Page 43 - WJOLS - Surgery Journal

Pramod T Shinde
paramount and parietex (Sofradim) which seems ideal because Various studies report from 0 to 6% of postoperative
it is easily glued and the polyester structure is rapidly integrated neuropathic complications. 13,32,33 In our total review, the
into the peritoneum. This is also helped by fixing with Tissucol. incidence is very low (0.09%) as surgeons tend to avoid staples
Polyester is a reticular knit able to promote genesis of new placement in nerve areas and to use the minimum number of
vessels, whilst polytetrafluoroethylene (PTFE) is of laminar staples. Chronic pain is not always due to staples, but may be
structure, and enhances cellular infiltration of the outer third of caused by inflammatory reaction around the mesh with scarring
the structure. Newly formed vessels do not penetrate PTFE around the nerve, which may induce neurologic pain as in open
because the laminar interface is not as good as the reticular technique. Bleeding and incisional hernia from the 10 mm trocar
one. Polyester is also better because it causes a milder site may be reduced using 5 mm ports. Another important aspect
inflammatory reaction and a great fibroblastic proliferation. For is recurrence after hernia repair; in the laparoscopic technique
these reasons we believe polyester and fibrin glue to be the the possible causes are: insufficient extent of dissection,
biomaterials of choice for peritoneal only laparoscopic inadequate size of the prosthesis, and incorrect kind of fixation
hernioplasty. of the mesh. It is important to reach on overlap of at least 2-3 cm
Laparoscopic hernia repair is a technique that cannot be from the hernia edge; if this is not possible the possibility of
learned as quickly as the conventional open technique by young migration of the prosthesis is too high. The use of fibrin glue to
surgeons or by surgeons who are not expert in minimal-invasive fix the mesh was not associated with an increased recurrence
surgery. Some surgeons consider a good learning curve of about rate, but no significant difference were observed in terms of
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250 operations for laparoscopic hernia repair to reach a neuropathic complications or seroma. It is the use of a 5 mm
recurrence rate similar to that of the Lichtenstein’s technique. trocar rather than 10 mm that reduces intraoperative bleeding,
This is not correct, as a young surgeon who works in a and postoperative trocar site pain, as well as incisional hernias.
mininvasive surgical department can easily learn the minimal- The use of Tissucol reduces epigastric vessels incidental
invasive technique working with an expert senior surgeon. lesions, and has a hemostatic effect, reducing hematomas.
The operative cost of laparoscopy is higher, but it is The operative time is longer by about 10 minutes compared
important to consider the results and patient satisfaction. The with the use of staples; this is due primarily to the peritoneum
costs depend on the operative time, use of disposable closure using a running laparoscopic suture. The operative
instruments, type of mesh and method of fixation, hospital stay, costs of the two techniques is similar if we use 2 ml of Tissucol
and time to return to normal activity. 28,29 In many cases however, for each hernia. In some studies the use of fibrin glue was less
the laparoscopic approach is adopted at the request of the expensive than stapling. 24
patient during their first visit. Complications in laparoscopic Results and complications (832 Patients)
approach may be important but are related to the surgeon’s
laparoscopic experience and to a good knowledge of Fibrin glue use Staples use
laparoscopic anatomy which can avoid the risks of vascular or Operative time (minutes) 35 25
nerve injury during dissection or clips positioning. Others Discharge (hours) 24 24
Complications:
complications are typical of laparoscopy (trocar lesions, • Groin chronic pain 0% 0%
electrocautery lesions, and so on). • Hematoma of scrotum 0% 1.14%
A laparoscopic or conventional open approach to repair • Seroma 2.4% 2.29%
inguinal hernia is used depending on the characteristics of the • Trocar hernia 0% 1.14%
• Trocar site bleeding
0%
4.41%
patient and hernia type, but when possible a minimal invasive • 10 mm trocar site pain 0% 5.88%
approach gives the patients more benefits and better results. Reccurence rate 0 0
The possibility of using different methods to fix the mesh, during Using the TAPP technique, chronic pain was only observed
recent years, may be an interesting possibility to reduce the in 0.13%. A statistically significant difference was found
complication rate and to obtain better postoperative recovery. concerning postoperative pain 30 days after surgery on the
The first experience in the use of human fibrin glue (Tissucol) right flank in the area of the 10 mm trocar. Other differences that
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for mesh fixation was in open hernia repair. For laparoscopic are worth mentioning are those related to some postoperative
hernia repair the possibility of nerve injury (pain or paresthesia) complications due to the 10 mm trocar on the right flank: reduced
caused by entrapment from incorrect placement of staples bleeding, reduced postoperative discomfort and the lower risk
(above all lateral cutaneus femoral nerve, but ilioinguinal, and of incisional hernias.This was a pilot study; it of course needs
genitofemoral are also at risk) 13,30 and epigastric vessels lesion confirmation in a larger randomized trial.
by clips application may be avoided using fibrin glue either in In some studies, TAPP hernia repair with Tissucol resulted
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the TAPP technique or in the TEP. 24,31 It seems that not only in a low rate of postoperative pain and rapid resumption of
entrapment but also postoperative fibrous scar around the normal activities. Postoperative complications affected only
staples can lead to nerve injury. 16 2.2% (7/320) of the hernias and were readily treated without the

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