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

months was significantly higher with staple/tack fixation (OR 3.25; 95%CI: 1.62-6.49). Whereas no
significant difference was seen in operative time, seroma formation, hospital stay, or time to return to
normal activities.

In summary the use of fibrin glue for mesh fixation in TAPP and TEP is a safe atraumatic fixation technique
and provides less chronic pain incidence compared to traumatic fixation.

The optimal application method is the spray technique to generate a thin adhesive layer.

Cyanoacrylates
Besides the biological fibrin glue, a synthetic cyanoacrylate (CA) is an alternative glue material. One of the
most serious problems of the surgical use of CAs involves its degradation and toxicity. The main toxic
products released by the degradation of CA alkyl chains are formaldehyde. A second basic problem
associated with CAs is the flexibility. After polymerization, these polymers become hard and brittle, which
[31]
[30]
might be counterproductive for tissue conditions . In an in vivo preclinical study by Pascual et al. CAs
currently used in clinical practice, with different alkyl chain lengths, Ifabond (n-hexyl), Glubran (n-butyl),
and OCA (n-octyl) obtained sufficient tissue integration, proper mesh fixation and effective short-term
biocompatibility. CA (n-octyl) revealed the lowest seroma formation macrophage response.

The largest number of mesh fixations by CAs (n-butyl) in TAPP repair was published by Kukleta et al.
[32]
showing excellent results in terms of biocompatibility and risk of recurrence. The technique recommended
by these authors for CA mesh fixation consists in applying just a few drops each to all four quadrants of the
mesh. Subwongcharoen et al. reported on a RCT comparing staple fixation versus CA (n-butyl) in TEP
[33]
repair. Postoperative pain assessed by VAS was significantly higher in the staple group after 24 hours (1.6
+/- 1.33 vs. 2.35 +/- 1.32) (P = 0.037). The rate of chronic pain after 3 months and 1 year was higher in the
staple group but did not reach significance. Complications rates and recurrences after one year were not
significant.

In summary, cyanoacrylate, preferably n-octyl cyanoacrylate, is safe to use for adhesive fixation of meshes in
TAPP and TEP. Care should be taken to ensure sparing spot application. This is in contrast to the large-area
trans-porous spray application of fibrin glue, which achieves elastic fixation of the fibrin glue .
[34]

Self-fixating mesh
So far, in contrast to the open mesh methods, there are only a very few publications for the use of self-
fixating mesh. In feasibility studies with the use of self-fixation mesh in TAPP by Birk et al. and Li et al.
[36]
[35]
[37]
in TAPP and TEP and by Bresnahan et al. in TEP, only one RCT by Denham et al. was published in
[38]
2019. In this study 217 patients with primary, unilateral inguinal hernias were randomized to non-self-
fixation or self-fixation group in TEP repair. A subgroup randomization was performed on the self-fixating
mesh group with direct hernias > 2 cm (n = 38). Fifty percent of this group (n = 19) were randomized to
receive tacker fixation. The median operative times and length of hospital stay were similar. More patients
in the non-fixating mesh group received tacks (43 vs. 19, P = 0.001). During the first 3 postoperative days
non-fixating mesh patients reported significantly less pain, whereas 3 weeks or 1 year postoperatively no
significant difference was detected. In the follow-up of one year, no recurrence was found in either of the
groups. A subgroup analysis of direct inguinal hernias could not be performed due to the low number of
patients. In conclusion, the authors stated that “self-fixating mesh does not appear to positively impact QoL
after TEP repair”.