|Year : 2018 | Volume
| Issue : 1 | Page : 140-144
Use of human fibrin glue versus staples for mesh fixation in laparoscopic transabdominal preperitoneal hernioplasty of inguinal hernia
Ashraf A ZeinElden, Asem F Moustafa, Mohammed N Shaker Nassar, Mohammed A Badr Etman
Department of General Surgery, Faculty of Medicine, Menoufia University, Shebin El Kom, Menoufia, Egypt
|Date of Submission||17-Oct-2016|
|Date of Acceptance||12-Dec-2016|
|Date of Web Publication||14-Jun-2018|
Mohammed A Badr Etman
Department of General Surgery, Faculty of Medicine, Menoufia University, Shebin El Kom, Menoufia
Source of Support: None, Conflict of Interest: None
To evaluate 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.
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 40 patients presented with inguinal hernia. Patients were randomized into two groups: group I mesh was fixed by fibrin glue and the group II mesh was fixed using staples. After TAPP hernioplasty, patients were followed up at 7–10 days to assess postoperative pain and within 6–12 months to detect recurrence.
A total of 40 patients, 20 in each group, were considered. Two cases in group II presented with severe pain postoperative, while no cases presented with severe pain in group I. On the other hand, nine cases in group II had mild pain in comparison with two cases in group one and this difference was statistically significant.
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 2021 Apr 23];31:140-4. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/140/234229
| Introduction|| |
Hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity .
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 .
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 .
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 .
There are many indications for both techniques, but the TAPP repair is particularly recommended for recurrent hernias and difficult hernias (sliding or incarcerated hernias) .
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 .
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 .
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 ,.
There is less postoperative pain and more rapid recovery after glue fixation than after staple fixation, without any significant difference in recurrence rate .
| Patients and Methods|| |
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:
Group A: the mesh was fixed by fibrin glue.
Group B: the mesh was fixed by staples.
- Inclusion criteria:
- Age: 18 years or older complaining of primary inguinal hernia
- Sex: male and female
- No current treatment with psychopharmaceutical drugs
- Informed consent
- No comorbidity or allergy to drugs
- Exclusion criteria:
- Patients unfit for general anesthesia
- Patients with systemic disease that is forming a constant threat to their life
- Those with complicated inguinal hernia such as irreducibility, bowel obstruction, bowel strangulation, peritonitis, or bowel perforation
- Patients under 18 years 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 8 h. Abdominal and groin hair was shaved from costal margin to middle of the thigh.
All patients received general anesthesia. A prophylactic dose of antibiotic was given at induction of anesthesia .
At an umbilical site, a Veress needle is inserted to induce a pneumoperitoneum, and then the needle is replaced with a 10–12 mm optical trocar. Next, two 5 mm 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 7–8 cm.
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 × 13 cm 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 staples or 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 7–10 days and 6–12 months to detect recurrence in each group.
Statistical presentation and analysis of the present study were conducted using the statistical package for the social sciences (SPSS, version 20; SPSS Inc., Chicago, Illinois, USA) on an IBM compatible computer.
Descriptive statistics included percentage, mean ± SD value.
Mean value 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|| |
This study was conducted at Menoufia University Hospital over a period from August 2015 to August 2016. It included 40 patients complaining of inguinal hernia who were fit for the surgery.
All of them underwent laparoscopic (TAPP) hernioplasty. Patients were randomly divided into two groups:
Group I mesh was fixed by fibrin glue.
Group II mesh was fixed by staples.
The patient's age ranged from 18 to 55 years.
Patients were followed up by routine clinical examination for 6 months up to 12 months to determine the incidence of recurrence in each group.
This study did not find statistically significant differences between the two groups as regards age [Table 1].
|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 [Table 2].
|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 [Table 3].
Two cases in group II presented with severe postoperative pain, while no cases presented with severe pain in group I. On the other hand, nine cases in group II had mild pain in comparison with two cases in group one and this difference was statistically significant (P = 0.0003) [Table 4].
There was no statistically significant difference between the two groups; as regards intraoperative complication one case in group II had intraoperative surgical emphysema and oozing of blood [Table 5].
There was no statistically significant difference between two groups as regards postoperative hospital stay. However in group II, three cases stayed more than 1 day as they were complaining of pain and scrotal edema [Table 6].
There was no statistically significant difference between the two groups as regards recurrence: there is no recurrent cases in group I and there was one case in group II [Table 7].
| Discussion|| |
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 .
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 .
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 .
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 .
