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ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 1  |  Page : 140-144

Use of human fibrin glue versus staples for mesh fixation in laparoscopic transabdominal preperitoneal hernioplasty of inguinal hernia


Department of General Surgery, Faculty of Medicine, Menoufia University, Shebin El Kom, Menoufia, Egypt

Date of Submission17-Oct-2016
Date of Acceptance12-Dec-2016
Date of Web Publication14-Jun-2018

Correspondence Address:
Mohammed A Badr Etman
Department of General Surgery, Faculty of Medicine, Menoufia University, Shebin El Kom, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.234229

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  Abstract 


Objective
Toevaluate the uses of human fibrin glue versus staples for mesh fixation in laparoscopic transabdominal preperitoneal(TAPP) hernioplasty of inguinal hernia as regards postoperative pain, operative time, hospital stay, morbidity, and return to work.
Background
Inguinal hernia is one of the commonest conditions encountered in clinical practice. This procedure is increasingly performed with laparoscopy. Many surgeons prefer to cover the hernia gap with a mesh to prevent recurrence. During laparoscopic surgery, the mesh is generally fixed with staples or tissue glue. We designed a trial that aims to determine whether mesh fixation with glue might cause less postoperative pain than fixation with staples during TAPP repair.
Patients and methods
Between August 2015 and August 2016, this prospective randomized study included 40patients presented with inguinal hernia. Patients were randomized into two groups: groupI mesh was fixed by fibrin glue and the groupII mesh was fixed using staples. After TAPP hernioplasty, patients were followed up at 7–10days to assess postoperative pain and within 6–12months to detect recurrence.
Results
A total of 40patients, 20 in each group, were considered. Two cases in groupII presented with severe pain postoperative, while no cases presented with severe pain in groupI. On the other hand, nine cases in groupII had mild pain in comparison with two cases in group one and this difference was statistically significant.
Conclusion
There is less postoperative pain in mesh fixation with fibrin glue and less analgesia is needed after the operation compared with mesh fixation with staples.

Keywords: fibrin glue, inguinal hernia, laparoscopy, mesh, postoperative pain, staples


How to cite this article:
ZeinElden AA, Moustafa AF, Shaker Nassar MN, Badr Etman MA. Use of human fibrin glue versus staples for mesh fixation in laparoscopic transabdominal preperitoneal hernioplasty of inguinal hernia. Menoufia Med J 2018;31:140-4

How to cite this URL:
ZeinElden AA, Moustafa AF, Shaker Nassar MN, Badr Etman MA. Use of human fibrin glue versus staples for mesh fixation in laparoscopic transabdominal preperitoneal hernioplasty of inguinal hernia. Menoufia Med J [serial online] 2018 [cited 2018 Oct 17];31:140-4. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/140/234229




  Introduction Top


Hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containingcavity [1].

Inguinal hernias are the most common hernia; they account for 90% of all spontaneous hernias. Moreover, inguinal hernia repair is the most frequently performed procedure in general surgery [2].

The standard method for repairing an inguinal hernia, originally described by Bassini in 1889, is to close the inguinal canal with sutures. Owing to the high recurrence rate with this technique, new methods were established that used tension-free implantation of synthetic meshes [3].

With the revolution in laparoscopic surgery in 1990 came the development of inguinal hernia repairs using the introduction of mesh through a laparoscope. There are two major laparoscopic approaches, the transabdominal preperitoneal repair(TAPP) and the total extraperitoneal repair [4].

There are many indications for both techniques, but the TAPP repair is particularly recommended for recurrent hernias and difficult hernias(sliding or incarcerated hernias) [4].

The TAPP repair has the advantage that it is easier to perform, learn, can be better standardized, and offers the possibility to perform a diagnostic laparoscopy [5].

In general, the TAPP repair is easier to learn than the total extraperitoneal repair. Most randomized studies that compared laparoscopic with open repair found that laparoscopy was associated with less postoperative pain, earlier return to work, higher costs, a longer operating time, a longer learning period, and a higher recurrence and complication rate during the early learning phase [6].

In TAPP repair mesh fixation can be done through different methods such as tacker clips and fibrin glue and suturing and self-adhesive mesh or leaving mesh without fixation [7],[8].

There is less postoperative pain and more rapid recovery after glue fixation than after staple fixation, without any significant difference in recurrence rate [9].


  Patients and Methods Top


After Menoufia Ethics Committee approval for the study proposal and between August 2015 and August 2016, this prospective randomized study was conducted in Menoufia University Hospitals. Randomization was carried out as listed by the randomization technique in Microsoft Excel Program.

