Fibrin sealant for mesh fixation in Lichtenstein repair: biomechanical analysis of different techniques

Background Mesh fixation using sealants is becoming increasingly popular in hernia surgery. Fibrin sealant is an atraumatic alternative to suture or stapler fixation and is currently the most frequently used sealant. There are currently no biomechanical data available for evaluation of the quality of adhesion achieved with fibrin sealant during Lichtenstein hernia repair. Methods Five different suture and sealant techniques were evaluated and compared during simulated Lichtenstein hernia repair in an established, standardised biomechanical model for abdominal wall hernias. Results Significantly greater stability was achieved with fibrin sealant fixation of meshes than with point-by-point suture fixation. Fibrin adhesion protected meshes from dislocation at least as well as suture fixation with additional running-suture closure of the hernia orifice. Fibrin mesh fixation combined with additional support from running-suture hernia closure was significantly (P ≤ 0.002) superior to all other methods. Conclusions On the basis of these favourable biomechanical properties, mesh fixation using fibrin sealant can be recommended for use in onlay repair of transinguinal hernias.     

The use of fibrin sealant in urology

PURPOSE: Fibrin sealant has been increasingly applied in various surgical fields, including urological surgery, in the last 2 decades. We determined the safety and efficacy of fibrin sealant in urological surgery and identified areas that need further clinical investigation. MATERIALS AND METHODS: A MEDLINE search of all available literature regarding the use of fibrin sealant was performed. All articles, including experimental animal studies, prospective and retrospective studies, case series and case reports of fibrin sealant for hemostasis and/or other urological applications, were identified and reviewed. RESULTS: Prospective randomized studies in the field of thoracic and trauma surgery show the efficacy and safety of fibrin sealant for hemostasis. Based on these data fibrin sealant has been used successfully for hemostasis during partial nephrectomy and traumatic renal reconstruction. A number of experimental animal studies, case series and case reports show the efficacy of fibrin sealant for ureteral anastomosis, microsurgical vasal anastomosis, fistula repair, circumcision and orchiopexy as well as it use as an adjunct in other areas of reconstruction. CONCLUSIONS: Fibrin sealant is an effective and safe topical agent for controlling surface bleeding during elective and trauma related urological procedures. Using fibrin sealant as an adhesive for reconstruction requires further prospective studies. The introduction of laparoscopic procedures in urology may expand the indications for fibrin sealant as an alternative method of tissue reapproximation. Limiting the routine use of fibrin sealant to procedures with demonstrable benefits is desirable and would lead to a cost saving approach.     

Partial nephrectomy with fibrin glue repair: measurement of vascular and pelvicaliceal hydrodynamic bond integrity in a live and abbatoir porcine model

PURPOSE: Some of the challenges during partial nephrectomy include control of bleeding and repair of the pelvicaliceal system. Fibrin tissue sealants have recently been used to achieve hemostasis and collecting system closure in open and laparoscopic partial nephrectomy. However, there exist little data regarding the intrinsic strength of the bond, especially when applied to the vasculature and the urinary collecting system of the transected kidney. We examined the hydrodynamic bond integrity of a commercially available fibrin tissue sealant in a live porcine animal model undergoing partial nephrectomy. MATERIALS AND METHODS: Open partial nephrectomy was performed in 19 porcine renal units. Collecting system entry was confirmed by methylene blue instillation into the proximal ureter. Fibrin tissue sealant was used to repair 16 renal units, that is 8 kidneys hardened in vivo for 10 minutes and 8 hardened in vivo for 60 minutes. In an additional 3 renal units monopolar electrocautery was used to achieve hemostasis (no fibrin glue used). The strength of vasculature repair was performed by infusing saline into the renal artery (renal vein ligated) and measuring pressure at bond rupture. Similarly the integrity of pelvicaliceal repair was evaluated by retrograde infusion of saline into the collecting system via the proximal ureter and measurement of pressure at bond rupture. RESULTS: Fibrin tissue sealant was successful in achieving prompt hemostasis and it was subjectively superior to cautery alone with regard to bleeding control. Mean renal vascular and pelvicaliceal burst pressure for fibrin sealant treated kidneys was 378 (median 420) and 166 mm Hg (median 170), respectively. There was no significant difference in 10 vs 60-minute hardening times in treated kidneys. In comparison, vascular and pelvicaliceal burst pressure for nontreated (cautery alone) kidneys was 230 (median 220) and 87 mm Hg (median 90), respectively. CONCLUSIONS: Commercially available fibrin tissue sealants can provide supraphysiological renal parenchyma and collecting system sealing pressures after partial nephrectomy. This information supports the potential use of fibrin sealants during open and laparoscopic partial nephrectomy.     

