The impact of atraumatic fibrin sealant vs. staple mesh fixation in TAPP hernia repair on chronic pain and quality of life: results of a randomized controlled study.

BACKGROUND: Mesh reinforcement has become the standard of care in the open and laparoscopic repair of inguinal hernia. Chronic pain after inguinal hernia repair is often due to nerve injury by penetrating mesh fixation devices such as staples (ST), tacks, or sutures. In several studies on hernioplasty, atraumatic mesh fixation with fibrin sealant (FS) proved to be efficient in terms of fixation strength and elasticity. Unfortunately, most of these studies did not provide a standardized follow-up and assessment of the development of chronic pain (CP) and the quality of life (QoL). Therefore, a randomized controlled trial comparing CP and QoL after FS fixation of mesh with ST in transabdominal preperitoneal hernioplasty (TAPP) was performed at our department. The primary end point of our study was to assess the patient outcome by using a visual analog scale (VAS) and the short form 36 (SF-36). The evaluation of recurrence rates was the secondary aim. METHODS: According to the randomization, a macroporous mesh (TiMESH(®)) was fixed in group A (44 patients with 54 inguinal hernias) with FS (TISSEEL) or in group B (45 patients with 56 inguinal hernias) with ST (EMS(®) Stapler). The observation period was 1 year with regular clinical check ups and assessment of VAS and SF-36. RESULTS: Patient characteristics expressed by BMI, ASA scores, and Schumpelick hernia classification were similar in both treatment groups. In each group there was one recurrence within 8 (FS) and 9 months (ST) postsurgery. The mean preoperative pain values scored by VAS were 1.7 (range = 0-7.5) in the FS group and 2.2 (range = 0-6) in the ST group. Postoperative mean VAS scores measured at 1 year postsurgery were 0.4 (range = 0-3) in the FS group and 0.9 (range = 0-7.5) in the ST group. One year postsurgery there was no significant difference between the two groups with respect to the parameter pain in the SF-36 and VAS. CONCLUSION: Fibrin sealant fixation leads to a low rate of hernia recurrence and avoids tissue trauma. ST provide similar results in the hand of the expert but bear inherent risks of complications due to tissue perforation.

[Biomechanics of the shoulder and therapeutic applications]. / Biomechanik der Schulter und ihre therapeutische Anwendung.

The influence of biomechanics in surgery of the locomotor apparatus has been constantly increasing over the last few decades. The purpose of this study was to determine wether biomechanical studies can significantly influence therapy and treatment of shoulder injuries, especially shoulder instability. The investigation was performed on 23 fresh human specimens with intact capsular ligaments of the glenohumeral joint. A Bankart lesion from 3 o'clock to 6 o'clock was repaired, and a Bankart repair and anterior inferior capsular shift, as described by Neer, were performed. The measurement was done on six clinically relevant positions of instability: superior, anterior, anterior-inferior, inferior, posterior-inferior, posterior. Measurement was done using a specially developed strain-gauge system. It was demonstrated that both instability and too much stability of the shoulder joint lead to a significant change in shoulder biomechanics. The anatomical O-position of the glenohumeral joint in 110 degrees of abduction is a position of about 60 degrees of external rotation compared to the O-position for clinical measurement. From the therapy point of view, one has to ask for anatomical reconstruction instead of tight repair in soft-tissue repair in the glenohumeral joint. Immediate post-operative rehabilitation in a 60 degrees range of motion is possible.