Laparoscopic repair of inguinal hernias using an intraperitoneal onlay mesh technique and a Parietex composite mesh fixed with fibrin glue (Tissucol). Personal technique and preliminary results

Strategy for laparoscopic repair of inguinal hernia after robot-assisted radical prostatectomy

INTRODUCTION

Robot-assisted radical prostatectomy (RARP) is nowadays being performed worldwide, and inguinal hernia (IH) continues to be a common complication of radical prostatectomy. Laparoscopic repair of IH is often difficult via internal dissection because of adhesion of the preperitoneal cavity. This study aimed to categorize the intraoperative condition of, and devise a strategy for, IH after RARP.

METHODS

Of 577 patients who underwent RARP, 18 developed IH. These 18 patients then underwent laparoscopic IH repair using the transabdominal preperitoneal approach (TAPP) or modified intraperitoneal onlay mesh repair (mIPOM). Internal dissection was categorized into two groups according to the appearance of Cooper's ligament (exposed or not exposed).

RESULTS

After RARP, four patients had exposure of Cooper's ligament while 14 patients showed no exposure. Both patients in the exposed group underwent TAPP and all patients in the not-exposed group underwent mIPOM. There was no significant difference between normal TAPP and RARP regarding operative factors, and IH recurrence was not observed.

CONCLUSION

Laparoscopic repair of IH after RARP is rendered safe and efficient by using our categorization based on the exposure of Cooper's ligament and extension of preperitoneal space.

Use of fibrin glue in bariatric surgery: analysis of complications after laparoscopic sleeve gastrectomy on 450 consecutive patients

Laparoscopic Sleeve Gastrectomy (LSG) is one of the most performed surgical procedures in bariatric surgery. Staple line leak and bleeding are by far the two most feared complications after LSG. In this study, we retrospectively compared the efficacy of Fibrin Glue in preventing staple line leak and bleeding. From September 2019 to January 2020, 450 obese patients underwent elective LSG and were placed into groups with Fibrin Glue reinforcement (Group A) or without Fibrin Glue reinforcement (Group B). Primary endpoints were postoperative staple line leak and bleeding; while, secondary endpoints were reintervention rate, total operative time and mortality. Mean Body Mass Index (BMI) was 45.4 ± 7.9 kg/m² (range: 35.1-81.8). Mean age was 43.3 ± 11.8 years (range: 18-65). No intraoperative complications or conversion to laparotomy were reported. Mean operative time was comparable between the groups (48 ± 18 min in Group A vs 48 ± 14 min in Group B; p > 0.05). No decrease in overall postoperative complications was found in Group A (5.1% vs 7.0%; p > 0.05), but after stratification according to Clavien-Dindo classification, we found a higher rate of Grade II (0.0% vs 1.6%; p < 0.05) and Grade IIIb (0.0% vs 1%; p < 0.05) complications in group B. Our study showed that Fibrin Glue as a reinforcement method during LSG is a reliable tool, without affecting the operative time of surgery and mortality. A significant reduction in complications (Clavien-Dindo grade II and grade IIIb) was observed in patients undergoing LSG with Fibrin Glue.

Causes of recurrence in laparoscopic inguinal hernia repair

PURPOSE

Recurrence after laparoscopic inguinal herniorrhaphy is poorly understood. Reports suggest that up to 13% of all inguinal herniorrhaphies worldwide, irrespective of the approach, are repaired for recurrence. We aim to review the risk factors responsible for these recurrences in laparoscopic mesh techniques.

METHODS

A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified English language, peer reviewed articles on the causes of recurrence following laparoscopic mesh inguinal herniorrhaphy published between 1990 and 2018. The search terms included 'Laparoscopic methods', 'Inguinal hernia; Mesh repair', 'Recurrence', 'Causes', 'Humans'.

RESULTS

The literature revealed several contributing risk factors that were responsible for recurrence following laparoscopic mesh inguinal herniorrhaphy. These included modifiable and non-modifiable risk factors related to patient and surgical techniques.

