Fibrin glue for securing the mesh in laparoscopic totally extraperitoneal inguinal hernia repair

Background Anchoring the mesh in laparoscopic totally extraperitoneal groin hernia repair (TEP) with human fibrin glue has theoretical advantages. However, these have been supported and reported previously only in animal studies. Before the initiation of large patient trials, the authors wanted to confirm the feasibility, assess the costs, and rule out any flagrant short- and long-term adverse effects of fibrin glue usage in a small series of patients. Methods Nine consecutive TEP repairs with fibrin glue mesh fixation were performed. The perioperative and postoperative outcomes at 1, 16, and 40 months were compared with those for a control group of 96 stapled repairs. Results Gluing was easy and is less expensive than stapling. No fibrin glue–related adverse effects were found. The overall outcome was similar to that for stapled repairs, with no indication that the glued repairs were inferior. Conclusions Fibrin glue seems to be a reasonable, feasible, and maybe even competitive alternative to the standard tissue-penetrating mesh fixation. The results of this study justify launching larger trials. Presented at the 11th International Congress of the European Association for Endoscopic Surgery (EAES), Glasgow, Scotland, 15–18 June 2003, and as an updated version at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting, Denver, CO, USA, 31 March 31–3 April 2004.     

Laparoscopic hernia repair: the learning curve

The performance of a laparoscopic inguinal hernia repair requires unique technical and cognitive skills which, until recently, were not routinely taught to general surgeons. The initial experience of three surgeons with laparoscopic hernia repair was audited prospectively to assess the learning curve for the technique. From March 1992 to June 1994, transabdominal preperitoneal (TAP) mesh repair was attempted on 172 consecutive inguinal hernias. Three procedures were converted to traditional repairs. The three independent surgeons that performed the repairs had minimal or no prior clinical experience with the technique in the role as primary surgeon. The hernia repairs were divided into two groups. Group 1 consisted of the first 90 hernia repairs in the series, 30 repairs per surgeon. This group was compared to the subsequent 82 repairs (group 2), approximately 27 repairs per surgeon. Patients were followed up for a median of 31 months. Group 1 had more patients who were hospitalized overnight (37% versus 31%), a greater rate of conversion (2.2% versus 1.2%), a higher complication rate (11.7% versus 0%), a higher recurrence rate (12.2% versus 0%), and a longer delay in the return to full activity (11 weeks versus 8 weeks). Also, overall patient satisfaction with their hernia repair was slightly greater in group 2 (score, 9.0/10 versus 8.2/10). The lack of prior experience with the TAP technique (one surgeon) was associated with a marked increase in the number of conversions (two of three total conversions), complications (four of eight total), and hernia recurrences (8 of 11 total). This study demonstrates that a surgeon's initial experience with laparoscopic herniorrhaphy is associated with an identifiable learning curve. Significant improvements in complication and recurrence rates and overall patient satisfaction can be expected after the initial learning phase. Also, a complete lack of prior experience with laparoscopic herniorrhaphy is associated with a higher rate of conversion and significant increases in complications and hernia recurrences.     

Fibrin glue applications in urology

Fibrin glue is used as a hemostatic and adhesive agent. Until recently, safety issues had delayed approval of the commercial preparation in the United States. Fibrin glue has found several urologic applications, especially as an adhesive agent. It has excellent potential in laparoscopic surgery, where conventional tissue approximation techniques are cumbersome and time-consuming. Fibrin glue has also been used as a delivery vehicle for autologous cell transplantation and may play a major role in tissue engineering techniques in the future.     

Fibrin glue in gastroenteric surgery

In order to compare the results obtained in terminoterminal and terminolateral intestinal anastomoses using fibrin glue, both fibrin glue and the tissucol KIT were used on a group of rats: comparison of the wounds so treated revealed that both products gave good results. It is claimed that with certain technical improvements the use of fibrin glue could be extended to microsurgery of the nerves and blood vessels.     

Fibrin glue and bone regeneration

The osteoinductive property of fibrin glue with and without admixture of aprotinin was proven in animal model. Aprotinin as an inhibitor of the fibrinolysis is supposed to be an inhibitor of the osteogenesis, too. Three holes of 4 mm diameter and 2 mm depth were placed into the diaphysis of both femura in 12 adults dogs. The defects were filled with either pure fibrin glue or with glue containing aprotinin (3000 KIE), or with nothing (vacant). After 8 weeks the quantity of the new built woven-bone was examined by plane geometry and the "Bone Metabolising Unit (BMU)" (Frost) which are crossing the border of lamellar bone and new woven bone were counted out. There was seen no statistical significantly between the three groups neither in the quantity of new bone nor in the BMU. Therefore the fibrin glue has no osteoinductive property.     

