Qual a melhor técnica de fixação da tela na cirurgia laparoscópica da hérnia inguinal? / What is the best mesh fixation technique in laparoscopic inguinal hernia surgery?

Introdução: As operações laparoscópicas têm aumentado anualmente, bem como os casos de prevalência das hérnias da parede abdominal. Com isso, as técnicas de se realizar as operações, bem como certos procedimentos vem sendo estudados. Uma das questões debatidas é a respeito do tipo de fixação da tela. Objetivo: Avaliar as técnicas de fixação da tela na cirurgia laparoscópica ventral da hérnia inguinal. Método: Trata-se de um estudo de revisão sistemática. Três bases de dados foram consultadas: Cochrane Database of Systematic Reviews (CDSR), EMBASE e PUBMED. Durante as buscas foram utilizados descritores com vocabulário controlado e text words. Resultados: Em relação ao desenho do estudo 1 revisão incluiu apenas ECA, 2 ECA e ECNA e 1 combinou a inclusão de ECA e estudos observacionais. Em relação ao tipo de fixação 2 estudos compararam os efeitos da fixação por tacha vs. cola de fibrina e outros 2 a comparação da fixação do grampo vs. cola de fibrina. De todos os desfechos de metanálise avaliados, apenas a redução da dor inguinal crônica pela fixação por cola de fibrina foi estatisticamente superior ao método de fixação mecânico em 3 dos 4 estudos. Conclusão: Os achados mostram que a diferença entre as técnicas de fixação da tela na cirurgia laparoscópica ventral da hérnia inguinal é que a fixação por cola diminui a incidência de dor crônica pós-operatória.

Introduction: Laparoscopic operations have increased annually, as well as the prevalence of abdominal wall hernias. With this, the techniques of performing the operations, as well as certain procedures, have been studied. One of the debated questions is about the type of fixation of the mesh. Objective: To evaluate mesh fixation techniques in ventral laparoscopic surgery for inguinal hernia. Method: This is a systematic review. Three databases were consulted: Cochrane Database of Systematic Reviews (CDSR), EMBASE and PUBMED. During the searches, descriptors with controlled vocabulary and text words were used. Results: Regarding the study design, 1 review included only ACE, 2 ACE and ECNA and 1 combined the inclusion of ACE and observational studies. Regarding the type of fixation, 2 studies compared the effects of stud fixation vs. fibrin glue and 2 others comparison of staple vs. fibrin glue. Of all the meta-analysis outcomes evaluated, only the reduction of chronic groin pain by fibrin glue fixation was statistically superior to the mechanical fixation method in 3 of 4 studies. Conclusion: The findings show that the difference between mesh fixation techniques in laparoscopic ventral inguinal hernia surgery is that glue fixation decreases the incidence of postoperative chronic pain.

Evaluation of new technique of mesh fixation in laparoscopic inguinal hernia repair

Background: Hernia is a common problem of the modern world with an incidence ranging from 5 to 7%. Of all groin hernias, around 75% are inguinal hernias. Recently with the advancement in laparoscopy, endoscopic repairs seem to offer better quality of life, decreasing hospital stay and early return to work. Aim of the work was to evaluate a new technique for mesh fixation by Zein method of suturing and compare it with stapled mesh fixation in laparoscopic inguinal hernia repair transabdominal preperitoneal approach.Methods: The study is a randomized, prospective single group study. The study was conducted after the approval of the ethical committee of the surgical department, Menoufia University. It was conducted in Menoufia University Hospital on 50 patients with inguinal hernia who were operated upon between September 2018 and September 2019 with a minimal follow-up of 6 months.Results: Age of studied patients ranged from 27 to 55 years with mean 42.82±7.90 age/years. Regarding sex of studied patients, more than half (74%) of studied patients were males and (26%) were females. Regarding comparsion between high and low overall cost burden on the patient, it was interestingly found that high cost is associated with presence of complication like hematoma, prolonged stay in the hospital and prolonged use of antibiotics.Conclusions: Both the use of sutures and fixation of mesh by absorbable tacks approaches are similarly effective in terms of operative time, the incidence of recurrence, complications, and chronic pain coinciding with all the available literature.