CONCLUSIONS

Recurrence can occur at any stage following inguinal hernia surgery. Patients' risk factors such as higher BMI, smoking, diabetes and postoperative surgical site infections increase the risk of recurrence and can be modified. Amongst the surgical factors, surgeon's experience, larger mesh with better tissue overlap and careful surgical techniques to reduce the incidence of seroma or hematoma help reduce the recurrence rate. Other factors including type of mesh and fixation of mesh have not shown any difference in the incidence of recurrence. It is hoped that future randomized controlled trials will address some of these issues and initiate preoperative management strategies to modify some of these risk factors to lower the risk of recurrence following laparoscopic inguinal herniorrhaphy.

Laparoscopic Experience for Recurrent Inguinal Hernia Repair in a Single Center for 14 Years

Laparoscopic techniques are now well pervading in the treatment of inguinal hernia. This study aims to investigate the laparoscopic strategy for recurrent inguinal hernia repair. Laparoscopic technique was retrospectively applied to 330 patients with 352 recurrent inguinal hernias in the past 14 years. The surgical strategies were further evaluated. There were 22 cases with bilateral recurrent hernias, whereas the rest 308 cases with unilateral disorders. Patients were further categorized by previous repair approaches as high ligation, sclerotherapy, conventional suture repair, Lichtenstein repair, plug and patch repair, and preperitoneal repair. All cases were successfully repaired by laparoscopic approaches including transabdominal preperitoneal (TAPP) (288 cases), totally extraperitoneal (50 cases), and intraperitoneal onlay mesh (14 cases). The median operation duration was 39.5 ± 13.4 minutes. The average Visual Analog Scales score on postoperative day 1 was 2.4 ± 1.1. The median follow-up time was 36 (14–61) months. There was one case of recurrence during the follow-ups. One severe complication, i.e., bowel injury, was observed and cured, whereas other complications were as follows: 22 seroma, 8 urinary retention, 3 transient paresthesia, and 1 ileus. Laparoscopic procedures for recurrence inguinal hernia are safe and applicable. A surgeon can choose to reinforce the myopectineal orifice or only fix the hernia defect accordingly. The strategy of choosing TAPP and/or totally extraperitoneal depends on the type of previous repair, the exact anatomical position of the previous implanted mesh, and more importantly, the surgeon's experience. Moreover, the intraperitoneal onlay mesh technique can be regarded as a backup option for TAPP in certain cases.

The use of fibrin sealant during non-emergency surgery: a systematic review of evidence of benefits and harms

BACKGROUND

Fibrin sealants are used in different types of surgery to prevent the accumulation of post-operative fluid (seroma) or blood (haematoma) or to arrest haemorrhage (bleeding). However, there is uncertainty around the benefits and harms of fibrin sealant use.

OBJECTIVES

To systematically review the evidence on the benefits and harms of fibrin sealants in non-emergency surgery in adults.

DATA SOURCES

Electronic databases [MEDLINE, EMBASE and The Cochrane Library (including the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment database and the Cochrane Central Register of Controlled Trials)] were searched from inception to May 2015. The websites of regulatory bodies (the Medicines and Healthcare products Regulatory Agency, the European Medicines Agency and the Food and Drug Administration) were also searched to identify evidence of harms.

REVIEW METHODS

This review included randomised controlled trials (RCTs) and observational studies using any type of fibrin sealant compared with standard care in non-emergency surgery in adults. The primary outcome was risk of developing seroma and haematoma. Only RCTs were used to inform clinical effectiveness and both RCTs and observational studies were used for the assessment of harms related to the use of fibrin sealant. Two reviewers independently screened all titles and abstracts to identify potentially relevant studies. Data extraction was undertaken by one reviewer and validated by a second. The quality of included studies was assessed independently by two reviewers using the Cochrane Collaboration risk-of-bias tool for RCTs and the Centre for Reviews and Dissemination guidance for adverse events for observational studies. A fixed-effects model was used for meta-analysis.