Forty patients with inguinal hernia were included in this study. Patients were divided into two groups:

GroupA: the mesh was fixed by fibrin glue.

GroupB: the mesh was fixed by staples.

  1. Inclusion criteria:


    1. Age: 18years or older complaining of primary inguinal hernia
    2. Sex: male and female
    3. No current treatment with psychopharmaceutical drugs
    4. Informed consent
    5. No comorbidity or allergy to drugs


  2. Exclusion criteria:


    1. Patients unfit for general anesthesia
    2. Patients with systemic disease that is forming a constant threat to their life
    3. Those with complicated inguinal hernia such as irreducibility, bowel obstruction, bowel strangulation, peritonitis, or bowel perforation
    4. Patients under 18years of age.


    Each patient was subjected to full history taking, thorough clinical examination, laboratory investigations, and radiological investigation in the form of chest radiography and pelviabdominal ultrasound.

    Preoperative fasting for 8h. Abdominal and groin hair was shaved from costal margin to middle of the thigh.

    All patients received general anesthesia. Aprophylactic dose of antibiotic was given at induction of anesthesia [10].

    At an umbilical site, a Veress needle is inserted to induce a pneumoperitoneum, and then the needle is replaced with a 10–12mm optical trocar. Next, two 5mm trocars are positioned bilaterally on the umbilical line in the iliac fossa. An incision is made in the peritoneal wall, starting at the level of the superior margin of the internal inguinal ring and at the level of the epigastric vessels. The incision is extended medially, up to the medial umbilical ligament, and then laterally to anterior superior iliac spine; the total incision length is 7–8cm.

    In the presence of a direct hernia, the hernial sac is directly isolated and reduced. In the case of an indirect or femoral hernia, the preperitoneal parapubic adipose tissue is carefully dissected medially to expose the horizontal pubic ramus and Cooper's ligament. Accurate dissection of the preperitoneal retrovesical tissue facilitates positioning the mesh. The internal inguinal ring is explored, and the hernial sac is isolated and reduced, then mesh is inserted like a proline mesh. The mesh is cut to 10×13cm and placed in the preperitoneal space. The mesh covers Cooper's ligament, rests on the inguinal region, and it extends laterally over the epigastric vessels, followed by mesh fixation either by staples or glue, and then the peritoneum will be returned to its anatomical position by staplesor using Vicryl 3/0 (One Johnson & Johnson Plaza, New Brunswick, New Jersey, U.S.). All data were collected and statistically analyzed to present the results.

    The follow-up for postoperative pain was 7–10days and 6–12months to detect recurrence in each group.

    Statistical analysis

    Statistical presentation and analysis of the present study were conducted using the statistical package for the social sciences(SPSS, version20; SPSS Inc., Chicago, Illinois, USA) on an IBM compatible computer.

    Descriptive statistics included percentage, mean±SD value.

    Meanvalue is the sum of all observations divided by the number of observations.

    SD measures the degree of scatter of individual values around their mean.

    Analysis of variance was performed for comparison among different times in the same group for quantitative data, using the computer program SPSS for Windows.


      Results Top


    This study was conducted at Menoufia University Hospital over a period from August 2015 to August 2016. It included 40patients complaining of inguinal hernia who were fit for the surgery.

    All of them underwent laparoscopic(TAPP) hernioplasty. Patients were randomly divided into two groups:

    GroupI mesh was fixed by fibrin glue.

    GroupII mesh was fixed by staples.

    The patient's age ranged from 18 to 55years.

    Patients were followed up by routine clinical examination for 6months up to 12months to determine the incidence of recurrence in each group.

    This study did not find statistically significant differences between the two groups as regards age[Table1].
    Table 1: Difference between the two groups regarding patient characteristics: age

    Click here to view


    There was no statistically significant difference between the two groups regarding sex[Table2].
    Table 2: Difference between the two groups regarding patient characteristics: sex

    Click here to view


    There was no statistically significant difference between the two groups as regards operative duration[Table3].
    Table 3: Operative time among the studied groups

    Click here to view


    Two cases in groupII presented with severe postoperative pain, while no cases presented with severe pain in groupI. On the other hand, nine cases in groupII had mild pain in comparison with two cases in group one and this difference was statistically significant(P=0.0003)[Table4].
    Table 4: Postoperative pain among the studied groups

    Click here to view


    There was no statistically significant difference between the two groups; as regards intraoperative complication one case in groupII had intraoperative surgical emphysema and oozing of blood[Table5].
    Table 5: Intraoperative complication among the studied groups

