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Use of fibrin glue in preventing pseudorecurrence after laparoscopic total extraperitoneal repair of large indirect inguinal hernia

View Article: PubMed Central - PubMed

ABSTRACT

Purpose: Seroma is among the most common complications of laparoscopic total extraperitoneal (TEP) for especially large indirect inguinal hernia, and may be regarded as a recurrence by some patients. A potential area localized behind the mesh and extending from the inguinal cord into the scrotum may be one of the major etiological factors of this complication. Our aim is to describe a novel technique in preventing pseudorecurrence by using fibrin sealant to close that potential dead space.

Methods: Forty male patients who underwent laparoscopic TEP for indirect inguinal hernia with at least 100-mL volume were included in this prospective clinical study. While fibrin sealant was used to close the potential dead space in the study group, nothing was used in the control group. The volume of postoperative fluid collection on ultrasound was compared between the groups.

Results: Patient characteristics and the volumes of hernia sac were similar between the 2 groups. The mean volume of postoperative fluid collection was found as 120.2 mL in the control group and 53.7 mL in the study group, indicating a statistical significance (P < 0.001).

Conclusion: Minimizing the potential dead space with a fibrin sealant can reduce the amount of postoperative fluid collection, namely the incidence of pseudorecurrence.

No MeSH data available.


(A) A drawing showing the placement of the trocars in a patient of study group. (B) Application of fibrin sealant into the potential dead space by using a laparoscopic applicator through the trocar near the anterior superior iliac spine.
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Figure 1: (A) A drawing showing the placement of the trocars in a patient of study group. (B) Application of fibrin sealant into the potential dead space by using a laparoscopic applicator through the trocar near the anterior superior iliac spine.

Mentions: All patients were operated on in a supine Trendelenburg's position under general anesthesia. Antibiotic prophylaxis with 1-g cephalosporin was given intravenously on induction of anesthesia. A standard three-port technique was used. After disinfection of the surgical area with bovidine iodine, a transverse 2-cm infraumbilical incision was made, and the subcutaneous tissue was dissected down to the anterior sheath of rectus abdominis muscle. The anterior sheath was opened, and a spacemaker balloon (Covidien, Mansfield, MA, USA) was inserted between the muscle and the posterior sheath to open a preperitoneal space. It was then removed and replaced with a 12-mm structural balloon trocar (in the form of crow's feet). A 30-degree camera was inserted through this trocar, and carbon dioxide was insufflated at a pressure of 12 mmHg. Then, 2 other trocars were inserted at standard points (5-mm trocar approximately 8–10 cm proximal to the symphysis pubis in each group, another 5-mm trocar about 3 cm proximal to the right or left anterior superior iliac spine in study group and about 3-cm left or right to the symphysis pubis in control group) (Fig. 1A). After dissecting the extraperitoneal space by using endoscissors and diathermy, the indirect hernia sac was reduced and the spermatic cord was parietalized for a length of 3–4 cm. In the study group, the fibrin sealant (8 mL) was sprayed into the inner surfaces of the potential dead space located behind the mesh and extending along the inguinal canal into the scrotum by using a laparoscopic applicator (Duplocath 35 M.I.C, Baxter AG, Vienna, Austria) through the trocar near the anterior superior iliac spine (in order to provide a suitable angle for the application of fibrin sealant) (Fig. 1B). On the other hand, no adhesive material and/or mechanical devices were used for the dead space in the control group. A standard 10 cm × 15 cm polypropylene mesh (ProLite, Atrium Medical, Hudson, NH, USA) was introduced to cover the posterior wall of the inguinal canal, deep inguinal ring, and femoral ring on each side. Titanium tacks (ProTack, Covidien) were used for the fixation of mesh in each group. After bleeding control, the wound was closed without using a drain. Finally, compression was applied to the wound by using a 5-kg sandbag for a duration of 6 hours.


Use of fibrin glue in preventing pseudorecurrence after laparoscopic total extraperitoneal repair of large indirect inguinal hernia
(A) A drawing showing the placement of the trocars in a patient of study group. (B) Application of fibrin sealant into the potential dead space by using a laparoscopic applicator through the trocar near the anterior superior iliac spine.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5016602&req=5

Figure 1: (A) A drawing showing the placement of the trocars in a patient of study group. (B) Application of fibrin sealant into the potential dead space by using a laparoscopic applicator through the trocar near the anterior superior iliac spine.
Mentions: All patients were operated on in a supine Trendelenburg's position under general anesthesia. Antibiotic prophylaxis with 1-g cephalosporin was given intravenously on induction of anesthesia. A standard three-port technique was used. After disinfection of the surgical area with bovidine iodine, a transverse 2-cm infraumbilical incision was made, and the subcutaneous tissue was dissected down to the anterior sheath of rectus abdominis muscle. The anterior sheath was opened, and a spacemaker balloon (Covidien, Mansfield, MA, USA) was inserted between the muscle and the posterior sheath to open a preperitoneal space. It was then removed and replaced with a 12-mm structural balloon trocar (in the form of crow's feet). A 30-degree camera was inserted through this trocar, and carbon dioxide was insufflated at a pressure of 12 mmHg. Then, 2 other trocars were inserted at standard points (5-mm trocar approximately 8–10 cm proximal to the symphysis pubis in each group, another 5-mm trocar about 3 cm proximal to the right or left anterior superior iliac spine in study group and about 3-cm left or right to the symphysis pubis in control group) (Fig. 1A). After dissecting the extraperitoneal space by using endoscissors and diathermy, the indirect hernia sac was reduced and the spermatic cord was parietalized for a length of 3–4 cm. In the study group, the fibrin sealant (8 mL) was sprayed into the inner surfaces of the potential dead space located behind the mesh and extending along the inguinal canal into the scrotum by using a laparoscopic applicator (Duplocath 35 M.I.C, Baxter AG, Vienna, Austria) through the trocar near the anterior superior iliac spine (in order to provide a suitable angle for the application of fibrin sealant) (Fig. 1B). On the other hand, no adhesive material and/or mechanical devices were used for the dead space in the control group. A standard 10 cm × 15 cm polypropylene mesh (ProLite, Atrium Medical, Hudson, NH, USA) was introduced to cover the posterior wall of the inguinal canal, deep inguinal ring, and femoral ring on each side. Titanium tacks (ProTack, Covidien) were used for the fixation of mesh in each group. After bleeding control, the wound was closed without using a drain. Finally, compression was applied to the wound by using a 5-kg sandbag for a duration of 6 hours.

View Article: PubMed Central - PubMed

ABSTRACT

Purpose: Seroma is among the most common complications of laparoscopic total extraperitoneal (TEP) for especially large indirect inguinal hernia, and may be regarded as a recurrence by some patients. A potential area localized behind the mesh and extending from the inguinal cord into the scrotum may be one of the major etiological factors of this complication. Our aim is to describe a novel technique in preventing pseudorecurrence by using fibrin sealant to close that potential dead space.

Methods: Forty male patients who underwent laparoscopic TEP for indirect inguinal hernia with at least 100-mL volume were included in this prospective clinical study. While fibrin sealant was used to close the potential dead space in the study group, nothing was used in the control group. The volume of postoperative fluid collection on ultrasound was compared between the groups.

Results: Patient characteristics and the volumes of hernia sac were similar between the 2 groups. The mean volume of postoperative fluid collection was found as 120.2 mL in the control group and 53.7 mL in the study group, indicating a statistical significance (P < 0.001).

Conclusion: Minimizing the potential dead space with a fibrin sealant can reduce the amount of postoperative fluid collection, namely the incidence of pseudorecurrence.

No MeSH data available.