N-butyl cyanoacrylate versus conventional suturing for fixation of meshes in an incisional hernia model

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.

Minimally Invasive Precise Application of Bioadhesives to Prevent IPPROM on a Pregnant Sheep Model

INTRODUCTION

Iatrogenic preterm premature rupture of the membrane remains the Achille's heel of fetoscopy. The aim of this study was to show in vivo feasibility of fetal membrane (FM) defect sealing by the application of tissue glues with umbrella-shaped receptors.

METHODS

First, we adapted our previously described ex vivo strategy and evaluated the adhesion strength of different tissue glues, Histoacryl® and Glubran2®, by bonding polytetrafluoroethylene or silicone encapsulated nitinol glue receptor to human FM. Then, we exposed pregnant sheep uterus through a laparotomy and placed a 10-French trocar into the amniotic cavity through which the umbrella-shaped glue receptor (n = 9) was inserted and fixated onto the FM with the tissue glues (n = 8). The tightness of the sealed defects was assessed 4 h post-surgery.

RESULTS

Both tissue glues tested resulted in adhesion of the glue receptors to the FM ex vivo. In vivo, all glue receptors opened in the amniotic cavity (n = 9) and all successfully placed glue receptors sealed the FM defect (n = 8). Four hours post-surgery, 2 treatment sites showed minimal leakage whereas the negative control without glue (n = 1) showed substantial leakage.

DISCUSSION

This in vivo study confirms that fetoscopically induced FM defects can be sealed by the application of tissue adhesives.

Results of a Prospective Cohort Study on Open Rives Technique of the Midline Incisional Hernia: Midline Closure and Mesh Overlap

Background. Rives repair has been traditionally used for large abdominal wall defects with good results on terms of recurrence. However, it is limited by the lateral border of the posterior rectus sheath. The objective of our study was to evaluate recurrence rate, midline closure and mesh overlap in patients operated on elective midline incisional hernia by open Rives retromuscular repair. Methods. This is a prospective observational study of 83 patients who underwent elective open Rives technique between January 2014 and December 2018. Main inclusion criteria were adults with a midline incisional hernia. Recurrence, midline closure and mesh overlap were determined. Results. At a median postoperative follow-up of 32 (5-59) months, 8 cases of recurrence were reported. Patients with recurrence had wider hernia defects (101 ± 52 mm vs 66 ± 36 mm, P = .014) and were repaired with wider meshes (191 ± 93 mm vs 137 ± 68 mm, P = .042). However, although it was not statistically significant, midline closure was lower (38% vs 59%), as well as the overlapping relationship between mesh area and hernia defect area (2.937:1 vs 3.732:1) on patients that developed a recurrence. Conclusions. Rives technique provides good mid-term results in a midline incisional hernia (10% of recurrence at 36 months), including wider hernias in the recurrent cohort. The authors believe that other techniques which allow midline closure and placement of bigger meshes should be considered, especially in those hernias classified as W3 on EuraHS classification (more than 10 cm on width size).

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.

Pre-clinical assay of the tissue integration and mechanical adhesion of several types of cyanoacrylate adhesives in the fixation of lightweight polypropylene meshes for abdominal hernia repair

INTRODUCTION

Lightweight (LW) polypropylene (PP) meshes better adapt to host tissue, causing less fibrosis and inflammatory responses than high-density meshes. Mesh fixation using tissue adhesives (TA) that replace conventional sutures may improve the process of hernia repair and tissue trauma. This preclinical study compares the behavior of different cyanoacrylate-based adhesives in the fixation of LW-PP meshes for hernia repair.

METHODS

Partial abdominal wall defects were repaired using LW-PP Optilene meshes in New Zealand rabbits. The following groups were established according to the mesh fixation method: Suture (control), Glubran 2 (n-butyl), Ifabond (n-hexyl), SafetySeal (n-butyl) and Evobond (n-octyl). At 14, 90 and 180 days after surgery, the recovered implants were examined to assess the host tissue integration, the macrophage response and the biomechanical strength.