Fixation and Non-Fixation of MESH in Transabdominal Preperitoneal Hernia Repair: A Randomized Study

Background: Transabdominal pre-peritoneal repair is a wellaccepted method of inguinal hernia repair involving bothoptions of fixation or non-fixation of mesh. Objective was toanalyse the comparison between mesh fixation versus nomesh fixation in laparoscopic inguinal hernia repair– TAPP, interms of: operative time, post-operative pain, length of hospitalstay and recurrence.Materials and Methods: This prospective randomised studywas conducted on a sample of 30 male patients whounderwent TAPP inguinal hernia repair. 15 of these underwentfixation and the remaining 15 with non-fixation of mesh.Results: Mesh fixation increases postoperative pain andoperative time. No difference observed in terms of hospital staybetween the 2 groups. Fixation doesn’t prevent recurrence.Conclusion: Mesh non -fixation can be utilised as a safe andeffective approach in TAPP hernia repair.

The Impact of Double Fixation with Titanium Tack and N-Butyl Cyanoacrylate Glue (NBCG) Mesh Fixation versus NBCG Fixation Only in Totally Extra-Peritoneal Hernioplasty with 3-Dimensional Configured Polyester Mesh: A Comparative Study

PURPOSE: Our aim is to compare 3-dimensional mesh fixation using titanium tacks combine with n-butyl cyanoacrylate glue (NBCG) (COMBINE group) versus NBCG only (NBCG group) in totally extraperitoneal inguinal hernioplasty (TEP). METHODS: This is a retrospectively study of patients diagnosed with unilateral inguinal hernia and underwent TEP with 3-dimensional configured polyester mesh fixation using titanium tacks combine NBCG or NBCG only at the University of Hong Kong-Shenzhen Hospital with data prospectively collected. Operative details and outcomes were compared including: operating time, size of defect, total hospital cost, post-operative pain scores and recurrence. RESULTS: From 08.2013 to 03.2016 a total of 219 patients were included. There was no significant difference between COMBINE group and NBCG group in mean age (52.5 years versus 48.2 years), mean size of defects (2.4 cm versus 2.6 cm), and operating time (121 mins versus 111 mins). There were significant differences between COMBINE group and NBCG group in total hospital cost (3035 USD versus 2022 USD), post-operative pain score on day 2 to day 4 (VAS: 1.4 versus 1.0, 1.0 versus 0.4, 0.5 versus 0.2). There was one recurrence in COMBINE group (p=0.276) with overall recurrence of 0.46%. CONCLUSION: Patients with inguinal hernia underwent TEP with 3-dimensional configured polyester mesh with NBCG fixation only having comparative surgical outcome to COMBINE group. A recurrence of 0.46% can be achieved with this combination. Tacks fixation may cause more post-operative pain and increase hospital cost. Use of N-butyl cyanoacrylate glue in TEP is safe and effective in our clinical series.

Análise de custo-efetividade do n-butil-cianoacrilato para fixação de telas em hernioplastias inguinais sob a perspectiva da saúde suplementar brasileira / Cost-effectiveness of n-buthyl-cyanoacrylate for mesh fixation in inguinal hernioplasty under the perspective of Supplementary Healthcare in Brazil

Objetivo: Estimar a custo-efetividade do n-butil-cianoacrilato (NBCA) para fixação de telas em pacientes submetidos a hernioplastias inguinais por reparo aberto ou laparoscópico, sob a perspectiva da Saúde Suplementar do Brasil. Métodos: Foi elaborado modelo analítico de decisão para estimar a razão de custo efetividade incremental (RCEI) em horizonte de tempo de um ano após procedimento cirúrgico com o uso do adesivo sintético versus técnicas tradicionais de fixação (sutura e grampos). Alternativamente, o uso de NBCA foi comparado à cola de fibrina. Os desfechos clínicos avaliados foram incidência de dor aguda e crônica. A estimativa de custos médicos diretos totais para as diferentes abordagens cirúrgicas e terapia da dor foi elaborada a partir da opinião de especialistas e coletadas em bases de dados secundárias. Resultados: A RCEI obtida através do modelo evidenciou economia substancial de recursos financeiros relacionada ao uso de NBCA de aproximadamente R$ 2.800 por procedimento após reparo laparoscópico e R$ 60 reais por procedimento para reparo aberto, resultados direcionados majoritariamente pela menor tendência de dor (efetividade incremental de 21,74% em termos de dor evitada) versus métodos de fixação tradicional. No cenário alternativo, no qual comparou-se NBCA com a cola biológica (adesivo de fibrina), atingiu-se economia financeira com nível de efetividade equivalente do ponto de vista estatístico entre os comparadores. Conclusão: Pode-se atribuir que o uso de NBCA para fixação de telas em cirurgias de reparo de hérnia inguinal constitui alternativa segura, efetiva e viável economicamente, quando comparado tanto a técnicas de fixação tradicionais como à cola biológica.