RESULTS

We included 186 RCTs and eight observational studies across 14 surgical specialties and five reports from the regulatory bodies. Most RCTs were judged to be at an unclear risk of bias. Adverse events were inappropriately reported in observational studies. Meta-analysis across non-emergency surgical specialties did not show a statistically significant difference in the risk of seroma for fibrin sealants versus standard care in 32 RCTs analysed [n = 3472, odds ratio (OR) 0.84, 95% confidence interval (CI) 0.68 to 1.04; p = 0.13; I² = 12.7%], but a statistically significant benefit was found on haematoma development in 24 RCTs (n = 2403, OR 0.62, 95% CI 0.44 to 0.86; p = 0.01; I² = 0%). Adverse events related to fibrin sealant use were reported in 10 RCTs and eight observational studies across surgical specialties, and 22 RCTs explicitly stated that there were no adverse events. One RCT reported a single death but no other study reported mortality or any serious adverse events. Five regulatory body reports noted death from air emboli associated with fibrin sprays.

LIMITATIONS

It was not possible to provide a detailed evaluation of individual RCTs in their specific contexts because of the limited resources that were available for this research. In addition, the number of RCTs that were identified made it impractical to conduct independent data extraction by two reviewers in the time available.

CONCLUSIONS

The effectiveness of fibrin sealants does not appear to vary according to surgical procedures with regard to reducing the risk of seroma or haematoma. Surgeons should note the potential risk of gas embolism if spray application of fibrin sealants is used and not to exceed the recommended pressure and spraying distance. Future research should be carried out in surgery specialties for which only limited data were found, including neurological, gynaecological, oral and maxillofacial, urology, colorectal and orthopaedics surgery (for any outcome); breast surgery and upper gastrointestinal (development of haematoma); and cardiothoracic heart or lung surgery (reoperation rates). In addition, studies need to use adequate sample sizes, to blind participants and outcome assessors, and to follow reporting guidelines.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015020710.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

[Postoperative ventral hernia - unsolved issues of surgical tactics]

Currently, there is no unified opinion on some problematic issues of surgical treatment of postoperative ventral hernias. Current approaches and surgical aspects of primary and recurrent postoperative ventral are reviewed in the article.

Hernioplasty and testicular perfusion

Open and laparoscopic tension-free techniques of hernia repair using synthetic meshes are a well-accepted practice with an excellent patient comfort and a low recurrence rate. It is well known that, direct contact of the mesh to the vessels in the inguinal canal and perimesh fibrosis may have a negative impact on testicular flow. Whether different operative techniques or mesh materials used have an effect on the integrity of the testicle, the influence of the resulting fibrosis on testicular perfusion, and spermatic cord structures is still unclear. Our objective is to review whether there is an association between inguinal hernia and hernia repair techniques, pitfalls of various manipulations and also specific applications on spermatic cord structures and testicular perfusion in view of the literature. Most of the clinical and experimental studies result support the idea that inguinal mesh application for hernioplasty is still a safe procedure in patients. Testicular blood flow may be influenced during open and laparoscopic inguinal hernia surgery. But, so far, there is no evidence for a significant impairment of cord structures after open or laparoscopic hernia repair using tension free techniques. It is clear that fine surgical dissection and reconstruction, doing respect for anatomy and using proper prosthetic material could be obtain the best results. Whether changes in flow parameters remain in the late postoperative period, and whether they have an impact on complications should be evaluated in further clinical and experimental studies.

Use of fibrin sealant (Tisseel/Tissucol) in hernia repair: a systematic review

BACKGROUND

Abdominal wall and inguinal hernia repair are the most frequently performed surgical procedures in the United States and Europe. However, traditional methods of mesh fixation are associated with a number of problems including substantial risks of recurrence and of postoperative and chronic pain. The aim of this systematic review is to summarize the clinical safety and efficacy of Tisseel/Tissucol fibrin sealant for hernia mesh fixation.

METHODS

A PubMed title/abstract search was conducted using the following terms: (fibrin glue OR fibrin sealant OR Tisseel OR Tissucol) AND hernia repair. The bibliographies of the publications identified in the search were reviewed for additional references.