In this study, we found the average time of surgery for laparoscopic TAPP was about 45 min but it differs between the two methods used for mesh fixation; it was about 45 min in group I, about 50 min in group II. This difference was statistically insignificant in agreement with Lau et al.  who mentioned that the mean operative duration for laparoscopic TAPP inguinal hernioplasty was about 45 min.
In this study, the difference between the two groups regarding intraoperative complications was statistically insignificant. In group I there were no intraopeartive complications, but in group II one case had intraopeartive complications in the form of surgical emphysema, and oozing of blood during dissection and this agrees with McComark et al. . 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 1 day, but in group I two cases have stayed more than 1 day (10%) as they were complaining of groin pain and in group II also three cases have stayed more than 1 day (15%) as they complained of scrotal edema and groin pain. These results agree with the results of Cheah et al. . Having said that postoperative hospital stay in group I whose mesh was fixed by using fibrin glue was 1 day, but in group II whose mesh was fixed by staples, two cases have stayed for more than 1 day.
In this study, the difference between the two groups regarding postoperative recurrence was statistically insignificant as there were no recurrent cases in group I (0%) and one recurrent case in group II (10%). The recurrence that occurred in group II may be due to mesh migration or may be due to not fixing the mesh; this agrees with the result of Andersson et al.  who reported that there was no recurrent case in group I (0%) in which the mesh was fixed by fibrin glue and one case recurrent in group II (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 group II complaining of severe postoperative pain (10%), while no cases presented with severe pain in group I. On the other hand, nine cases in group II (45%) had mild pain in comparison with two cases in group I (10%), which agrees with Andersson et al.  who reported that postoperative pain is less in fibrin glue fixation than with staples.
| Conclusion|| |
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Abrahamson J. Hernias in Maingot's abdominal operations. Zinner M, Schwartz S, Ellis S, editors. Appleton and Lang
ed. Stanford: Prentice hall international; 1997. 1
Moazzez A1, Mason RJ, Katkhouda N. A new technique for minimally invasive abdominal wall reconstruction of complex incisional hernias: totally laparoscopic component separation and incisional hernia repair. Surg Technol Int. 2010; 20
Amid PK. Lichtenstein tention free hernioplasty. In: Baker R, Fischer J. Mastry of surgery
ed. Philadelphia, PA: Lippincott Williams and Wilkins Co.; 2001. 1968–1974.
Amid PK. Lichtenstein tention free hernioplasty for the repair of primary and recurrent inguinal hernias. In: Fitzgibbson RJ, Greenburg AG, editors. Nyhus and Condon's hernia
ed. Philadelphia, PA: Lippincott Williams and Wilkins Co.; 2002. 14
Bendavid R. Complications of groin hernia surgery. Surg Clin North Am 1998; 78
Bird SB, Dickson EW. Clinically significant changes in pain along the visual analog scale. Ann Emerg Med 2001; 38
Bogojavlensky S. Laparoscopic treatment of inguinal hernia. Presented at the 18th annual meeting of the American Association of Gynachological Laparoscopist
. Washington, DC: Bull. John Hopkins; 1893. 4
Avisse C, Delattre JF, Jean-Bernard F. The inguinofemoral area from a laparoscopic stand point. Surgical Clinics of North America 1989; 80
Colack T, Akca T, Aydin S. Randamized Clinical trial comparing laparoscopic totally extraperitoneal approach with open mesh repair of ingunal hernia repair, Surg Lap Endosc Percut Tech 2003; 13
Ibrahim AH, El-Gammal AS, Heikal MMM. Comparative study between 'onlay' and 'sublay' hernioplasty in the treatment of uncomplicated ventral hernia. Menoufia Med J 2015; 28:
Kingsnorth A, Leblance K. Inguinal and incisional hernia. Lancet 2003; 362
Knook MT, Wiedema WF, Stassen LP, van Steensel CJ. Endoscopic trans abdominal pre peritoneal repair of primary and recurrent inguinal hernias. Surg Endosc 1999; 13
Lau H. Fibrin sealant versus mechanical stapling for mesh fixation during endoscopic trans abdominal preperitoneal inguinal hernioplasty. Ann Sur 2002; 242:
McCormack K, Scott NW, Go PM, Ross S, Grant AM. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2003; 1
Cheah WK, So JB, Lomanto D. Endoscopic extraperitoneal ingunal hernia repair. Singapore Med J 2004; 45
Andersson B, Hallen M, Leveau P, Bergenfel A, Westerdahl J. Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair, a prospective randomized controlled trial. Surgery 2003; 133
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]