    Click here to view


    There was no statistically significant difference between two groups as regards postoperative hospital stay. However in groupII, three cases stayed more than 1day as they were complaining of pain and scrotal edema[Table6].
    Table 6: Hospital stay among the studied groups

    Click here to view


    There was no statistically significant difference between the two groups as regards recurrence: there is no recurrent cases in groupI and there was one case in groupII[Table7].
    Table 7: Postoperative recurrence among the studied groups

    Click here to view



      Discussion Top


    Inguinal hernia is the commonest problem among all external hernias and surgery for inguinal hernia is one of the most common procedures performed in a general surgical service, accounting for approximately one-third of all interventions. Although many patients are asymptomatic, most of them have local symptoms and, if left untreated, hernia itself has potential complications such as irreducibility, incarceration, strangulation, peritonitis, and sepsis. Since inguinal hernia repair represents one of the most frequently performed surgical procedures, mesh repair is accepted as a gold standard in inguinal hernia repair worldwide [11].

    The laparoscopic operations caused significantly less pain in the early postoperative period, leading to earlier mobilization and earlier return to work than open mesh repair. This was clearly seen in the manual workers who have undergone laparoscopic operation [12].

    Laparoscopic TAPP has the following potential advantages:

    • The ability to treat bilateral hernia
    • Easier repair of recurrent hernia because repair is done in tissues that have not been previously dissected
    • Less postoperative pain and discomfort
    • Reduced recovery time allowing early return to full activity
    • The highest possible ligation of the sac
    • Improved cosmoses [12].


    One of the controversies in TAPP is how to fix the mesh. Mesh can be fixed either by fibrin glue, tucker clips, or leaving the mesh without fixation [12].

    In this study, we found the average time of surgery for laparoscopic TAPP was about 45min but it differs between the two methods used for mesh fixation; it was about 45min in groupI, about 50min in groupII. This difference was statistically insignificant in agreement with Lau etal. [13] who mentioned that the mean operative duration for laparoscopic TAPP inguinal hernioplasty was about 45min.

    In this study, the difference between the two groups regarding intraoperative complications was statistically insignificant. In groupI there were no intraopeartive complications, but in groupII one case had intraopeartive complications in the form of surgical emphysema, and oozing of blood during dissection and this agrees with McComark etal. [14]. Having said that, intraoperative complications such as surgical emphysema was insignificant as expected after gas insufflation and resolved spontaneously in the two groups.

    There was no statistically significant difference between the two groups regarding postoperative hospital stay. The mean hospital stay after laparoscopic TAPP was 1day, but in groupI two cases have stayed more than 1day(10%) as they were complaining of groin pain and in groupII also three cases have stayed more than 1day(15%) as they complained of scrotal edema and groin pain. These results agree with the results of Cheah etal. [15]. Having said that postoperative hospital stay in groupI whose mesh was fixed by using fibrin glue was 1day, but in groupII whose mesh was fixed by staples, two cases have stayed for more than 1day.

    In this study, the difference between the two groups regarding postoperative recurrence was statistically insignificant as there were no recurrent cases in groupI(0%) and one recurrent case in groupII(10%). The recurrence that occurred in groupII may be due to mesh migration or may be due to not fixing the mesh; this agrees with the result of Andersson etal. [16] who reported that there was no recurrent case in groupI(0%) in which the mesh was fixed by fibrin glue and one case recurrent in groupII(10%) in which the mesh was fixed by staples.

    In this study, the differences between the two groups regarding postoperative pain were statistically significant; there were two cases in groupII complaining of severe postoperative pain(10%), while no cases presented with severe pain in groupI. On the other hand, nine cases in groupII(45%) had mild pain in comparison with two cases in groupI(10%), which agrees with Andersson etal. [16] who reported that postoperative pain is less in fibrin glue fixation than with staples.


      Conclusion Top


    Mesh fixation by fibrin glue is better than with staples as mesh fixation with glue causes less postoperative pain and less analgesia is needed.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

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    KnookMT, WiedemaWF, StassenLP, van SteenselCJ. Endoscopic trans abdominal pre peritoneal repair of primary and recurrent inguinal hernias. Surg Endosc 1999; 13:507–511.  Back to cited text no. 12
        
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    McCormackK, ScottNW, GoPM, RossS, GrantAM. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2003; 1:1785–1791.  Back to cited text no. 14
        
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        Tables

      [Table1], [Table2], [Table3], [Table4], [Table5], [Table6], [Table7]



     

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Introduction
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