RESULTS

There were 36 Tisseel/Tissucol studies included in this review involving 5,993 patients undergoing surgery for hernia. In open repair of inguinal hernias, Tisseel compared favorably with traditional methods of mesh fixation, being associated with shorter operative times and hospital stays and a lower incidence of chronic pain. Similarly, after laparoscopic/endoscopic inguinal hernia repair, Tisseel/Tissucol was associated with less use of postoperative analgesics and less acute and chronic postoperative pain than tissue-penetrating mesh-fixation methods. Other end points of concern to surgeons and patients are the risks of inguinal hernia recurrence and of complications such as hematoma formation and intraoperative bleeding. Comparative studies show that Tisseel/Tissucol does not increase the risk of these outcomes and may, in fact, decrease the risk compared with tissue-penetrating fixation methods. When used in the repair of incisional hernias, Tisseel/Tissucol significantly decreased both postoperative morbidity and duration of hospital stay.

CONCLUSIONS

Clinical evidence published to date supports the use of Tisseel/Tissucol as an option for mesh fixation in open and laparoscopic/endoscopic repair of inguinal and incisional hernias. Guidelines of the International Endohernia Society recommend fibrin sealant mesh fixation, especially in inguinal hernia repair. Nonfixation is reserved for selected cases.

Natural orifice translumenal endoscopic surgery inguinal hernia repair: a survival canine model

INTRODUCTION

With over 20 million repairs performed worldwide annually, inguinal hernias represent a significant source of disability and loss of productivity. Natural orifice translumenal endoscopic surgery (NOTES™), as a potentially less invasive form of surgery may reduce postoperative disability and accelerate return to work. The objective of this study was to assess the safety and short-term effectiveness of transgastric inguinal herniorrhaphy using a biologic mesh in a survival canine model.

MATERIALS AND METHODS

Under general anesthesia with the animal in Trendelenburg position, a gastrostomy was created. A 4 × 6 cm acellular dermal implant was deployed endoscopically across the myopectineal orifice, draped over the cord structures, and secured with Bioglue. Following completion of bilateral repairs the animals were survived for 14 days. At the end of the study period, the animals were euthanized and a necropsy performed. Cultures of a random site within the peritoneal cavity and at the site of implant deployment were obtained. In addition, a visual inspection of the peritoneal cavity was performed.

RESULTS

All animals thrived postoperatively and did not manifest signs of peritonitis or sepsis at any point. At necropsy accurate placement and adequate myopectineal coverage was confirmed in all subjects. Cultures of a random site within the peritoneal cavity and at the site of implant deployment had no growth.

DISCUSSION

This study confirms that NOTES-inguinal herniorrhaphy using a biologic implant can be performed safely. In addition, the transgastric technique provided good short-term myopectineal coverage without infectious sequelae.

Systematic review of the use of fibrin sealant in abdominal-wall repair surgery

PURPOSE

Our objective was to analyze the advantages and inconveniences associated with the use of fibrin sealant compared with mechanical means for mesh fixation following abdominal-wall surgery.

METHODS

Literature search was conducted in MedLine, EMBASE, and Cochrane Library Plus databases. Articles were randomized clinical trials, nonrandomized comparative studies, and case series containing at least ten patients.

RESULTS

The fibrin sealant was shown to be biocompatible with the surrounding tissue. In patients treated with fibrin sealant, lower prevalence of acute and chronic postoperative pain was observed, and less hemorrhagic complications occurred. There are no data on the influence of fibrin sealant on seroma decrease. Efficiency in experimental models was similar to that observed for mechanical methods of fixation. Also, adhesions with fibrin sealant were less than that for mechanical methods.

CONCLUSIONS

Compared with mechanical methods, fibrin sealant is an efficacious alternative for mesh fixation postsurgery of the abdominal wall.

Laparoscopic incisional hernia repair with fibrin glue in select patients

Hi-Tex dual-sided mesh fixed to the abdominal wall with fibrin glue was successful in the repair of incisional hernia in select patients.

Background and Objective:

Laparoscopic treatment of incisional hernias can be performed using different types of fixation devices and prosthesis. We present a case series of 19 patients with incisional hernias with a diameter of <6cm, who underwent laparoscopic repair using Hi-tex dual-side mesh, positioned intraperitoneally, fixed to the abdominal wall by fibrin glue (Tissucol).

