Eriksen J R, Bech J I, Linnemann D, Rosenberg J
Department of Surgical Gastroenterology D, Gentofte University Hospital, Copenhagen, Denmark.
Hernia. 2008 Oct;12(5):483-91. doi: 10.1007/s10029-008-0375-z. Epub 2008 May 16.
The main reason for hospital stay after laparoscopic ventral hernia repair (LVHR) is probably pain, which also causes a lengthening of the patient's time to assume normal daily activities and work. It is likely that titanium tacks may be the main contributing factor to early (and maybe chronic) pain after LVHR. Therefore, non-invasive and patient-friendly mesh fixation methods must be considered. The present study was designed to investigate the technical applicability, safety and effect of Tisseel for intraperitoneal mesh fixation.
Nine 40-kg Danish Landrace female pigs had two pieces of MotifMESH and two pieces of Proceed mesh fixed in the intraperitoneal position by a laparoscopic technique. The two pieces of the same mesh were fixed with fibrin glue (Tisseel) and titanium tacks, respectively. All pigs were euthanised on the 30th postoperative day and the mesh-tissue samples were tested for strength of ingrowth (peel test), adhesion formation, mesh shrinkage and examined for histological alterations.
No meshes were displaced from their initial position at autopsy, but we observed two cases of mesh folding that could have resulted in hernia recurrence in real patients. There were no significant differences in the strength of ingrowth between different mesh types or fixation methods, measured as peel work per area of mesh (J/m2) and peak force per width of mesh (Nmax/cm). The Proceed mesh shrank by 11% compared to 4% for the MotifMESH mesh (p = 0.002). There was no difference in the grade of adhesions (%) between fixation methods (p = 0.794) or different mesh types (p = 0.296). In the same fashion, there was no difference in the strength of adhesions (grades 0-4) between the two fixation methods or different mesh types (p > 0.5, chi2 test). There was no significant difference in the formation of fibrosis or inflammation between the different meshes or fixation methods. All samples showed significant foreign-body reaction with giant cells.
Our results suggest that the laparoscopic fixation of an intraperitoneal mesh with Tisseel is safe and technically feasible in a pig model. There is still no evidence that fibrin-sealing alone is appropriate for intraperitoneal mesh fixation in hernia repair, but the technique might become an alternative or supplement to mechanical mesh fixation. Until then, further experimental research in animal hernia models with larger meshes is needed, especially with a focus on mesh folding and displacement.
腹腔镜腹疝修补术（LVHR）后住院的主要原因可能是疼痛，这也会延长患者恢复正常日常活动和工作的时间。钛钉可能是LVHR后早期（甚至可能是慢性）疼痛的主要促成因素。因此，必须考虑采用非侵入性且对患者友好的补片固定方法。本研究旨在探讨纤维蛋白胶（Tisseel）用于腹腔内补片固定的技术适用性、安全性及效果。
选用9头体重40千克的丹麦长白母猪，通过腹腔镜技术将两片MotifMESH补片和两片Proceed补片固定于腹腔内。两片相同的补片分别用纤维蛋白胶（Tisseel）和钛钉固定。所有猪在术后第30天实施安乐死，并对补片 - 组织样本进行长入强度（剥离试验）、粘连形成、补片收缩测试以及组织学改变检查。
尸检时无补片从其初始位置移位，但我们观察到两例补片折叠情况，这在实际患者中可能导致疝复发。不同补片类型或固定方法之间，以每平方厘米补片面积的剥离功（J/m²）和每厘米补片宽度的峰值力（Nmax/cm）衡量的长入强度无显著差异。Proceed补片收缩了11%，而MotifMESH补片收缩了4%（p = 0.002）。固定方法之间（p = 0.794）或不同补片类型之间（p = 0.296）的粘连分级（%）无差异。同样，两种固定方法或不同补片类型之间的粘连强度（0 - 4级）无差异（p > 0.5，卡方检验）。不同补片或固定方法之间在纤维化或炎症形成方面无显著差异。所有样本均显示出明显的伴有巨细胞的异物反应。
我们的结果表明，在猪模型中，用Tisseel进行腹腔镜下腹腔内补片固定是安全且技术上可行的。目前仍没有证据表明单独使用纤维蛋白封闭适用于疝修补术中的腹腔内补片固定，但该技术可能成为机械补片固定的一种替代方法或补充。在此之前，需要在更大补片的动物疝模型中进行进一步的实验研究，尤其要关注补片折叠和移位情况。