Can fibrin sealant be used to prevent postoperative drainage?

. Fibrin sealant imitates the final phase of the blood coagulation process. A stable fibrin network is formed on the wound surface, which is thought to reduce the amount of postoperative bleeding and serous exudate from the wound. Fibrin sealants have proved effective in a wide range of surgical procedures. We undertook a prospective randomized, double blind, controlled trial in the use of a new fibrin sealant, Beriplast P, following axillary dissection (n=10), groin dissection (n=8), latissimus dorsi flaps (n=10) and adbominoplasties (n=16). Fibrin sealant (3 ml) was sprayed onto the wounds following haemostasis, prior to closure. Statistical analysis showed that drainage was reduced in the latissimus dorsi group in the first 24 h (P=0.011). However, there were no other significant differences, and length of hospital stay was similar in all groups. Whilst fibrin sealant may control bleeding and serous exudate in smaller surgical fields, we believe that the use of small volumes of sealant in relatively large wounds, particularly where the lymphatic drainage has been affected, is of limited clinical value. It does little to reduce total wound drainage or length of hospital stay. The cost of fibrin sealant is likely to preclude the use of larger volumes.     

Fibrin Glue as a Sealant for High-Risk Anastomosis in Surgery for Morbid Obesity

Background: Fibrin sealants promote hemostasis and wound healing. Complex revisional surgery is performed for morbid obesity, and high-risk patients undergo weight loss surgery routinely. Fibrin sealant, Tisseel™, was used by one surgeon on 120 consecutive patients at the gastrojejunal anastomosis in Roux-en-Y gastric bypass (RYGBP).We hypothesized that the application of fibrin sealant would decrease anastomotic leaks. Methods: One surgeon (Surgeon A) used fibrin sealant for 120 consecutive patients, while two other surgeons (Surgeons B & C) served as controls and did not use fibrin glue for their last 120 patients. Surgeon A did not use fibrin glue in 120 patients to serve as an internal control. All 480 patients underwent a RYGBP. Fibrin glue was applied at the gastrojejunal anastomosis. Results: The fibrin sealant group did not have any documented leaks on the previous 120 patients, while 5 patients with Surgeon B, 2 patients with Surgeon C and 1 patient with Surgeon A without fibrin sealant experienced enteric leaks requiring re-operation, drainage, or long-term total parenteral nutrition (N=480 total patients). Conclusions: Fibrin sealant may be useful in preventing leaks and promoting healing of the "high risk" anastomosis during complex gastrointestinal surgery. While the cost of fibrin glue is to be considered, re-operation and management of subsequent enterocutanous fistulas or anastomotic strictures may be more costly than routine use for high-risk morbidly obese patients.     

Lower reoperation rates with the use of fibrin sealant versus tacks for mesh fixation

Background

Groin hernia repair may be associated with long-term complications such as chronic pain, believed to result from damage to regional nerves by tissue penetrating mesh fixation. Studies have shown that mesh fixation with fibrin sealant reduces the risk of these long-term complications, but data on recurrence and reoperation rates after the use of fibrin sealant compared with tacks are not available. This study aimed to determine whether fibrin sealant is a safe and feasible alternative to tacks with regard to reoperation rates after laparoscopic groin hernia repair.

Methods

The current study compared reoperation rates after laparoscopic groin hernia repair between fibrin sealant and tacks used for mesh fixation. The study used data collected prospectively from The National Danish Hernia Database and analyzed 8,314 laparoscopic groin hernia repairs for reoperation rates. Mesh fixation was performed with fibrin sealant (n = 784) or tacks (n = 7,530).