Methods:

Nineteen patients with incisional hernias <6cm in diameter were enrolled in this study and treated laparoscopically with Hi-tex and Tissucol. Surgical complications and patient outcomes were assessed with a clinical follow-up.

Results:

Laparoscopic repair of incisional hernias by using Hi-tex mesh affixed to the parietal wall with fibrin glue was feasible and easy in patients with parietal defects <6cm in diameter. Mean operating time was 30 minutes. Mean hospital stay was 1.5 days. Almost no postoperative pain, major surgical complications, seroma formation, relapses, or prosthesis infection occurred during a mean follow-up of 20 months.

Conclusions:

In select patients, Hi-tex mesh affixed using fibrin glue allows laparoscopic repair of incisional hernias with very good patient outcomes, especially in terms of postoperative pain and seroma formation.

The feasibility of FS mesh fixation by a transgastric approach--an important benefit in future NOTES procedures?

BACKGROUND

Preserving the integrity of the abdominal wall is a major benefit in NOTES procedures. It may result in a decrease of postoperative (postOP) pain, infection, and port site hernia. This experimental study on intra-peritoneal onlay mesh (IPOM) repair was designed to apply meshes by a transgastric access (TGA) and to use a combination of transfascial sutures and fibrin sealant as fixation.

MATERIALS AND METHODS

Four abdominal wall defects were created by TGA under laparoscopic control in five nonsurvival and three survival pigs (4, 11, and 22 d observation period). Titanized polypropylene meshes were fixed transfascially by four polypropylene sutures using a "suture passer" device. Meshes were additionally fixed with 0.2 mL of fibrin sealant (FS) by an endoscopic application. TGA was closed with endoclips in the nonsurvival model and with laparoscopic suturing in survival pigs.

RESULTS

The three survival pigs were euthanized on the d 4, 11, and 22 postOP. The macroscopic evaluation revealed excellent integration of the meshes without signs of shrinkage, dislocation, or inflammation. Histology confirmed macroscopic findings.

CONCLUSIONS

Our findings confirm that IPOM repair of ventral hernia in an experimental NOTES hybrid procedure is feasible. This study also demonstrates the technical feasibility and the potential advantages of FS mesh fixation to further reduce trauma to the abdominal wall following the key principles of the NOTES approach.

Umbrella and roll-up techniques of mesh insertion for laparoscopic hernia repair: a comparative study

BACKGROUND

Deploying a mesh during laparoscopic hernia repair can be difficult and possibly challenging for a trainee surgeon.

METHODS

A novel method of mesh insertion by folding the mesh like the fabric of an umbrella and loading it into the 10-mm cannula for delivery into the peritoneal cavity is described. This method uses the inherent ability of meshes to spring back into shape. In this study on 30 patients who underwent transabdominal preperitoneal hernia repair, the umbrella method of mesh insertion was compared with the traditional roll up type of mesh insertion in terms of easiness mesh deployment and operating time. In bilateral procedures, each side was considered as a separate operation.

RESULTS

The operative time for the mesh insertion was reduced slightly (6 min), from 18 min for the roll-up technique to 12 min for the umbrella technique.

CONCLUSION

The umbrella method has a distinct advantage over the roll-up technique, in which unrolling of the mesh is done in a plane parallel to the mesh. This may explain the time saved, as demonstrated in this pilot study.

Fibrin sealant in inguinal hernioplasty: an observational multicentre study in 1,201 patients

Purpose

A prospective, multicentre, observational study was undertaken to assess Tisseel^® fibrin sealant for atraumatic mesh fixation in inguinal hernia repair throughout France.

Methods

Surgeons recorded data on patients undergoing tension-free inguinal hernioplasty with mesh fixation with Tisseel^®, regardless of the hernioplasty technique used. Assessments were made at 2 days and 1 month after surgery. Data on local complications, operation times and ease of product use were collected.