Laparoscopic ventral hernia repair during the learning curve

Abstract. Large series of laparoscopic ventral hernia repair have shown excellent results. However, published comparative studies have had conflicting outcomes. We retrospectively reviewed the first 29 laparoscopic ventral hernia repairs performed at a VA Medical Center from January 2000 to June 2001. The outcome was compared to that of open repairs performed during the same time period. Outcomes between the groups were similar in all respects, except for the length of stay. The conversion rate for the laparoscopic approach was 13.8%. There was one death in the laparoscopic group due to an unrecognized enterotomy. There were three recurrences in the open group and one in the laparoscopic group with a mean follow up of 13 months. In our series, laparoscopic hernia repair resulted in a shorter hospital stay but no other significant benefits, along with a risk of missed enterotomy. The risk-benefit ratio for this procedure may be high during the learning curve. Electronic Publication     

Fibrin glue osteosynthesis of epiphyseal injuries

Osteosynthesis of epiphyseal injuries by fibrin glue was tested in an experiment on ten dogs. In was successful in types II and III epiphyseal injuries (Salter and Harris) but failed in 50% of unstable type IV fractures. Plaster fixation of the extremity was necessary for the completion of osteosynthesis. Histology revealed uncomplicated bone healing. Clinical application of fibrin glue is to be expected primarily in the therapy of more stable type II and III epiphyseal injuries (Salter and Harris) with the fragments not exposed to major traction.     

Fibrin glue in the management of anal fistulae

OBJECTIVE: Fibrin glue has been used as a sphincter sparing approach for the treatment of anal fistulae for two decades. However, there is uncertainty about its short and long-term efficacy. The objective of this review was to ascertain the role of fibrin glue in the management of anal fistulae, including assessment of recurrence rates, continence disturbance and other complications. METHODS: We searched Medline (January 1966 to February 2004), the Cochrane database, and EMBASE using the terms anal fistulae, fistula-in-ano, and fibrin glue. Relevant papers from the reference lists of these articles and from the authors' personal collections were also reviewed. A systematic review of all articles relating to the use of fibrin glue in the treatment of anal fistulae was performed. This included 19 studies. Reviewers performed data extraction independently. Outcomes evaluated included recurrence rates, continence disturbance, septic complications, adverse drug reactions, and duration of follow-up. Heterogeneity of the clinical trials made direct comparisons difficult and meta-analysis impossible. RESULTS: The success rates reported in published studies range from 0% to 100%. Differences in patient selection (including fistula aetiology and type), treatment protocols, and follow-up duration may contribute to such diverse results. CONCLUSIONS: Fibrin glue is simple to use, has a minimal morbidity and should not affect later treatment options in the event of its failure. It is therefore theoretically attractive as a first line treatment in the management of those types of anal fistula in which it has been shown to work. However, further research into 'biological' glues is merited and these subject to randomised controlled study.     

影响腹腔镜疝修补学习曲线因素的分析

目的评价腹腔镜腹股沟疝修补术不同阶段的手术效果,探讨其学习曲线问题。方法回顾性分析2013年3—11月,南京医科大学鼓楼临床医学院由同一术者开展的连续60例腹腔镜腹股沟疝修补术（LIHR）手术的资料,所有患者按手术先后顺序分为1—5组,每组各12例,观察各组患者手术时间、术中术后不良事件、术后复发率。结果1、2、3组手术时间与4、5组有统计学差异（F=6．603,P=0．000）;术中术后不良事件（并发症）逐渐减少,多可不经处理自行缓解,无严重并发症发生。无修补失败发生,随访期内无复发。结论具有良好腹腔镜操作基础者约在20-30例后即能熟悉LIHR的操作．而真正度过学习曲线、具有很好的控制和处理并发症的能力,至少要达到150～200例。     

Fibrin glue for partial nephrectomy.

Fibrin glue, a mixture of concentrated autologous fibrinogen and bovine-derived thrombin, was used to achieve hemostasis during 7 partial nephrectomies. After transected vessels were suture ligated, topically applied fibrin glue filled all renal defects with an adherent clot that resulted in immediate hemostasis. There was no case of delayed hematoma or abscess formation, and no complications were referrable to the use of fibrin glue. Although fibrin glue is no substitute for early vascular control and careful surgical technique, its ability to stop venous oozing from the cut surface of renal parenchymal tissue dramatically facilitates hemostatic control.     

