Use of fibrin sealant for prosthetic mesh fixation in laparoscopic extraperitoneal inguinal hernia repair

Objective To evaluate the efficacy of mesh fixation with fibrin sealant (FS) in lapar oscopic preperitoneal inguinal hernia repair and to compare it with stapled fixation. Summary Background Data Laparoscopic hernia repair involves the fixation of the prosthetic mesh in the preperitoneal space with staples to avoid displacement leading to recur rence. The use of staples is associated with a small but significant number of complications, mainly nerve injury and hematomas. FS (Tisseel) is a bio degradable adhesive obtained by a combination of human-derived fibrinogen a nd thrombin, duplicating the last step of the coagulation cascade. It can b e used as an alternative method of fixation. Methods A prosthetic mesh was placed laparoscopically into the preperitoneal space in both groins in 25 female pigs and fixed with either FS or staples or lef t without fixation. The method of fixation was chosen by randomization. The pigs were killed after 12 days to assess early graft incorporation. The fo llowing outcome measures were evaluated: macroscopic findings, including gr aft alignment and motion, tensile strength between the grafts and surroundi ng tissues, and histologic findings (fibrous reaction and inflammatory resp onse). Results The procedures were completed laparoscopically in 49 sites, Eighteen grafts were fixed with FS and 16 with staples; 15 were not fixed. There was no si gnificant difference in graft motion between the FS and stapled groups, but the nonfixed mesh had significantly more graft motion than in either of th e fixed groups. There was no significant difference in median tensile stren gth between the FS and stapled groups. The tensile strength in the nonfixed group was significantly lower than the other two groups. FS triggered a si gnificantly stronger fibrous reaction and inflammatory response than in the stapled and control groups. No infection related to method of fixation was observed in any group. Conclusion An adequate mesh fixation in the extraperitoneal inguinal area can be accom plished using FS. This method is mechanically equivalent to the fixation ac hieved by staples and superior to nonfixed grafts. Biologic soft fixation w ith FS will prevent early graft migration and will avoid the complications associated with staple use.