Results

The findings showed a significantly lower reoperation rate for the fibrin sealant than for the tacks (0.89 vs 2.94 %, p = 0.031). The median follow-up period was 17 months (range, 0–44 months) for the fibrin sealant group and 21 months (range, 0–44 months) for the tacks group.

Conclusions

Fibrin sealant was superior to tacks for mesh fixation in laparoscopic groin hernia repair with regard to reoperation rates. The study could not differentiate between different hernia defect sizes, and future studies should therefore explore whether the superior effect of fibrin sealant applies for all hernia types and sizes.     

Stability of fibrin sealant in cerebrospinal fluid: an in vitro study

OBJECTIVE: The in vitro stability of fibrin sealant in cerebrospinal fluid (CSF) was investigated to verify the efficacy of intracranial application of fibrin sealant. METHODS: Human CSF was collected from 11 patients. Fibrin glue spheres (diameter, 5 mm) were incubated in CSF specimens at 37 degrees C. At 2, 4, 8, 24, and 48 hours, the diameter of the spheres was measured and the ultrastructure was evaluated by transmission electron microscopy. A control group consisted of sealant spheres in physiological saline (n = 2). RESULTS: In all CSF samples, the fibrin sealant did not degrade with time. The size, consistency, color, and shape of the sealant remained unchanged, even 48 hours after placement in the CSF. Transmission electron microscopic analysis of the fibrin sealant revealed an amorphous, fibrinous meshwork. No morphological differences existed between fibrin sealant complex placed in the CSF for different time periods and sealant placed in physiological saline. CONCLUSION: Within the limitations of this in vitro study, human CSF has no adverse effects on fibrin sealant in terms of alteration of structure and morphology. Fibrin sealant is stable in a CSF environment and can be effectively used in the cisternal or subarachnoidal space.     

Fibrin sealing versus stapling of hernia meshes in an onlay model in the rat

Incisional and inguinal hernia repair are among the most common procedures of general surgery. Mesh fixation by means of staples or sutures may lead to severe complications. The use of fibrin sealant (FS) has been suggested as alternative, but data on biocompatibility and adhesive strength of FS in combination with macroporous meshes is limited. Ventral hernia (n=8 per group) was treated in rats in onlay technique with two types of meshes, fibrin sealed or stapled. TI-Mesh (TMxl) extralight and VYPROII (VPII) were tested 17 days post op. No failure in mechanical tests (tensile and burst strength) occurred in sealed or stapled meshes. Histology revealed equally good tissue integration and neovascularization in all groups. Fibrin sealant yields excellent fixation in experimental hernia repair. This rat model is suitable for testing meshes and fixation techniques. A.H. Petter-Puchner and R. Fortelny have contributed equally to this study     

Combination of a liquid fibrin sealant with sheet‐type hemostatic agents: Experimental evaluation in partial nephrectomy animal model

Liquid fibrin sealants, together with sheet‐type hemostatic agents, have been used during partial nephrectomies to secure effective hemostasis at the suture site. Using animal kidneys, we investigated which hemostatic agent might adhere most effectively to the renal tissue and serve best as a bolster. Liquid fibrin sealant alone, or in combination with a sheet‐type hemostat, such as collagen, gelatin or oxidized‐cellulose hemostat, was applied to the cut surface of the kidney of anesthetized rabbits, and the differences in the degree of adherence to the kidney and resultant hemostatic efficacy were evaluated. Histological analyses were also carried out to compare the degree of adherence of each of the aforementioned hemostats to the kidney tissue. Fibrin sealant plus the collagen or gelatin hemostat was found to have a stronger hemostatic effect than fibrin sealant applied alone or fibrin sealant plus oxidized‐cellulose hemostat. The histological investigation showed that the fibrin sealant adhered well to kidney tissue when it was applied with the collagen or gelatin hemostat, showing the advantage of combining these two materials for achieving effective hemostasis. Fibrin sealant used in combination with the collagen or gelatin hemostat was the most suitable for obtaining a reinforced hemostatic effect at the suture site in a partial nephrectomy animal model.     

