1. “Tacking, Gluing, or No Fixation”
Koray TOPGÜL M.D.
Ondokuz Mayıs University Samsun/ TÜRKİYE
Dear Chairman, ladies and gentelmen. My name is Koray Topgül . I’m from Ondokuz Mayıs University in Turkey. First of all, thank you to the organising committee for inviting me to present. I feel honoured. I will talk about fixation or no fixation and gluing methods to fixing meshe in laparoscopic inguinal hernia repair, during the 12 minutes given to me.

2. Inguinal Hernia Surgery
Recurrences 0%
Pain 0%
Infection %
Seroma 0%
Hematoma 0%
Vascular injury 0%
Testicular atrophy 0%
Work loss 0%
The hernia surgeons want to reach this conclusion. Is it realistic? Is it possible? I don’t know but it will be possible in the future. The surgeons, the researches are still working achieve these results. All of our efforts to reach these results.

3. Laparoscopic Inguinal Hernia Repair
Less postoperative pain
Lesser morbidity
Faster recovery
Earlier return to normal activities
Barkun JS et al; Surgery 1995
Tanphiphat C et al; Surg Endosc 1998
In that way laparoscopic hernia repair has made great contribution. It has some advantages compared with open hernia surgery. But, the laparoscopic herniorraphy is not devoid of complications.

4. Recurrences Pain Infection Vascular injury Tecticular atrophy
Work loss
Today, large proportion nearly zero other complications, recurrencs and pain are still being questioned.

5. Recurrence small mesh inadequate fixation migration of mesh missed hernia inexperience Pain nerve interruption by stapler pubalgia because of stapler local effects of mesh on nerve
You can see in this slide that some factors are held responsible for recurrence and pain.

6. Hernia Surgery IN OUT Pain Recurrence
Especially, pain is more important problem in terms of being a quality of life indicators in this days. Recurrence rates has been decreased under 1% in many studies. Currently, more concern is directed to patient comfort after the operation.

7. USA 800.000 herniorraphy 34.800 patients/year chronic pain
“inguinodynia”
Nienhuijs SW, International J Surg,2008
Nienhuijs SW, Am J Surg, 2007
Bozuk M, Am J Surg, 2003
Madura JA, Am J Surg, 2005
Herniorrhaphy is one of the most common surgical procedure. And chronic pain after inguinal hernia repair is well known compliction and its rate is not less.

8. Left Groin İlioopubic tract
At the beginning, the laparoscopic approach was associated with problems of postoperative pain related to nerve lesions due to trapping with stapler or tacks. But now, we know the concept of nerve compression and we do not make fixation with stapler under the iliopubic tractus level to prevent neuralgia. Also we use adequate mesh size like cm a to prevent recurrence. The technique has been standardized. Today laproscopic inguinal hernia repair is more widely used and laparoscopic surgeons have adequate experience.

9. How can we avoid these complications?
And should not lead to relapse and pain
And so,…..
Lets we discuss these issues in the light of literature.

10. We should use stapler but small number and according to the rules
We should use stapler but small number and according to the rules. Otherwise at increased risk of recurrence
Fixation is unnecessary , the rate of recurrence is not increase if you can use adequate size mesh and perform good technique. Also it is cheap method.
Use of the FS is feasible. It is not increase the rate of recurrence and protect pain. (what about the cost of ?)
There are some different ideas and some different results of the researcher reports related to this topics.
Some authors said..

11. Fixation X No Fixation
Should we fixation applied?

12. *Only one recurrence (0.2%) in
*500 hernias, , prospective multicenter double-blinded randomised trial, TEP, follow-up 6-13 months
*Only one recurrence (0.2%) in
fixation group
*The cost of disposable materials and equipment was 375 AUD less per patients in the nonfixation group.
In this study, Taylor and colleagues investigated the effects on pain and recurrence of no fixation method. They were found less pain in nonfixation group. Theye were also reported importance of tacks number. Theye were dedected significant differences between six tacks and more. The cost of the nonfixation group less than fixation group. There were differences between the two groups of 375 AUD.

13. Conclusion of their study was

14. *They were operated 311 hernias between 2004-2006
*96 % patients have been followed up one year
*They were used polyester and slit meshes
This study was conducted by Messaris and colleagues.

15. No fixation reduced the operating room costs by 350-450 USD
No hernia recurrence
%6.1 seroma
Chronic pain was nil (analgesic requirement was nearly 2 weeks mostly in patients with seroma )
No fixation reduced the operating room costs by USD
Fixation is not necassary in hands of experienced laparoscopic surgeons

16. No recurrence and no nerve injury
, prospective randomized, two groups-- with or without tacking
Postoperative pain levels in their study were also decreased in patients who did not receive mesh fixation compared with patients in whom the mesh was fixed; however, the differences were not statistically significant
No recurrence and no nerve injury
They determined some differences between two groups, but it was insignificant.

17. Conclusion: They recommend a tackless endoscopic TEP inguinal hernia
repair in select patients.
They do not believe that eliminating the fixation of the mesh in patients with smaller defects (3 cm) will lead to an increased incidence of hernia recurrence.