RESULTS

All the groups showed optimal host tissue incorporation regardless of the fixation procedure. Significantly increased levels of collagen 1 and collagen 3 gene expression (p<0.001) were observed at 14 days compared to the medium- and long-term durations, where the Suture and Glubran groups showed the highest expression of collagen 1. All the adhesives increased the macrophage reaction (p<0.001) compared to sutures at all implant times. Maximal macrophage response was observed in the short-term Glubran group (p<0.01) compared to the rest of the groups. Although SafetySeal and Evobond did not reach the biomechanical resistance of sutures at 14 days, all the adhesives did reach this level in the medium- to long-term periods, providing significantly higher resistance (p<0.05).

CONCLUSIONS

All the cyanoacrylates, despite inducing a significantly increased macrophage response versus sutures, showed optimal host tissue integration and long-term mechanical behavior; thus, they might be good choices for LW-PP mesh hernia repairs.

Surface modification of polypropylene surgical meshes for improving adhesion with poloxamine hydrogel adhesive

Tissue adhesive has notable clinical benefits in hernia repair fixation. A novel poloxamine tissue adhesive was previously shown to successfully bond collagen tissue with adequate adhesive strength. In application related to attachment of polypropylene (PP) mesh, the adhesive strength between the mesh and poloxamine hydrogel adhesive is limited by the hydrophobicity of PP monofilaments and lack of covalent bond formation. The purpose of this study was to compare two different surface modifications [bovine serum albumin (BSA) adsorption and poly-glycidyl methacrylate/human serum albumin (PGMA/HSA) grafting] of PP mesh for improving the adhesive strength between poloxamine hydrogel adhesive and PP mesh. The PGMA/HSA surface modification significantly improved the adhesive strength for meshes attached with poloxamine hydrogel tissue adhesive compared with unmodified meshes and meshes modified by BSA adsorption. An area of 1 cm² adhesive provided for a maximum adhesive strength of 65-70 kPa for meshes modified by PGMA/HSA, 4-13 kPa for meshes modified by BSA, and 22-45 kPa for unmodified meshes. Optical microscopy and infrared spectroscopy (FTIR) confirmed the improved adhesive strength was achieved through mechanical interlock of the hydrogel tissue adhesive into the PP mesh pores and chemical bonding of the albumin after successful PGMA/HSA grafting onto the PP monofilaments. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1047-1055, 2019.

Host tissue response by the expression of collagen to cyanoacrylate adhesives used in implant fixation for abdominal hernia repair

The less traumatic use of surgical adhesives rather than sutures for mesh fixation in hernia repair has started to gain popularity because they induce less host tissue damage and provoke less postoperative pain. This study examines the host tissue response to a new cyanoacrylate (CA) adhesive (n-octyl, OCA). Partial defects (3 × 5 cm) created in the rabbit anterior abdominal wall were repaired by mesh fixation using OCA, Glubran2^®(n-butyl-CA), Ifabond^®(n-hexyl-CA) or sutures. Samples were obtained at 14/90 days for morphology, collagens qRT-PCR/immunofluorescence and biomechanical studies. All meshes were successfully fixed. Seroma was detected mainly in the Glubran group at 14 days. Meshes fixed using all methods showed good host tissue incorporation. No signs of degradation of any of the adhesives were observed. At 14 days, collagen 1 and 3 mRNA expression levels were greater in the suture and OCA groups, and lower in Ifabond, with levels varying significantly in the latter group with respect to the others. By 90 days, expression levels had fallen in all groups, except for collagen 3 mRNA in Ifabond. Collagen I and III protein expression was marked in the suture and OCA groups at 90 days, but lower in Ifabond at both time points. Tensile strengths were similar across groups. Our findings indicate the similar behavior of the adhesives to sutures in terms of good tissue incorporation of the meshes and optimal repair zone strength. The lower seroma rate and similar collagenization to controls induced by OCA suggests its improved behavior over the other two glues. This article deals with a preclinical study to examine different aspects of the repair process in the host of three alkyl cyanoacrylates (n-butyl (GLUBRAN 2), n-hexyl (IFABOND), and n-octyl cyanoacrylate (EVOBOND)) compared to sutures (control), in the fixation of surgical meshes for hernia repair. It goes into detail about collagen deposition in the repair zone at short and medium term. The results obtained demonstrate lower seroma rate and similar collagenization to sutures induced by the n-octyl suggesting better behavior than the other two cyanoacrylates.

