Page 41 - WJOLS - Surgery Journal

World Journal of Laparoscopic Surgery, January-April 2009;2(1):42-48
Pramod T Shinde
Fibrin Sealant versus Use of Tackers for

Fixation of Mesh in Laparoscopic Inguinal

Hernia Repair

Pramod T Shinde
Consultant Laparoscopic Surgeon, Bhagwati Hospital, Mumbai, Maharashtra, India

Abstract mesh size has to be adequate; peritoneum closure with a running
Background: Laparoscopic fixation of meshes prior to their fibrous suture is more time consuming. Large randomized trials and longer
incorporation should be reliable to minimize recurrences following follow-up are required to demonstrate the advantages of either
transabdominal preperitoneal hernia repair (TAPP) and totally technique.
extraperitoneal repair (TEP) repair of inguinal hernias. However, suture, Keywords: Laparoscopic hernia mesh repair, fibrin sealant and tackers,
tack and staple-based fixation systems are associated with postoperative mesh fixation.
chronic inguinal pain. Initial fixation with fibrin sealant offers an
atraumatic alternative, but there is little data showing that fibrin-based INTRODUCTION
mesh adhesion provides adequate biomechanical stability for repair of
inguinal hernia by TAPP and TEP. Laparoscopic repair of inguinal hernias can be accomplished
by totally extraperitoneal (TEP) or transabdominal preperitoneal
Methods: A literature search was performed using medline and the (TAPP) techniques. It involves mesh fixation to avoid
search Google, Springer link and Highwire press. The following search
terms were used: Laparoscopic hernia mesh, Fibrin glue, and Tackers. displacement and recurrence. Fixation usually uses staples that
1-4
2293 citations were found in total.Selected papers were screened for can lead to nerve injury and chronic postoperative pain.
further references. Criteria for selection of literature were the number The correct fixation of the mesh, as well as the right size of
of cases (excluded if less than 80), methods of analysis (statistical or the graft, are considered the most important surgical steps in
nonstatistical), operative procedure (only universally accepted the laparoscopic hernia repair to prevent the risk of recurrence. 7
procedures were selected) and the institution where the study was The use of 10 mm titanium staples to fix the mesh is the
done (specialized institution for laparoscopic surgery). conventional approach. Some studies of laparoscopic hernia
Results: Mesh fixation has always invited lots of interest amongst repair have shown that recurrences are caused by the rolling up
surgeons and instrument companies due to the wide range of post- of the mesh, incorrect stretching of the mesh, or by incomplete
operative complications each of them caused. TAPP and TEP usually covering of the hernia defect. A correct method of securing the
involves fixation of mesh, however many studies challenging the mesh mesh has been recommended by several authors. Anyhow,
fixation in TEP are being published. There are two most common some complications of laparoscopic hernia repair, such as nerve
methods of fixing mesh using fibrin glue (Tissucol) and tackers. Fibrin injury (chronic postoperative pain, neuralgias, pubalgias) and
sealant possesses both mechanical strength and elasticity. Overall, hematomas in the Retzius space (bleeding from vascular lesions)
data from previous studies, shows that mesh stability with fibrin are inherent to the use of the staples. 10
sealant fixation is at least equivalent to suture fixation, indicating that Fibrin glue (Tissucol/Tisseel, Baxter health care, Deerfield,
fibrin sealant could be considered the fixation method of choice in IL, USA) offers an atraumatic alternative, but there is insufficient
inguinal hernia repair. This new method of mesh fixation is obviously data giving direct evidence whether fibrin-based mesh adhesion
potentially less harmful than stapling the mesh and can help reduce provides adequate biomechanical stability. 9,11
the risk of chronic postoperative pain at a comparative or even lower
cost than a stapling device. Tackers are associated with a certain amount of surgical
trauma and complications such as neuralgia or paresthesia
Conclusions: Fibrin glue gives an adequate mesh fixation with a less because of nerve entrapment. Pubalgia is caused by stapling of
chance of chronic postoperative pain. It appears to be an alternative to the prosthesis to Cooper’s ligament. Bleeding or hematomas in
staples and may help reduce the postoperative pain problems after
hernia repair. All methods give the same results in terms of recurrence Retzius space (muscular, corona mortis) also can occur. In terms
rate, hospital stay, and costs; but with better results in terms of post- of tensile strength and mesh dislocation, fibrin glue is equivalent
operative pain, seromas, and trocar-related trauma. However the use to stapling and better than no fixation of the mesh.
of fibrin glue needs extensive study, as the anatomical dissection and Some data suggest that mesh fixation is not needed for
inguinal region preparation have to be carefully performed, and the preserving satisfactory long-term results, stapling of the mesh
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