Lichtenstein repair of inguinal hernia: fibrin glue or suture for mesh fixation?

Abstract

First of all, we wish to thank Tripoloni and Schierano [1] for the attention they paid to our trial comparing fibrin glue versus suture for open tension-free Lichtenstein hernia repair [2]. We appreciate their interest in the details. We agree that the two groups may have included subgroups that could cause bias, but we have to remember that this was a prospective observational multicenter study. The study was not randomized or blinded and, for this reason, no formal power calculations were undertaken. This is what happens with observational studies (cohort studies) which, for this reason, reach the level of evidence 2B with grade of recommendation B. Nonetheless, they can provide interesting results or suggestions for clinical practice. In our study, fewer patients in the fibrin glue group reported pain, numbness, and discomfort compared with patients in the sutures group at 1 month, and this occurred until the third month, when all differences disappeared, with the exception of numbness, which continued to be more prevalent in the sutures group. Tripoloni and Schierano [1] noted that the difference in pain intensity in favor of fibrin glue is not clinically meaningful. We agree with this, but the fact remains statistically meaningful. Anyway, in the literature, comparisons among different techniques for hernia repair, i.e., open versus laparoscopic repair, are often based on little variation in terms of mild or mild moderate pain. In our study, the mean operating time was reduced by 9% in the fibrin glue group compared to the sutures group. Although this value is statistically meaningful, Tripoloni and Schierano [1] believe that 6 min for each procedure is of little practical importance. We wish to underline that our study included 16 centers with extensive experience in hernia surgery. In less expert hands, i.e., residents and young surgeons, this saving of time is probably greater, with economic advantages. Of greater importance seems to be the remark on the risk of recurrence and that fibrin glue should expose to higher recurrence risk if compared to the sutures group. Actually, the two recurrences in our study occurred in the first group and in patients with direct hernias (type M) (more numerous in the fibrin glue group for the lack of stratification). We revised the files of both patients that were re-operated for recurrence. In both cases, a mesh of inadequate size was used. Both hernias recurred distally to the mesh, close to the pubic tubercle, type M1. The letter by Tripoloni and Schierano [1] provides us the opportunity to stress the importance of using a mesh of sufficient size to overlap the pubic tubercle, as requested also when a tension-free suture Lichtenstein repair for direct hernia is performed. With this solution, the difference in the recurrence rate between the two techniques nullifies. We, together with all the co-workers in our study, continue to believe that, in the future, the use of fibrin or synthetic glue for mesh fixation or self-gripping meshes will probably replace sutures in groin hernia repair.