Page 44 - WJOLS - Surgery Journal

Fibrin Sealant versus Use of Tackers for Fixation of Mesh in Laparoscopic Inguinal Hernia Repair
need to extend the hospital stay. Importantly, no recurrences of the nonfixed mesh group. In addition, histological
have been observed in this study. These results compare examinations revealed that the fibrin glue triggered a stronger
favorably with those reported by other studies of laparoscopic fibrous reaction and inflammatory response with more
hernia repair. A multicenter study of 9,955 laparoscopic hernia fibroblastic mesh ingrowth in comparison to the other two
repairs reported postoperative complication rates of 4.6% for groups. This again suggests that mesh fixation is preferable
hematomas, 2% for neuralgias, and 0.4% for chronic pain. 46 and that the fibrin glue meets the requirements for both efficiency
Reports of persistent neuralgia with inguinal pain attributable and security of fixation.
to stapling vary in the literature from 0.5 to 14%. 37,41,46 It applies particularly to unilateral TEP repairs but more so
49
In a study by Stark et al, the rate of nerve entrapment in to bilateral repairs in which the dissected space for the mesh
laparoscopic patients was 4.2% (19/448). The genitofemoral implantation is the same as the working space, making it larger
nerve was affected with a high frequency (2%), and the than needed for mesh placement as opposed to the space in
ilioinguinal or lateral cutaneous nerve of the thigh was affected which mesh is placed in TAPP repairs. The recurrence rate in
in 1.1% of the cases. the fibrin glue group was slightly lower than in the tack staples
Some studies have investigated the use of mesh without group but did not differ significantly, and the case of recurrence
any fixation. Like the application of fibrin glue, this method is reported in the fibrin glue group is probably related to an
23
nontraumatic because it avoids all stapling problems. Ferzli inadequate mesh size in a large direct hernia. Overall, the
39
et al reported a 1.8% recurrence rate for patients without recurrence rate in the fibrin glue group remains within the value
fixation of their prosthesis. Other studies comparing stapling range of most of the reports on TEP repairs irrespective of mesh
without fixation of the mesh found no difference. 41,47,48 fixation. 39,49,52
However, these studies have been criticized as having too
few patients, too short a follow-up period (range, 1-32 months), DISCUSSION
or too great a loss to follow-up evaluation(8-12% of During the past few years, there has been more focus on the
patients). 5,6 The size of the prosthesis is an important factor. pain that may arise after groin hernia surgery. Chronic pain
In few experience, fixation of a 14.13 cm mesh ensures better after hernia surgery is a complex and controversial problem that
prosthesis stability, and consequently less dislocation and affects not only open but also laparoscopic procedures. Three
recurrence. The use of smaller stapled prostheses (11·6 cm) is pain syndromes have been identified: somatic, neuropathic,
associated with recurrence rates of up to 5%, whereas patients and visceral pain. Besides nerve damage during dissection,
42
treated using TAPP with no mesh fixation have recurrence rates thermal injury due to electrocautery, and inflammatory and/or
as low as 0.16%. 41,47 Inadequate lateral fixation is a main cause mechanical reaction to the mesh, stapling of the mesh is the
38
of recurrence after both TAPP (36%) and TEP (22%). The most frequent evocated mechanism. 34,45,48
reason for this is that most of the nerves run laterally where no Among other potential factors causing postoperative pain
staples can be applied. is the repair of recurrent hernias. There is a great variation in the
Gluing a large mesh on the triangles of disaster and pain is rate of postoperative chronic pain, ranging from 0.1 to 0.4% and
likely to stop the prosthesis from lifting and dislocating, thereby 22.5% 41,45,49 in laparoscopic repairs for which staples are used
38
avoiding inferomedial and inferolateral recurrence, as seen in to attach the mesh. Among the explanations for such a wide
45
0.4% (3/715) of the hernias treated with staples. Fibrin glue is discrepancy are the range of pain evaluation methods used,
reported to have hemostatic properties,thus reducing seroma which include clinical examination of the patients, phone calls,
and hematoma formation. 44 and mailed questionnaires and tools to score the severity of the
In other study, the incidence of postoperative seromas pain. Some studies have reported only cases of pain clinic
was1.8% (6/320), whereas the incidence reported in the attendance, possibly underestimating the problem. 8
literature varies from 3.8 to 10.5%. 40,41,47 Tissucol also is The rate of chronic postoperative pain observed in the tack
cheaper than any other means of mesh fixation. For example, staples group (14.7%) is among the highest reported in the
1 ml of Tissucol costs e80, as compared with e300 for literature, 45,49 but it included all patients who reported even
Endoanchor (Ethicon Endo-Surgery) and e250 for Protak (Tyco, transient or mild pain in the long-term. To date, the series
Norwalk, CT, USA). The use of fibrin glue instead of stapling reporting the lowest postoperative chronic pain rates have not
means that the TAPP procedure is nontraumatic and minimally used any means of mesh fixation. 34,35,52
52
34
invasive, as evidenced by the absence of inguinofemoral pain Tamme et al. and Beattie et al. observed 2.55 and 0%
in this study. 36 chronic pain problems, respectively, after TEP repair, with a
In an animal study in which TEP groin hernia repairs were recurrence rate of less than 0.6%. However, the largest of these
43
performed, Katkhouda et al. demonstrated that graft motion two series did not specify the length of follow-up and the other
and tensile strength were similar in the staples and fibrin glue one was a rather small series (n = 89). Although two randomized
groups, and both were significantly superior compared to those studies with a short follow-up of nonfixed mesh in laparoscopic

45