Heterologous fibrin sealant potentiates axonal regeneration after peripheral nerve injury with reduction in the number of suture points

The use of suture associated with heterologous fibrin sealant has been highlighted for reconstruction after peripheral nerve injury, having the advantage of being safe for clinical use. In this study we compared the use of this sealant associated with reduced number of stitches with conventional suture after ischiatic nerve injury. 36 Wistar rats were divided into 4 groups: Control (C), Denervated (D), ischiatic nerve neurotmesis (6 mm gap); Suture (S), epineural anastomosis after 7 days from neurotmesis, Suture + Fibrin Sealant (SFS), anastomosis with only one suture point associated with Fibrin Sealant. Catwalk, electromyography, ischiatic and tibial nerve, soleus muscle morphological and morphometric analyses were performed. The amplitude and latency values of the Suture and Suture + Fibrin Sealant groups were similar and indicative of nerve regeneration.The ischiatic nerve morphometric analysis in the Suture + Fibrin Sealant showed superior values related to axons and nerve fibers area and diameter when compared to Suture group. In the Suture and Suture + Fibrin Sealant groups, there was an increase in muscle weight and in fast fibers frequency, it was a decrease in the percentage of collagen compared to group Denervated and in the neuromuscular junctions, the synaptic boutons were reestablished.The results suggest a protective effect at the lesion site caused by the fibrin sealant use. The stitches reduction minimizes the trauma caused by the needle and it accelerates the surgical practice. So the heterologous fibrin sealant use in nerve reconstruction should be considered.     

Hemostatic effectiveness of fibrin glue derived from single-donor fresh frozen plasma

Fibrin glue derived from pooled human blood is an effective sealant for high-porosity vascular grafts and a valuable topical hemostatic agent in heparinized patients. Use of this agent in the United States is prohibited because of potential transmission of hepatitis B, acquired immunodeficiency syndrome, and other serologically transmitted illnesses. We have developed a cryoprecipitation technique that allows preparation of fibrin glue from single-donor fresh frozen plasma. Use of this agent presumably entails no greater risk of disease transmission than intravenous administration of single-unit fresh frozen plasma. This report describes our early clinical experience with this material. Fibrin glue was used as a sealant for porous woven Dacron tubular prostheses and cardiovascular patches in 19 patients. The fibrin glue sealant has also been employed to control bleeding from needle holes and small anastomotic tears in 22 patients. No patient in this series had a bleeding complication from a suture line or graft treated with fibrin glue. This experience indicates that like fibrin glue from pooled blood, fibrin glue from single-donor plasma is effective as a graft sealant and topical hemostatic agent. Preparation of fibrin glue from single-donor plasma is simple and economical, and may provide cardiothoracic surgeons in the United States with a widely available, valuable hemostatic adjunct.     

Fibrin glue fixation of a digital osteochondral fracture: case report and review of the literature

Surgical treatment options for digital osteochondral fractures are limited by the small amount of bone available for fixation and the propensity for digital stiffness with the introduction of hardware. Fibrin sealant is used in a variety of clinical settings as a biologic bonding agent and may circumvent the drawbacks of traditional fixation or simple excision for certain digital osteochondral injuries. Successful use of fibrin sealant fixation for a patient with an osteochondral fracture involving the proximal interphalangeal joint is documented, and the literature on fibrin sealant for osseous fixation is reviewed.     

Sutureless repair of a partially transected median nerve using Tisseel glue and Axoguard nerve protector: A case report

Peripheral nerve injuries in which the nerve is not completely severed often result in neuromas-in-continuity. These can cause sensory and functional deficits and must be resected and reconstructed. In defects greater than 5 mm in length, nerve graft is indicated, and suture neurorrhaphy is typically used to secure the nerve ends. However, sutures may negatively impact nerve regeneration. Fibrin glue has recently been used to mitigate the inflammatory response associated with suture neurorrhaphy. Most of the literature regarding fibrin glue covers animal models and supports its use for nerve reconstruction. Tisseel, a fibrin sealant developed as an adjunct to hemostasis, has recently shown utility in peripheral nerve repair by increasing tensile strength without additional sutures. We present the successful use of Tisseel sealant in a neuroma resection and reconstruction. In this case, a 35-year-old female presented with persistent neuropathic pain and neurologic dysfunction related to the median nerve in her hand with a history of distal forearm laceration and prior carpal tunnel release. Upon exploration, a neuroma-in-continuity involving 75% of the nerve was identified, resected, and reconstructed using processed human nerve allograft, as well as Tisseel sealant and Axoguard nerve protector to secure the repair and offload tension. At 1-year follow-up, pain was resolved, with ≤8 mm static 2-point discrimination in the median nerve distribution, and excellent improvement in hand strength compared with preoperative conditions. The outcome of this case indicates that fibrin glue may be useful to avoid excess sutures in cases of neuroma-in-continuity not involving the entire cross-section of the nerve.     

