Fixation of mesh to the peritoneum using a fibrin glue: investigations with a biomechanical model and an experimental laparoscopic porcine model

Abstract

A recent article published by Schug-Pass et al. [1] highlights a very important problem in laparoscopic ventral hernia repair. The authors studied mesh fixation to the peritoneum using fibrin glue and thereby add further information to the sparse literature in this area. Alternative noninvasive and degradable fixation techniques are highly warranted because of potential complications related to traditional fixation with tacks. The authors performed a biomechanical ‘‘dry-lab’’ test to test strength of ingrowth, and an experimental pig study. In the biomechanical test, a 10 9 15 cm TiMesh light was placed above a prefabricated 4.5-cm defect in a muscle– peritoneum specimen and 2 ml Tissucol was sprayed onto the mesh. Strength of fixation was tested 3 min after glue application and was found to be significantly higher when applied to muscle tissue than to bare peritoneum. In the experimental test, six pigs had a 10 9 15 cm TiMesh light fixed to the nontraumatized peritoneum by spray application of 2 ml Tissucol. After 4 months the pigs were euthanized and mesh migration and adhesions were measured. The authors found incomplete integration/dislocation of the mesh in half of cases (3/6 meshes). Based on these results the authors conclude that glue as a standalone fixation method to the bare peritoneum cannot be recommended. The article correctly states that: ‘‘To date, no randomized clinical trials have investigated intraperitoneal application (of fibrin glue)’’ [1]. However, a few experimental and human studies concerning the safety aspects of the procedure are available. A randomized laparoscopic pig study comparing fibrin glue with tacks for mesh fixation found the glue procedure to be safe with no mesh migrations in 18 meshes (folding was seen in two meshes) [2]. Olmi et al. published a series of 40 patients undergoing laparoscopic ventral hernia repair with glue fixation without recurrences at mean follow-up of 16 months [3] and 60 intraperitoneal onlay mesh (IPOM) procedures for inguinal hernia with no recurrences after 2-year mean follow-up [4]. Recently, Fortelny et al. reported a case of successful paraesophageal hernia repair with mesh fixated with fibrin glue [5]. The amount of glue used may be important for successful repair. In our own study [2] we used 1 ml Tisseel/ 30 cm mesh, and Olmi et al. used 1 ml/50–60 cm mesh [3]. Tisseel/Tissucol is not registered for mesh fixation and, consequently, no minimum dose of glue per mesh area is recommended by the manufacturer to ensure adequate initial fixation. Schug-Pass et al. used 1 ml Tissucol/ 75 cm mesh, which may not have been enough. Which application method should be used: spray or catheter? It is my personal experience that spray application posses some difficulties. The aerosol is nearly invisible and therefore it is actually quite difficult to see when application starts, where the glue ends, and the amount delivered. The initial strength of ingrowth was tested 3 min after application. I am a little critical of this modus operandi. If the aim was to test clinically relevant strength of ingrowth of the initial mesh fixation, 3 min is too early and leaves no chance for the technique. Coagulated Tisseel/Tissucol reaches its maximum strength after 2 h, and 70% strength is achieved after 10 min, a time when most patients are still asleep. J. R. Eriksen (&) Department of Surgical Gastroenterology D, Herlev University Hospital, Copenhagen, Herlev Ringvej 75, 2730 Herlev, Denmark e-mail: jravn@dadlnet.dk