Cytotoxicity of Cyanoacrylate-Based Tissue Adhesives and Short-Term Preclinical In Vivo Biocompatibility in Abdominal Hernia Repair

Background

Cyanoacrylate(CA)-based tissue adhesives, although not widely used, are a feasible option to fix a mesh during abdominal hernia repair, due to its fast action and great bond strength. Their main disadvantage, toxicity, can be mitigated by increasing the length of their alkyl chain. The objective was to assess the in vitro cytotoxicity and in vivo biocompatibility in hernia repair of CAs currently used in clinical practice (Glubran(n-butyl) and Ifabond(n-hexyl)) and a longer-chain CA (OCA(n-octyl)), that has never been used in the medical field.

Methods

Formaldehyde release and cytotoxicity of unpolymerized(UCAs) and polymerized CAs(PCAs) were evaluated by macroscopic visual assessment, flow cytometry and Alamar Blue assays. In the preclinical evaluation, partial defects were created in the rabbit abdominal wall and repaired by fixing polypropylene prostheses using the CAs. At 14 days post-surgery, animals were euthanized for morphology, macrophage response and cell damage analyses.

Results

Formaldehyde release was lower as the molecular weight of the monomer increased. The longest side-chain CA(OCA) showed the highest cytotoxicity in the UCA condition. However, after polymerization, was the one that showed better behavior on most occasions. In vivo, all CAs promoted optimal mesh fixation without displacements or detachments. Seroma was evident with the use of Glubran, (four of six animals: 4/6) and Ifabond (2/6), but it was reduced with the use of OCA (1/6). Significantly greater macrophage responses were observed in groups where Glubran and Ifabond were used vs. sutures and OCA. TUNEL-positive cells were significantly higher in the Glubran and OCA groups vs. the suture group.

Conclusions

Although mild formaldehyde release occurred, OCA was the most cytotoxic during polymerization but the least once cured. The CAs promoted proper mesh fixation and have potential to replace traditional suturing techniques in hernia repair; the CAs exhibited good tissue integration and effective short-term biocompatibility, with the slightest seroma and macrophage response induced by OCA.

Is It Possible to Eliminate Sutures in Open (Lichtenstein Technique) and Laparoscopic (Totally Extraperitoneal Endoscopic) Inguinal Hernia Repair? A Randomized Controlled Trial With Tissue Adhesive (n-Hexyl-α-Cyanoacrylate)

Background. The morbidity linked to the use of sutures in inguinal hernioplasty is well known. Tissue adhesives may be an alternative, so as to be able to improve levels of postoperative comfort, but clinical experience using them is limited. The aim of this study is to evaluate the efficiency of cyanoacrylate as a substitute for sutures in the treatment of inguinal hernias. Patients. Randomized clinical trial in abdominal wall unit. A total of 208 patients were operated upon for inguinal hernias of which 102 were unilateral hernias via open surgery using the Lichtenstein technique, randomized to receive prolene sutures (n = 52) or n-hexyl-α-cyanoacrylate glue (n = 50) and 106 were patients with bilateral inguinal hernias operated upon via totally extraperitoneal laparoscopy and randomized to receive either tackers (n = 54) or glue (n = 52). Main Outcome Measures. The primary endpoints were pain and recurrence. Secondary endpoints were operating time, postoperative morbidity, pain, and analgesic consumption. Results. No morbidity associated with the use of the glue existed. The use of glue significantly reduced the mean of surgical time (12 minutes in open surgery, 13 minutes in laparoscopic surgery), pain, and analgesics consumption, both via the open and laparoscopic approaches ( P < .001). After 1 year the adhesive did not change the recurrence rate in either of the approaches. The economic analysis shows potential yearly savings of 123 916.3 Euros. Conclusions. Substituting sutures with glue ( n-hexyl-α-cyanoacrylate) in open or laparoscopic inguinal hernioplasty is safe with less postoperative pain and the same possibilities of recurrence.

