Page 9 - Read Online

Page 4 of 6 Ielpo. Mini-invasive Surg 2021;5:10 I http://dx.doi.org/10.20517/2574-1225.2021.01

Figure 4. Fibrine glue specific tool placement.

The mesh is secured with approximately 2 mL of fibrine glues (Tisseel, Baxter Healthcare), applied as
shown in Figure 4, at almost 1 cm distance from the mesh, using a specific laparoscopic tool.

This tip is very useful especially in those cases where a non-specific laparoscopic mesh is used, as their
structure does not fit in the preperitoneal space as with the specific mesh type.

Peritoneal closure
The original TAPP technique includes staples to both fix the mesh and close the peritoneum. This might be
the fastest and easiest method, but at the price of a higher risk of nerve injury and bleeding, since staples
[9]
may damage nerves and vessels . To decrease chronic pain, some absorbable staples have been introduced.
However, the potential decrease of bleeding cannot be avoided.

Currently, the most frequently used modification is that of the running suture to close the peritoneum.
However, suturing the peritoneum is not as easy as it seems; it remains a challenging maneuver, requiring
specific surgical skills to avoid tears or ruptures that may expose the mesh to the intestine, with secondary
obstruction or fistulation. With the attempt to further decrease the difficulty of this procedure, barbed
sutures have been introduced. However, even with this suture, it still requires some skills, and the
peritoneum closure time step, even with barbed suture, may require longer time compared with the overall
surgical step. With running suture, peritoneal ruptures still occur, especially in cases when the hernia
sac reduction maneuver has been particularly challenging (such as with large sliding hernias, where the
flap peritoneum is very thin and too weak to be closed with a suture or in cases with a large amount of
fat in the peritoneum, adding difficulty to its closure for increased tension). In addition, it is important
to state that running suture of the peritoneum does not avoid the risk of nerve entrapment or bleeding,
as the suture of the superior flap of the peritoneum frequently includes part of the abdominal wall. Even
if not well described in the literature, epigastric vessels have been frequently injured during the closing
of the peritoneum. When this occurs, it is challenging to face it. For this reason, there is a need for some
modifications of the technique that may not be the standard but are useful in those difficult cases.

For these cases, our specific tip is to use, when it is required, fibrine glue.

The most frequently studied glue product is N-2-butyl cyanoacrylate. It shows a great capacity for both
[10]
mesh and peritoneal closure that is achieved after only a few seconds . However, being a non-biological
glue, one of the main criticisms is that, when this product is in contact with the intestine, strong adhesions
[10]
may develop. Nevertheless, the study of Wilson et al. , which recently investigated their experience with
cyanoacrylate mesh and peritoneal closure, reported excellent results with no long-term complications.
However, considerable precautions are required when using this product in order to avoid dropping any
material into the intestine.