Objective: To estimate the cost-effectiveness of n-butyl-cyanoacrylate (NBCA) for mesh fixation in patients undergoing inguinal hernia repair by open or laparoscopic methods, from the perspective of the Brazilian supplementary health sector. Methods: A decision model was developed to estimate the incremental cost-effectiveness ratio (ICER) in time horizon of one year after surgery with the use of synthetic adhesive versus traditional fixation techniques (suture and staples). Alternatively, the use of NBCA was compared to the fibrin glue. Clinical outcomes applied to the model were incidence of acute and chronic pain. The estimation of total direct medical costs for surgical approach and pain therapy was developed based on experts' opinions and collected from secondary databases. Results: The ICER obtained through the model indicated substantial savings of financial resources related to the use of NBCA of approximately 2,800 BRL per procedure after laparoscopic repair and 60 BRL per procedure for open repair, results primarily due to the lower tendency of pain (incremental effectiveness of 21.74% in terms of avoided pain) versus traditional fixation methods. In the alternative scenario, which compared NBCA with biological glue (fibrin glue), it was achieved financial savings, with statistically equivalent level of effectiveness among the comparators. Conclusion: The use of NBCA for mesh fixation in inguinal hernia repair surgery is a safe, effective and feasible alternative from an economic point of view, when compared to both traditional fixation techniques as the biological glue.

Técnica de rives-stoppa en las eventraciones de la línea media: prescindencia de la fijación perimetral de la malla / Rives-Stoppa repair without mesh fixation for midline incisional hernias: long term follow up

Objetivo: La Técnica de Rives-Stoppa para las eventraciones de la línea media instala una malla retro rectal fijada en sus bordes con puntos percutáneos. Se han propuesto otras formas de fijación y en este estudio prescindimos de ella. Material y Método: El presente estudio observacional, descriptivo, prospectivo, se realizó en pacientes intervenidos consecutivamente entre los años 1995 y 2002. Se usó anestesia epidural con sedación profunda. Se usó la técnica estándar de Rives-Stoppa prescindiendo de la fijación perimetral. Los pacientes deambularon y se dieron de alta precozmente. Resultados: Se da cuenta de la evolución postoperatoria de 64 pacientes, 48 mujeres y 16 varones con una edad promedio de 58,9 (26-85) años. El 25 por ciento era hipertenso, el 9,3 por ciento diabético y el 80,2 por ciento obeso con un IMC > 30. La hospitalización promedio fue de 3,9 (2-16) días. Hubo 4 infecciones superficiales, un trombo embolismo pulmonar, un íleo abdominal prolongado y dos infecciones pulmonares. El seguimiento a largo plazo pudo realizarse en 48 pacientes (75 por ciento) comprobándose 5 recidivas (10,4 por ciento), ubicadas en el borde dista o proximal de la reparación herniaria, y 13,2 por ciento de dolor crónico moderado. A pesar de la recurrencia, el 97 por ciento de los pacientes se manifestó satisfecho o muy satisfecho con el tratamiento. Discusión: Los resultados son comparables con los dados a conocer con fijación de la malla. La modificación técnica propuesta disminuye el tiempo quirúrgico y el riego de infección y de neuralgia post operatoria. Para una ulterior disminución de las recidivas debe aumentarse el solapamiento cefálico y caudal de la malla.

Background: The Rives-Stoppa technique for midline incisional hernias places a Mersilene mesh in the retro rectal space, which is kept in place with transcutaneous sutures. Other forms of fixation have been proposed. Aim: To assess the long term results of the surgical technique without fixation of the mesh. Material and Methods: An observational, descriptive, prospective study performed in 64 patients aged 26 to 85 years (48 women) consecutively operated between 1995 and 2002. The standard Rives-Stoppa technique was used, except for the usage of a Prolene mesh without fixation. Ambulation was started on the first postoperative day and patients were discharged after removal of drains. Results: Eighty percent of patients were obese, 25% had high blood pressure and 9% were diabetic. Patients were discharged at a median of four (range two-16) days after surgery. Four superficial infections, one case of thromboembolic disease, one case of prolonged ileus and two pulmonary infections were recorded as complications. A long term follow-up was carried out in 48 patients (75%). Five patients had small recurrences (10%), localized at the cephalic or caudal borders of the mesh, and six patients (13%) reported slight abdominal pain. In spite of recurrences, 97% of patients were satisfied or very satisfied with the treatment. Conclusions: These results are similar to those obtained using mesh fixation. Increasing distal and proximal mesh overlap should enhance these results.