Page 15 - Read Online

Page 4 of 11 Fortelny. Mini-invasive Surg 2021;5:16 https://dx.doi.org/10.20517/2574-1225.2021.21

The advantage of direct defect closure in prevention of recurrence was also reported in a retrospective study
[13]
by Ng et al. in TAPP and TEP repair using interrupted non-resorbable single sutures for MII and MIII
inguinal hernias with a 6.4% recurrence rate in the non-closure group vs. 0% in the closure group after 1
year. In both studies [12,13] , besides the defect closure, mesh fixation was performed by resorbable tacker.

In another prospective study by Clout et al. patients were treated with Endoloop closure by long term
[14]
absorbable suture for MII or MIII direct defects in TEP repair. The meshes were fixated using fibrin sealant
only. After a median follow-up of 5.9 years, there was no recurrence.

In summary, no mesh fixation clearly has the lowest seroma rate in laparo-endoscopic inguinal hernia
surgery. But most of the studies with non-fixation of mesh excluded large direct inguinal hernias.

The defect closure respectively reducing the dilated transverse fascia by suture in MII and MII direct
inguinal hernia in combination with mesh fixation by tacker or glue seems to prevent not only
postoperative seroma formation but moreover the risk of recurrence.

Since atraumatic mesh fixation reduces the risk of postoperative pain, the combination of defect closure and
mesh fixation by glue or the use of self-fixing meshes in MII and MIII direct inguinal hernias seems
recommendable.

GLUE FIXATION IN TEP AND TAPP
Fibrin glue
Starting with the first experimental study by Katkhouda et al. by using fibrin glue for mesh fixation in
[15]
TEP repair, atraumatic fixation was born. Fibrin glue, known as Tissel or Tissucol (Baxter Healthcare,
®
®
Deerfield, IL, USA), is a biologic hemostatic agent consisting of human fibrinogen and thrombin. In an
experimental study, Schwab et al. carried out a biomechanical analysis of mesh fixation in TAPP and TEP
[16]
comparing non-fixation versus suture versus fibrin sealant fixation. Glue fixation obtained the highest stress
resistance compared to non-fixation and suture fixation. Regarding the application of fibrin sealant in
laparo-endoscopic inguinal hernia repair, a spray-application at 1.5 bar pressure and a dose of
2
approximately 0.014 mL/cm to achieve a thin layer with broad coverage of mesh and efficient trans-porous
contact with the underlaying tissue is recommended .
[17]
After the first clinical publication by Langrehr et al. in 2005, several RCTs followed with fibrin fixation of
[18]
mesh versus stapler and tacker fixation techniques in TAPP [18-22] and TEP [23-26] surgeries. The rate of
postoperative pain was predominantly significantly lower compared to the penetrating fixation techniques
without increased recurrence rates.

The systematic review and meta-analysis comparing fibrin glue versus staple mesh fixation in TAPP by Shi
et al. including four RCTs detected no significant difference in hernia recurrence OR 2.10, 95%CI: 0.61-
[27]
7.22), seroma or hematoma formation (OR 0.55, 95%CI: 0.27 to 1.14) and operating time (SMD 0.80, 95%CI:
-0.34 to 1.94). Another systematic review and meta-analysis, by Sajid et al. , with the inclusion of 5 RCTs
[28]
found no significant difference regarding operating time, postoperative pain, postoperative complication,
length of hospital stay and risk of recurrence, but a lower risk of chronic pain.

Kaul et al. published a systematic review and meta-analysis comparing fibrin glue and staple fixation in
[29]
TEP. In the four enrolled studies, no difference in inguinal hernia recurrence with fixation of mesh by
staples/tacks versus fibrin glue (OR 2.13; 95%CI: 0.60-7.63) was found. The incidence of chronic pain at 3