Retracted: Impact on quality of life of using an onlay mesh to prevent incisional hernia in midline laparotomy: a randomized clinical trial

BACKGROUND

Recent studies have demonstrated the effectiveness of using prophylactic meshes to achieve abdominal wall closure, decreasing the risk of incisional hernia. However, the effect of prophylactic mesh placement on a patient's quality of life has not yet been evaluated.

STUDY DESIGN

A controlled, prospective, randomized, and blind study was carried out. The patients in group A (mesh) were fitted with a polypropylene mesh to reinforce the standard abdominal wall closure. The patients in group B (nonmesh) were given a standard abdominal wall closure and were not fitted with the mesh. All patients were administered the 36-Item Short-Form generic health questionnaire during their preoperation visit and during their 1-month, 6-month, and 1-year follow-up appointments. The scores of the questionnaires have been compared with those recorded when the questionnaire was administered before surgery.

RESULTS

The Kaplan-Meier survival curves show that the likelihood of incisional hernia at 12 months is 1.5% in mesh group compared with 35.9% in nonmesh group (p > 0.0001), which means that the differences are statistically significant. Patients with mesh placement had greater improvement in general health and bodily pain than patients in nonmesh group at 1-month and 6-month post operation. One year after operation, patients in the mesh group had statistically significant better quality of life than patients in the nonmesh group in the physical functioning, general health perceptions, vitality, social role functioning, mental health, physical component summary and mental component summary dimensions.

CONCLUSIONS

Fitting a prophylactic supra-aponeurotic mesh prevents incisional hernia.

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.

Percutaneous obliteration of patent processus vaginalis: a rat model for future inguinal hernia repair in children

PURPOSE

Inguinal hernia repair is one of the most common procedures performed by pediatric surgeons. A percutaneous technique could be the next advance in inguinal hernia repair in children. We used a rat model to study the utility of percutaneous inguinal hernia repair (PHR) using 2-octyl-cyanoacrylate (OCT).

METHODS

Four-week-old Lewis male rats were randomly divided into three groups: bilateral PHR group (BH) (n=15), unilateral PHR group (UH) (n=12), and sham group (n=14). After inducing a pneumoperitoneum, a 24-gauge cannula was advanced into the patent processus vaginalis (PPV) once air was aspirated. The canal is then obliterated by injecting 0.2 ml of 2-octyl-cyanoacrylate. Mating and herniography were performed at postoperative weeks 2 and 6, respectively. All rats were sacrificed at week 12.

RESULTS

Herniography revealed complete closure of PPV in (25/30) BH, (12/12) UH, and (0/28) of the sham group. All OCT-treated sides were found obliterated at the post-mortem gross examination. Histological analysis of the inguinal region revealed patent vase in all rats. However, mild to moderate foreign body reactions and fat necrosis were noticed at the injected sites. All rats demonstrated fertility at mating.

CONCLUSION

Percutaneous obliteration of PPV was feasible and safe in rats and potentially less invasive than the current techniques used in children. However, demonstrating long-term effectiveness, the need for pneumoperitoneum and the risk of OCT intraperitoneal spillage remain as challenges to overcome.

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.

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.