Fibrin glue inhibits intra-abdominal adhesion formation

To determine the effect of fibrin glue on intra-abdominal adhesion formation, 45 rats were randomized to three groups. Each animal received two adhesion models. Group 1 received no further treatment. Groups 2 and 3 had the adhesion models covered with fibrinogen from fresh frozen plasma (1.77 g/L) and cryoprecipitate (23.6 g/L), respectively. In group 1, 13 of 15 rats had high-grade adhesions in both models. In group 2, high-grade adhesions were noted in nine of 15 rats in model 1 and in 12 of 15 rats in model 2. In group 3, however, high-grade adhesions were seen in only three of 15 rats in model 1, with 11 rats having no adhesions, and in only two of 15 rats in model 2. Histologic analysis suggested accelerated healing in group 3. We conclude that (1) fibrin glue inhibits intra-abdominal adhesion formation in rats, (2) the inhibitory action is dependent on the fibrinogen concentration of the fibrin glue, and (3) adhesions are reduced by fibrin glue regardless of whether the peritoneal defect is closed.     

Fibrin glue for all anal fistulas

The aim of this study was to determine if a new sphincter muscle-sparing technique that uses fibrin glue was effective in closing all types of anal fistulas. All patients with anal fistulas who were seen by a single surgeon over a 2-year period were treated with fibrin glue. Six to 8 weeks after a seton was placed in the fistula tract, either autologous fibrin glue or commercially available fibrin sealant was used to close the fistula tract. Twenty patients were treated with a mean follow-up of 10 months. Etiology of the anal fistulas was as follows: cryptoglandular in 13, Crohn’s disease in four, and miscellaneous in three. Fibrin glue closure of the anal fistula was successful initially in 15 patients (75%) and was successful after a second treatment in two additional patients, for an overall fibrin glue fistula closure rate of 85% (17 of 20). Functional results have remained excellent with no patient reporting any change in continence after treatment. Fibrin glue is simple and effective treatment for all anal fistulas with excellent functional results. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 21–24, 2000.     

Fibrin glue for the treatment of persistent lymphatic drainage

A 7-year-old girl underwent resection of an abdominal wall lymphangiomatous tumor. Postoperative serous drainage, up to 300 mL per day, developed despite application of external pressure to the wound. Thirty-three days after the initial procedure, fibrin glue was applied to the draining tract. Concentrated fibrinogen was prepared from one unit of blood donated by the patient's mother. Ten milliliters fibrinogen and 10 mL thrombin (1,000 U/mL) were injected simultaneously through the wound drain as it was slowly removed, and pressure was reapplied for 48 hours. No further drainage occurred, and at 2- and 14-week follow-up examinations the wound had healed normally without reaccumulation of fluid. Fibrin glue successfully sealed this persistently draining abdominal wall tract. It is a painless, safe, and effective biologic sealant, and when prepared from homologous plasma it carries a low risk of virus transmission.     

Fibrin glue in renal and ureteral trauma

Fibrin glue (FG) made with highly concentrated human fibrinogen and clotting factors was used to achieve hemostasis of fourteen renal injuries and to seal three ureteral anastomoses in 15 patients. The cause of injury included twelve gunshot wounds, four stab wounds, and one iatrogenic ureteral injury. The mean intraoperative blood loss was 1.6 +/- 1.1 L (SD), and patients received 4 +/- 5 units of blood perioperatively. Utilizing the described techniques, FG was effective in achieving hemostasis and sealing ureteral suture lines against leakage in all cases. There were no cases of renal infection, rebleeding, urinary fistulas, delayed rupture, stone formation, or urinary tract obstruction. Two patients underwent re-exploration for causes unrelated to their renal or ureteral injuries. The use of FG was associated with less reliance on suture redundancy to achieve parenchymal hemostasis and perform ureteral anastomoses. FG sealing of renal and ureteral injuries is a safe and effective technique for controlling hemorrhage and sealing anastomoses. It is effective in the management of both superficial and deep renal injuries.     

生物蛋白胶混合丝裂霉素治疗进展期胃癌

目的 观察胃癌手术中用生物胶蛋白混合丝裂霉素喷涂手术野联合口服化疗的疗效.方法 将64例确诊进展期胃癌患者随机分为治疗组和对照组.治疗组:32例行D2胃癌根治术,术中用生物胶蛋白混合丝裂霉素喷涂手术刨面进行术中淋巴化疗,术后口服希罗达化疗,服用3周停1周为1个疗程,共做6个疗程;对照组:32例进展期胃癌同样行D2胃癌根治术,术后口服希罗达化疗6个疗程.对比两组疗效.结果 治疗组和对照组的5年生存率分别为56.50%和37.25%,两者差异有统计学意义(P＜0.05),治疗组显著高于对照组.结论 术中应用生物胶蛋白混合丝裂霉素能提高胃癌术后化疗疗效.