Chemical Fixation of Mesh in Repair of Inguinal Hernia: Long Term Follow Up

Background : Repair of inguinal hernia is the most widely disseminated operation in general surgery, because of high incidence of occurrence, and high incidence of complications. Lichtenstein Tension free in repair of Open Inguinal Hernia remains the golden technique for repair as it has the least number of complications and least incidence of recurrence. But fixation of mesh is still challenge in early and late post-operative period, namely as regard pain which remain long lasting for a very long period. One of factors of occurrence of pain possibly due to entrapment of nerve or nerve compression by sutures during fixation of upper border of the mesh. Also, it may be due to periosteal reaction to sutures fixed to the periosteum. Other explanations, due to excessive tension on muscles, causing its ischemia. Hence many surgeons resort to alternative for mesh fixators, so one of these alternatives was fixation by Cyanoacrylate. Aim : Aiming to study the effectiveness of Cyanoacrylate as fixator of mesh in repair of inguinal hernia, as regard post-operative pain, hospital stay, time of mesh fixation, postoperative pain, hospital stay, and recurrence of hernia. In long term follow up. Conclusion: T he application of cyanoacrylate as fixator in Lichtenstein inguinal hernia repair looks like a golden method for mesh fixation as it is safe, simple, less operative time, less hospital stay with less complications as regard marked reduction in postoperative pain in both short and long post-operative follow up. Chemical fixation of mesh in repair of inguinal hernia: long term follow up.


Introduction
Inguinal hernia repair is one of the most common general surgical operations performed worldwide. More than a million inguinal hernia repairs are performed annually in the United States and Europe alone [1]. The Lichtenstein technique is the method of open repair most widely disseminated for treatment of inguinal hernia, with which the incidence of recurrence has been remarkably reduced, as we know this fact has been the most important quality index in inguinal hernia repair [2].

Objectives
More detailed information on cyanoacrylate in mesh fixation on Exclusion Criteria: Bilateral and/or recurrent hernia, femoral hernia, emergency presentation, unfit for surgery or suffering from associated acute or chronic illness.

Technique
Lichtenstein Tension free in repair of Open Inguinal Hernia but with Cyanoacrylate glue which was applied using specially syringe to cover the whole surface of the mesh using minimal amount of the glue (0.5-2ml); glue could be applied as drops at interrupted points over conjoint tendon, inguinal ligament and pubic tubercle. Lateral to the spermatic cord, the upper part of the mesh was flipped over the lower one and they were joined with one polypropylene stitch.
The mesh was compressed against the inguinal floor for about 2 min.

Statistical analysis
The results were statistically analyzed. Data were fed to the computer and analyzed using IBM SPSS software package version 20.0.(Armonk, NY: IBM Corp). Qualitative data were described using number and percent. The Kolmogorov-Smirnov test was used to verify the normality of distribution, quantitative data were described using range (minimum and maximum), mean, standard deviation and median. Significance of the obtained results was judged at the 5% level. The used tests were Chi-square test: For categorical variables, to compare between different groups. Monte

Results
This study was a prospective, randomized. It was held in Department of Surgery, AL-Hussein university hospital, Al-Azhar University (Cairo) on 10 cases who were attendant to outpatient surgery clinic for elective repair of uncomplicated inguinal hernia.
Using Prolene ® mesh. Patients underwent inguinal hernioplasty with mesh fixation using (Cyanoacrylte) glue, their age ranged from 25-60 years with a mean of 40.30 ± 13.04 and a median of 39.50.
70% had a right-side hernia while 30% had a left side one. 80% had an indirect inguinal hernia while 20% had a direct inguinal hernia.  [5]. There are two studies reported their preliminary results of cyanoacrylate glue versus the use of sutureless method for mesh fixation in Lichtenstein repair; After 3 months, no recurrence was observed. Minor pain was observed after 3 weeks in 33% patients in the sutureless group and in 18% patients in the cyanoacrylate glue group, 3 months postoperatively 16% patients in the sutureless group and 5% patient in the cyanoacrylate glue group recorded minor pain. Local numbness was documented in 60% vs. 44% patients3 weeks postoperatively and in 40% vs. 25% patients 3 months postoperatively in the sutureless group and cyanoacrylate group, respectively [6][7][8].
Shorter surgery time may be beneficial in terms of overall cost and reduced infection rate. In our series, there were no reported cases with mesh infection [3].

Conclusion
Finally, the application of cyanoacrylate as fixator in Lichtenstein inguinal hernia repair looks like a golden method for mesh fixation as it is safe, simple, less operative time, less hospital stays with less complications as regard marked reduction in postoperative pain in both short and long post-operative follow up. and can be used easily by any surgeon regardless the level of skills with no increase in the early or late recurrence rate. Of course, it will be of great value if larger, randomized, and controlled trial done to confirm the results of cyanoacrylate as fixator.