Randomized clinical trial of fibrin sealant in patients undergoing resternotomy or reoperation after cardiac operations. A multicenter study

A multicenter study was conducted to test the efficacy and safety of fibrin sealant as a topical hemostatic agent in patients undergoing either reoperative cardiac surgery (redo) or emergency resternotomy. A total of 333 patients from 11 centers in the United States were included in the study. Patients were randomly assigned to initially receive the fibrin sealant or a conventional topical hemostatic agent when such was required during an operation. The end point used to evaluate the agent's efficacy was local hemostasis, the number of bleeding episodes controlled within 5 minutes. The fibrin sealant group from the prospective study was compared with historical matched control subjects for postoperative blood loss, need for resternotomy, blood products received, and hospital stay. It was also compared with historical nonmatched control subjects for the incidence of resternotomy and mortality. The results showed a 92.6% success rate for fibrin sealant in controlling bleeding within 5 minutes of application, compared with only a 12.4% success rate with conventional topical agents (p less than 0.001). Fibrin sealant also rapidly controlled 82.0% of those bleeding episodes not initially controlled by conventional agents. High-volume postoperative blood loss was significantly less (p less than 0.05) in the fibrin sealant group than in the matched controls. Additionally, resternotomy rates after redo operations were significantly lower in the fibrin sealant group (5.6%) than in the nonmatched historical control group (10%) (p less than 0.0089). There were no significant differences in hospital stay or blood products received between the fibrin sealant group and matched historical controls and no difference in mortality between the fibrin sealant group and nonmatched historical controls. There were no documented instances of adverse reactions, transmission of viral infection (hepatitis B, non-A/non-B hepatitis), or human immunodeficiency virus seroconversion. This study shows that fibrin sealant is safe and highly effective in controlling localized bleeding in cardiac operations. Fibrin sealant reduces postoperative blood loss and decreases the incidence of emergency resternotomy. These findings make fibrin sealant a valuable hemostatic agent in cardiac surgery.     

New developments in the use of fibrin sealant: a surgeon's perspective

Fibrin sealant, a surgical tissue adhesive, has gained widespread use for its ability to achieve three major clinical goals: reducing hemorrhage, increasing tissue adherence, and allowing drug delivery. The object of this state-of-the-art review is to clarify the most recent developments in this field from a surgical perspective. The areas of greatest interest and progress relating to surgical uses for fibrin sealant--specifically, new methods of sealant production, new experimental or clinical uses, and new potential complications--are explored in this review.     

Fibrin versus polyethylene glycol sealant: an experimental study in rabbits

Fibrin glue has been applied universally in general surgery as an adhesive, hemostatic, or embolizing agent. In reconstructive surgery, fibrin has been used mainly for nerve and microvascular repair or as a substitute for sutures in skin closure and skin grafting. Another area of increasing use is in face-lift surgery, where the goal is to improve hemostasis on the raw surfaces and to discourage the occurrence of major hematomas. However, as most components of the fibrin glue are derived from human or bovine plasma, they may cause allergic reactions and transmit infectious agents such as hepatitis or AIDS virus, or prions such as the Creutzfeldt-Jakob disease agent. With these risks in mind, we tested polyethylene glycol (PEG) sealant, a recently introduced and purely synthetic vascular sealant, as an alternative to fibrin glue. A 2 × 2 cm subcutaneous pocket was created on the dorsal thighs of ten New Zealand White rabbits by an incision medial to the sciatic vein. The pockets were randomly filled with either 0.2 ml of thawed fibrin glue or PEG sealant. After the operation, the thighs were inspected macroscopically for hematoma, seroma, or granuloma formation. Eleven weeks later, the animals were killed, and the fibrin and polyethylene glycol-filled pockets were harvested en bloc with the overlying skin and processed for histological examination. A swelling, viewed macroscopically, was visible at the experimental site in three thighs of the fibrin group, but in none of the PEG group. Only two specimens of the fibrin group and five specimens of the PEG group showed no signs of inflammation. All other specimens revealed signs of chronic or granulomatous inflammation, with no significant difference between the groups. This experimental study showed that 11 weeks after application of either fibrin or PEG sealant, signs of chronic or even granulomatous inflammation were detectable in 2/3 of the specimens in the fibrin group and in approximately 50% of the specimens in the PEG group. Beyond the comparable potential of both sealants to induce inflammatory tissue reactions, PEG sealant has some notable advantages as it is purely synthetic and therefore carries no risk of transmission of viral pathogens or prions. The combination of this safety profile, the ease of application, and the consistently good reported hemostatic results obtained with PEG sealant makes it an interesting alternative to fibrin glue in plastic surgery.     