18. Morena-Egea and collageous were compared with fixation and nonfixation methods. The statistical study showed no significant differences
between the 2 groups with regard to complications, morbidity, postoperative pain and recurrences. The total cost of the process showed statistical differences according to the form of treatment. They stated that in comment section of the article “ our study…

19. This study is very large series
This study is very large series. They were evaluated nonfixation method in terms of complicatios, pain, recurrence and the other problems. Theye were reported that there was no statistical differences between groups in terms of recurrence. And they were found lower pain, urinary retantion, seroma formation and hospital stay rates. In the conclusion part of the article, they stated that TEP repair without mesh fixation is safe and feasible.

20. Gluing?

21. Fibrin Selants Fibrinogen & Thrombin Hemostasis Sealants Adhesives
Let's talk about the first FS. FS is a biodegradable adhesive formed by the combination of human-derived fibrinogen and thrombin activated by calcium chloride. It is leading to the formation of polimerized fibrin chains, effectively duplicating the last step of the coagulation cascade. The best feature of the FS is broken down by fibrinolysis and replaced by a fibrotic layer.
Byrne DJ, et al; Br J Surg, 1991
Spotnitz WD, et al; Transfusion theraphy: clinical principales and practice, 2004

22. Fibrin sealant indications
As you can see FS has been used different purposes in the surgical field.
Spotnitz WD, World J Surg, 2010

23. Spotnitz WD, World J Surg, 2010
We especially make use of its adhesive properties.
Spotnitz WD, World J Surg, 2010

24. K. Topgul et al. J Laparoendosc Adv Surg Tech A. 2005

26. Autologous Platelet-Rich Fibrin Sealant VİVOSTAT System
The Vivostat system is a medical device for preparing and applying autologous fibrin sealant from the patient’s own blood.
The system is fully automated and controlled by a microprocessor.
Due to the nature of autologous, it eliminates the incidence of pathogen transmission.
The other adhesive agent is autologous sealant.

27. 120 ml of the patient’s own blood is drawn into the preparation
To produce the fibrin,
120 ml of the patient’s own blood is drawn into the preparation
unit and mixed with a sodium citrate solution for anticoagulation.
The process results in the production
of 4±6 ml fibrin sealant. The production time for the fibrin is
20 min.
Preparation time and the cost is questioned
S. C. Schmidt J. M. Langrehr; Endoscopy; 2006
de Hingh et al, Eur Surg Res; 2009

29. Fixation materials in the laparoscopic repair ---which one?
EMS– Protak– EndoAnchor– Tisseal (FS)
in Tisseal group
Less pain
More rapid return to work
Less seroma/hematoma
No increase the rate of recurrence
Olmi S, Surgery, 2007
Novik B, Surg Endosc , 2006

30. Graft motion---- FS=S˃NF
Tensile Strength---- FS=S˃NF
Histologic findings---FS ˃S= NF

32. In this study TAPP technique was used for repair
In this study TAPP technique was used for repair. Fibrin glue and stapler fixation methods were copared. They were found no statistical differences between groups in terms of pain and recurrence. The operating time was reported longer in the fibrin glue because of the necessity of closing the peritoneum by running suture.

33. Schug-Pass C et al, Langenbecks Arch Surg;2010
Schwab and collageous were stated that use of fibrin glue is feasible and causes less chronic pain than stapler fixation method. The other outhers and the reports of their articles agree with Schwab. They were reported similar results with each other. They said that FS is feasible and safety method for fixation in laparoscopic inguinal hernia repair.
Schug-Pass C et al, Langenbecks Arch Surg;2010
Lovisetto F et al, Annals of Surgery; 2007
Lau H , Annals of Surgery; 2005
Olmi S et al, Surg Endosc; 2006
Novik B et al, Surg Endosc; 2006

34. The balance between these procedures is like a tilting board
The balance between these procedures is like a tilting board. The pain at the one side, the recurrence at the other side. When we used the stapler we are scared to develop pain. On the other hand, when we do not used any fixation method, we are afraid of recurrence. And, there are also cost problems and the other drawbacks like seroma, hematoma and so on. Probably, gluing can maintain a balance between our fear.

35. Conclusions/ Suggestions
FS is feasible.
Less pain, no increase of recurrence rate.
But it may be has some cost drawbacks depend on country, instution and insurance agent.
Yes, laparoscopic repair with fibrin sealant fixation is a feasible method. It has less posroperative pain rates and it does not increase of recurrence rate.

36. Good technique/adequate size mesh
No fixation, in small (2cm)hernias may be recommended. Does not increase recurrence rate in this group hernias.
Good technique/adequate size mesh
Less pain
most cost-effective
Without fixation method may be suitable for the small hernias. Many studies have shown that repair of without mesh fixation dose not increase recurrence rate. The important thing is appropriate and adequate surgical technique and appropriate size mesh. Also, it has less pain rate and it is the most cost-effective method.

37. (not enough evidence yet for no fixation)
If there is a large hernia over 4 cm, you should use stapler fixation
(not enough evidence yet for no fixation)
But you should use only a few number (2-4) stapler to avoid postoperative pain.
But, I think we can not to say same thing for the large hernias. We haven’t got enough evidence yet for no fixation in this group hernias. If you decided to use stapler for fixation, you should to use a few number stapler to avoid stapler releated complications.