721 
Stefano Olmi
MD
Department of Surgery
San Gerardo
Hospital, Monza
Italy
We studied the efficacy and safety of prosthesis fixation by fibrin glue (Tissucol®, Baxter Healthcare) during the laparoscopic transabdominal preperitoneal (TAPP) technique for inguinal hernia repair. Between September 2001 and December 2006 we treated 720 hernias in 500 patients. We observed no perioperative complications and no recurrence after an average follow-up of 40 months. Patients were discharged the day after operation and returned to work after five days.
At our institution, elective indications for laparoscopic herniorraphy include bilateral and recurrent hernias, the association of hernia with other pathologies amenable to laparoscopic intervention and unilateral primary hernias in athletes. Several kinds of staples are available for reliable mesh fixation, but the use of these is associated with a certain amount of surgical trauma. Reported complications include neuralgia or paraesthesia due to nerve entrapment; a chronic form of pubalgia caused by stapling of the prosthesis to Cooper’s ligament; and bleeding or haematomas in Retzius’ space. As an alternative, the application of fibrin glue reliably keeps the mesh in place and is not characterised by the complications associated with stapling.
Patients and methods
Between September 2001 and December 2006 we treated 720 hernias in 500 patients. Patients were reviewed at seven days, one month, six months and after every year. The procedure is carried out under general anaesthesia. The patient is placed in the supine position with a slight Trendelenburg tilt (15–20°), legs together and arms alongside the body. Pneumoperitoneum is induced by means of a Veress needle inserted just above the umbilical scar. After having obtained an endo‑abdominal pressure of 14 mmHg, a first 10 mm trocar is introduced at the same site. A 30° scope is then inserted. The other two trocars are inserted by transillumination at the level of the transverse umbilical line just laterally to the rectus sheath. The 5–12 mm operative trocar with a universal variable port (Endopath®, Ethicon Endo-Surgery) is always placed on the right-hand side for both unilateral and bilateral hernias, and a 5 mm trocar is placed on the opposite side. The pressure of the CO2 entering between peritoneum and abdominal wall helps dissection. The inferior peritoneal margin is now pulled towards the surgeon with tissue forceps and is bluntly dissected from the spermatic cord, which is parietalised to obtain an inverted triangle with the vas deferens running medially and the genital vessels laterally in between the iliac vessels in the so-called “triangle of disaster”. The ligament of Cooper is then identified by its consistency and greyish-white colour, and dissected. We normally use polypropylene mesh of 14 x 13 cm. It is important for the mesh to overlap the hernial foramen by at least 2 cm and that its medial margin be next to the pubic symphysis. We fix the mesh with 1 ml of Tissucol for unilateral hernias and 2 ml for bilateral ones. The prosthesis is fixed along its upper margin, from Cooper’s ligament to the triangle of disaster, and to the “triangle of pain” using a 3 mm catheter (Duplotip®, Baxter Healthcare), which fits the Tissucol syringe. The mesh may also be fixed wherever needed to increase its stability. The closure of the peritoneal flap requires extreme care to avoid leaving peritoneal breaches that could allow contact between the mesh and bowel loops. Some surgeons prefer metallic stapling, but we employ a dedicated polydiaxonone (PDS) running suture (MIC 54E, Ethicon Suture).
Results
Between September 2001 and December 2006, we used Tissucol for mesh fixation during TAPP to repair 720 hernias in 500 patients (486 male, 14 female), with a mean age of 45 years (range, 20–75 years). We observed no perioperative complications. Postoperative complications included 18 seromas (2.5%). The seromas were treated by percutaneous evacuation, resulting in immediate resolution. No patient developed an inguinal haematoma, which sometimes occurs following stapling. After a mean follow-up period of 40 months (range, 1–64 months), none of the patients reported immediate or late paraesthesia or neuralgia, and no recurrence. The average operating time was 25 minutes for unilateral hernias (range 15–40 min) and 45 minutes (range 30–70 min) for bilateral ones, both primary and recurrent. Most patients were discharged after an overnight stay, and no patients required a longer stay or readmission for postoperative problems. Patients returned to work after approximately five days (range 3–8 days) and sporting activities after 10 days (range 8–15 days).
Discussion
Some studies have looked at the use of mesh without any fixation. Like the application of fibrin glue, this method is nontraumatic because it avoids all stapling problems. Ferzli et al report a 1.8% recurrence rate in patients in whom the prosthesis was not fixed.(1) Size of the prosthesis is an important factor. In our experience, fixation of a 14 x 13cm mesh ensures a better prosthesis stability, and consequently less dislocation and recurrence. The use of smaller stapled prostheses (11 x 6 cm) is associated with recurrence rates of up to 5%, while patients treated by TAPP with no mesh fixation have recurrence rates as low as 0.16%. Inadequate lateral fixation is one of the main causes of recurrence after both TAPP (36%) and total extraperitoneal (TEP) (22%). The reason for this is that most of the nerves run laterally where no staples can be applied. Gluing a large mesh on the triangles of disaster and pain is likely to stop the prosthesis from lifting and dislocating, thereby avoiding infero–medial and infero–lateral recurrence, as seen in 0.4% (3/715) of hernias treated in an earlier study of ours in which staples were used. Fibrin glue is reported to have haemostatic properties, thus reducing seroma and haematoma formation. In our study, the incidence of postoperative seromas was 2.5% (18/720), whereas the incidence reported in the literature varies from 3.8 to 10.5%. Tissucol is also cheaper than any other means of mesh fixation.
Conclusion
Fibrin glue (Tissucol) is the preferred method of prosthesis fixation in TAPP operations. It ensures the same prosthetic stability as a mechanical device, but it is completely nontraumatic and avoids the problems that may arise with stapling.
Reference
- Ferzli GS, Frezza EE, Pecoraro AM, Ahern KD. Prospective randomized study of stapled versus unstapled mesh in a laparoscopic preperitoneal inguinal hernia repair. J Am Coll Surg 1999;188:461-5.
