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Tissue Glue in Laparoscopic Inguinal Hernia Repair: A Retrospective Comparative Analysis

recurrence. The mean visual analogue scale (VAS)-rated no recurrences have been observed. These statistics are in
pain scores were 3.2 preoperatively, 2.3 immediately after favor of fibrin glue mesh fixation, along with other studies,
surgery and 1.8 at one month. Surgeons rated the product which report postoperative complication rates of 4.6% for
as very easy to use. hematomas, 2% for neuralgias, and 0.4% for chronic pain.
Reported persistent neuralgia with inguinal pain attributable
DISCUSSIONS to stapling vary in the literature from 0.5 to 14%.
During the past few years, attention has focused on the To date, the series reporting the lowest postoperative
pain that may arise after groin hernia surgery. Chronic pain chronic pain rates have not used any means of mesh. Tamme
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after hernia surgery is a complex and controversial problem et al observed 2.55 and 0% chronic pain problems
that affects not only open but also laparoscopic procedures. respectively, after TEP repair with a recurrence rate of less
Three pain syndromes have been identified: Somatic, than 0.6%. However, the largest of these two series did not
neuropathic, and visceral pain. Besides nerve damage during specify the length of follow-up and the other one was a rather
dissection, thermal injury due to electrocautery, and small series (n = 89). Although, two randomized studies with
inflammatory and/or mechanical reaction to the mesh, a short follow-up of nonfixed mesh in laparoscopic repairs
stapling of the mesh is the most frequent evocated (one in TEP and the other in TAPP) did show promising
mechanism. According to various literature sources, there results in terms of recurrence justification for routine
is a great variation in the rate of postoperative chronic pain, nonstapling of the mesh in TEP is not yet substantiated.
ranging from 0.1 to 0.4% and 22.5% in laparoscopic repairs Studies points to the fact that mesh stapling does play a
for which staples are used to attach the mesh. Among the key role in generating postoperative pain after laparoscopic
explanations for such a wide discrepancy are the range of hernia repair. Mesh fixation with fibrin glue is preferable as
pain evaluation methods used, which include clinical it meets the requirements for both efficiency and security
examination of the patients, phone calls, and mailed of fixation.
questionnaires and tools to score the severity of the pain. The recurrence rate in the fibrin glue was found to be
For laparoscopic hernia repair, the possibility of nerve injury slightly lower than in the tack staples group but did not
(pain or parasthesia) caused by entrapment from incorrect differ significantly, and the case of recurrence reported in
placement of staples (above all lateral cutaneus femoral the fibrin glue group is probably related to an inadequate
nerve, but ilioinguinal, and genitofemoral are also at risk) mesh size in a large direct hernia. Overall, the recurrence
and epigastric vessels lesion by clips application may be rate in the fibrin glue group remains within the range most
avoided using fibrin glue either in the TAPP technique or in report approve. Inadequate lateral fixation is the main cause
the TEP. It seems that not only entrapment but also of recurrence after both TAPP (36%) and TEP (22%). The
postoperative fibrous scar around the staples can lead to reason for this is that most of the nerves run laterally, where
nerve injury. In conventional TAPP, the prosthesis is no staples can be applied. Gluing a large mesh on the triangles
anchored using metal clips. This is a critical step that requires of disaster and pain is likely to stop the prosthesis from
the utmost attention to avoid damaging the surrounding lifting and dislocating, thereby avoiding inferomedial and
nerves and blood vessels. Lesions arising due to such inferolateral recurrence. It is not known if the enhanced
intraoperative damage can lead to complications, including inflammatory response induced by fibrin glue may explain
hemorrhage, or painful neuralgia during follow-up. The the slightly higher rate of seromas in the fibrin glue mesh
nerves in the inguinal area that are most frequently involved fixation. There exists no significant difference in the
in postoperative pain following TAPP hernia repair include development of postoperative hematomas, even though the
the genitofemoral, lateral cutaneous femoral, and ilioinguinal rate is slightly lower in fibrin glue mesh fixation, as
and iliohypogastric nerves. Lesions of the lateral cutaneous compared to the tack staplers but the data available are
femoral nerve are the most frequent postoperative neurologic inconclusive to give the credit to the effect of fibrin glue on
complications associated with laparoscopy. Such lesions local hemostasis. Although, no comparison is available
are the result of damage or entrapment of the nerve during between the tack staples group and the fibrin glue group in
lateral fixation of the mesh to the deep inguinal ring with terms of operation duration, the use of fibrin glue and its
pain in the lateral region of thigh. TAPP hernia repair with application device did not seem to change the mean operative
Tisseel resulted in a low rate of postoperative pain and rapid time, which is comparable to that of other series using
resumption of normal activities. Postoperative complications tackers. This can be attributed primarily to the peritoneum
affected only 2.2% of the hernias and were readily treated closure using a running laparoscopic suture and the
without the need to extend the hospital stay. Importantly, preparation of fibrin glue and its applicator during the hernia

World Journal of Laparoscopic Surgery, September-December 2010;3(3):165-174 173