Results

In total, 1,201 patients were recruited (90% men, mean age 57 years), among which 526 procedures were performed using open techniques and 675 using laparoscopic repairs. Local complications occurred in 4.7% of patients: 3.0% haematoma, 1.4% seroma, 0.3% recurrence. The mean visual analogue scale (VAS)-rated pain scores were 3.2 pre-operatively, 2.3 immediately after surgery and 1.8 at 1 month. Surgeons rated the product as very easy to use.

Conclusions

Tisseel^® fibrin sealant appears to be a well-tolerated and easy-to-use alternative to traditional, tissue-penetrating devices for mesh fixation in hernia repair techniques.

Feasibility study of natural orifice transluminal endoscopic surgery inguinal hernia repair

BACKGROUND

A potentially less-invasive technique, transluminal surgery, may reduce or eliminate pain and decrease time to full return of activities after abdominal operations. Inguinal hernia repair is perfectly suited to the transgastric endoscopic approach and has not been previously reported.

OBJECTIVE

Our purpose was to evaluate the feasibility of transgastric bilateral inguinal herniorrhaphy (BIH).

DESIGN

Feasibility study with a nonsurvival canine model.

INTERVENTIONS

Under general anesthesia, male mongrel dogs weighing 20 to 30 kg had a dual-channel endoscope introduced into the peritoneal cavity over a percutaneously placed guidewire. An overtube with an insufflation channel was used. Peritoneoscopy was performed, and bilateral deep and superficial inguinal rings were identified. The endoscope was removed, premounted with a 4 x 6 cm acellular human dermal implant and then readvanced intraperitoneally through the overtube. The implant was then deployed across the entire myopectineal orifice and draped over the cord structures. Bioglue was then applied endoscopically, and the implant was attached to the peritoneum. After completion of bilateral repairs, the animals were killed and necropsy performed.

RESULTS

Five dogs underwent pure natural orifice transluminal endoscopic surgery (NOTES) intraperitoneal onlay mesh (IPOM) BIH. Accurate placement and adequate myopectineal coverage was accomplished in all subjects. At necropsy no injuries to the major structures were noted but Bioglue misapplication with contamination of unintended sites did occur.

LIMITATIONS

Our study involved only a small number of subjects in nonsurvival experiments, and no gastric closure was used.

CONCLUSIONS

Many of the characteristics of inguinal hernia repair are especially well suited to the transgastric approach. The repair is in line with the transgastric endoscope vector, bilateral defects are adjacent, and the IPOM technique does not require significant manipulation or novel instrumentation.

Fixation of mesh to the peritoneum using a fibrin glue: investigations with a biomechanical model and an experimental laparoscopic porcine model

BACKGROUND

In recent years, the use of fibrin glue has become an established practice in several areas of surgical treatment. For example, fibrin glue is used increasingly as an alternative method for mesh fixation in hernia surgery, significantly helping to reduce the incidence of chronic pain. The experiments in this study were aimed at elucidating the extent to which tack- or suture-based permanent fixation can be replaced by fixation with fibrin glue for laparoscopic intraperitoneal repair of abdominal wall hernias.

METHODS

In an initial series of experiments conducted with a biomechanical model, the strength of the fibrin glue for fixation of lightweight mesh (TiMesh light) to muscle tissue was compared with its strength of fixation to the peritoneum. In a second series of experiments, mesh was laparoscopically implanted in an established porcine model. Fibrin glue was used for mesh fixation in six animals. Laparoscopic exploration and explantation of the meshes were conducted after 4 months. Planimetric analysis was performed to investigate adhesion and shrinkage of the mesh surface.

RESULTS

The strength of fibrin glue for fixation of mesh to the peritoneum was significantly less than for its fixation to muscle tissue (11.86 N vs. 47.88 N; p = 0.001). Three of the implanted meshes were not completely integrated, and two of these were dislocated. On the average, adhesions were seen on 16% of the mesh surfaces. The mesh shrinkage rate was 24.2%.

CONCLUSION

Mesh fixation alone to the undamaged peritoneum in the intraperitoneal region cannot be recommended because of the risk for dislocation. Additional fixation using sutures, tacks, or both is needed until the mesh material is completely integrated.