Sobre el uso de pegamento en la cirugía de las hernias. Técnica de fijación combinada en la eventroplastia laparoscópica

Is It Possible to Eliminate Sutures in Open (Lichtenstein Technique) and Laparoscopic (Totally Extraperitoneal Endoscopic) Inguinal Hernia Repair? A Randomized Controlled Trial With Tissue Adhesive (n-Hexyl-α-Cyanoacrylate)

Background. The morbidity linked to the use of sutures in inguinal hernioplasty is well known. Tissue adhesives may be an alternative, so as to be able to improve levels of postoperative comfort, but clinical experience using them is limited. The aim of this study is to evaluate the efficiency of cyanoacrylate as a substitute for sutures in the treatment of inguinal hernias. Patients. Randomized clinical trial in abdominal wall unit. A total of 208 patients were operated upon for inguinal hernias of which 102 were unilateral hernias via open surgery using the Lichtenstein technique, randomized to receive prolene sutures (n = 52) or n-hexyl-α-cyanoacrylate glue (n = 50) and 106 were patients with bilateral inguinal hernias operated upon via totally extraperitoneal laparoscopy and randomized to receive either tackers (n = 54) or glue (n = 52). Main Outcome Measures. The primary endpoints were pain and recurrence. Secondary endpoints were operating time, postoperative morbidity, pain, and analgesic consumption. Results. No morbidity associated with the use of the glue existed. The use of glue significantly reduced the mean of surgical time (12 minutes in open surgery, 13 minutes in laparoscopic surgery), pain, and analgesics consumption, both via the open and laparoscopic approaches ( P < .001). After 1 year the adhesive did not change the recurrence rate in either of the approaches. The economic analysis shows potential yearly savings of 123 916.3 Euros. Conclusions. Substituting sutures with glue ( n-hexyl-α-cyanoacrylate) in open or laparoscopic inguinal hernioplasty is safe with less postoperative pain and the same possibilities of recurrence.

Which should be the gold standard laparoscopic technique for handling Spigelian hernias?

BACKGROUND

The advantages and disadvantages of both extraperitoneal and intra-abdominal laparoscopic Spigelian hernia repair are still being discussed. To our knowledge, no study has compared both techniques in terms of safety, feasibility, and cost-effectiveness.

METHOD

Prospective data were collected to compare the results of the extraperitoneal approach with the intra-abdominal approach in laparoscopic Spigelian hernia repair, between 2000 and 2012 (n = 16). Diagnosis was confirmed preoperatively by ultrasonography and/or tomography.

RESULTS

Spigelian hernias occur mostly in women (69 %), on the left side (56 %) and at a median age of 62 (range: 38-83). In our study, the extraperitoneal technique was performed in seven patients, while the intra-abdominal approach was indicated in nine. No complications, re-admissions, or recurrences were detected in either during a mean follow-up of 48 months (range: 18 months-9 years). The statistical study showed that there was no difference in either morbidity or the recurrence rate between a totally extraperitoneal (TEP) and an intraperitoneal onlay mesh (IPOM) repair. The mean duration of an IPOM repair was, though, shorter than that of a TEP repair (30 vs. 48 min, P = 0.06). The combined fixation technique (tacks + glue) did not modify the results but did reduce the costs, as shown in the cost-effectiveness study where the intra-abdominal approach was cheaper (1260 vs. 2200 euros, P < 0.001).

CONCLUSION

Laparoscopy seems to be a safe and feasible technique whichever the approach chosen, be it intra or extraperitoneal. Our experience shows that intra-abdominal laparoscopic Spigelian hernia repair should be recommended as the gold standard because of its technical and economic advantages. The IPOM procedure with a lightweight titanium-coated mesh fixed using a combined technique is a highly effective option for Spigelian hernia repair.