh utilizing a “double-crown” technique. Laparoscopy at 30 days was used to evaluate the presence and area coverage of attachments (Diamond Score) and percentage of engaged fasteners. At 90 days, following necropsy, each mesh was evaluated for the presence, percentage, and tenacity (Butler Score) of attachments and fastener engagement. Samples were biomechanically evaluated to assess tissue integration via T-peel testing.

Results

HC-Capped fasteners demonstrated a significantly lower attachment area score compared to the HC-Non-Capped group at 30 days (0.92 ± 0.26 vs. 2.50 ± 0.29/3.00, p = 0.002) and 90 days (0.60 ± 0.22 vs. 2.08 ± 0.29/3.00, p = 0.004). At 90 days, the HC-Capped group evidenced significantly lower attachment tenacity score (1.00 ± 0.37 vs. 2.75 ± 0.33/4.00, p = 0.013). Furthermore, at 30 and 90 days, a significantly greater percentage of HC-Capped fasteners remained properly engaged (30 days: 99.7 % vs. 86.5 %, p < 0.001 and 90 days: 99.4 % vs. 74.5 %, p = 0.001). T-peel biomechanical testing demonstrated significantly greater mesh/tissue integration for HC-Capped group (2.16 ± 0.24 vs. 1.16 ± 0.29 N/cm, p = 0.038).

Conclusions

In a porcine model, HC-Capped fasteners demonstrated significantly less attachment coverage and tenacity in the early postoperative period. Furthermore, the HC-Capped cohort evidenced significantly greater percentage of properly engaged fasteners and greater mesh/tissue integration. Data suggest that shielding exposed fastener points on the visceral mesh surface with polymer caps may reduce attachment formation and aid in mesh fixation and integration.