纤维蛋白胶在实验性皮肤损伤愈合中的作用

纤维蛋白胶是一种理想的组织粘合剂和止血剂,它具有为成纤维细胞生长提供骨架、刺激修复细胞生长和封闭受损血管等作用.本文观察了它在动物皮肤损伤愈合模型中的作用.     

Current applications of fibrin sealant in urologic surgery

Biosurgical preparations designed to promote surgical hemostasis and tissue adhesion are being increasingly employed across all surgical disciplines. Fibrin sealant is the most widely studied and utilized biosurgical adjunct in urology. Complex reconstructive, oncologic, and laparoscopic genitourinary procedures are those most appropriate for sealant use. This article details the diverse urologic applications of fibrin sealant in the management of genitourinary injuries, surgery, and complications.     

The effect of fibrin sealant on the healing of laser-resurfaced skin

Background: Fibrin sealant is an effective hemostatic agent and a useful tissue sealant. Studies have also suggested that fibrin sealant may accelerate the normal wound-healing process. Objective: This study was designed to ascertain whether fibrin sealant would enhance wound healing after CO₂ laser resurfacing in a guinea pig model. Methods: The CO₂ laser was used to create equal areas of skin resurfacing on both sides of 14 Dunkin Hartley guinea pigs. Fibrin sealant was applied to the treatment side, whereas bacitracin was applied to the control side. Biopsies of these areas were performed on days 1, 3, 7, and 10. A histologic evaluation was performed with the use of a grading scale that compared acute and chronic inflammation, granulation tissue, collagen deposition, and epidermal regeneration. Results: The wounds treated with fibrin sealant demonstrated a statistically significant reduction in the degree of acute and chronic inflammation as well as collagen deposition. At day 7, fibrin sealant was noted to enhance neovascularization and result in a slight delay in reepithelialization. All wounds were completely reepithelialized at day 10. No wound infections or other complications were noted as a result of the application of fibrin sealant. Conclusions: Although wound healing was not accelerated, the application of fibrin sealant after CO₂ laser resurfacing diminished the acute and chronic inflammatory response, enhanced neovascularization, and reduced collagen accumulation. Further research is needed to assess whether the effects of fibrin sealant noted in this study result in improved cosmetic healing after CO₂ laser resurfacing. (Aesthetic Surg J 2001;21:509-517.)     

Fibrin sealant treatment of splenic injury during open and laparoscopic left radical nephrectomy

PURPOSE: We describe the use of fibrin sealant for rapid and definitive hemostasis of splenic injuries incurred during open and laparoscopic left nephrectomy. MATERIALS AND METHODS: In 2 patients undergoing left nephrectomy for a suspicious renal mass splenic laceration occurred during mobilization of the colonic splenic flexure at open nephrectomy and laparoscopic upper pole dissection, respectively. Fibrin sealant was applied topically in each case. RESULTS: In each patient fibrin sealant achieved immediate hemostasis and each recovered without further splenic bleeding. CONCLUSIONS: The topical application of fibrin sealant safely, rapidly and reliably achieves definitive hemostasis of splenic injuries. It is simple to use in the open and laparoscopic approaches.