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Dinkova A, Petrov P, Shopova D, Daskalov H, Harizanova S. Biomaterial-Based and Surgical Approaches to Local Hemostasis in Contemporary Oral Surgery: A Narrative Review. J Funct Biomater 2025; 16:190. [PMID: 40422854 DOI: 10.3390/jfb16050190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2025] [Revised: 05/18/2025] [Accepted: 05/19/2025] [Indexed: 05/28/2025] Open
Abstract
Effective local hemostasis is essential in oral surgery to prevent complications such as delayed healing, infection, and the need for re-intervention. Postoperative bleeding occurs in 4-6% of cases, increasing to 9-12% in patients receiving anticoagulant or antiplatelet therapy. This review evaluates the efficacy, safety, and clinical utility of local hemostatic agents based on 51 studies published between 1990 and 2023. Traditional agents, such as oxidized cellulose and gelatin sponges, control bleeding in over 85% of standard cases but offer limited regenerative benefits. Autologous platelet concentrates (APCs), including platelet-rich plasma (PRP) and leukocyte- and platelet-rich fibrin (L-PRF), reduce bleeding time by 30-50% and enhance soft tissue healing. Studies show the PRP may reduce postoperative bleeding in dental surgery by 30-50%, and in orthopedic and cardiac surgery by 10-30%, particularly in patients on anticoagulants. Tranexamic Acid mouthwash can reduce postoperative bleeding by up to 50-60%. Fibrin sealants achieve a 70-90% reduction in bleeding among high-risk patients, while topical tranexamic acid decreases hemorrhagic events by up to 80% in anticoagulated individuals without increasing thromboembolic risk. However, comparative studies remain limited, particularly in medically compromised populations. Additional gaps persist regarding long-term outcomes, cost-effectiveness, and the standardized use of emerging agents such as nanomaterials. Future research should prioritize high-quality trials across diverse patient groups and develop clinical guidelines that integrate both safety and regenerative outcomes.
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Affiliation(s)
- Atanaska Dinkova
- Department of Dental, Oral, and Maxillofacial Surgery, Faculty of Dental Medicine, Medical University-Plovdiv, 4000 Plovdiv, Bulgaria
| | - Petko Petrov
- Department of Maxillofacial Surgery, Faculty of Dental Medicine, Medical University-Plovdiv, 4000 Plovdiv, Bulgaria
| | - Dobromira Shopova
- Department of Prosthetic Dentistry, Faculty of Dental Medicine, Medical University-Plovdiv, 4000 Plovdiv, Bulgaria
| | - Hristo Daskalov
- Department of Dental, Oral, and Maxillofacial Surgery, Faculty of Dental Medicine, Medical University-Plovdiv, 4000 Plovdiv, Bulgaria
| | - Stanislava Harizanova
- Department of Hygiene and Ecomedicine, Faculty of Public Health, Medical University-Plovdiv, 4000 Plovdiv, Bulgaria
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Alkemade EAJ, Baranski AG. Managing a large incisional hernia in an obese and immunosuppressed patient: A case report. Int J Surg Case Rep 2025; 128:111029. [PMID: 39965522 PMCID: PMC11879663 DOI: 10.1016/j.ijscr.2025.111029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2024] [Revised: 02/04/2025] [Accepted: 02/06/2025] [Indexed: 02/20/2025] Open
Abstract
BACKGROUND Large incisional hernias in high-risk patients, such as those undergoing immunosuppressive therapy, represent an extra surgical challenge due to elevated risks of infection and poor wound healing. This case report details the reconstruction of an abdominal wall defect in a high-risk patient using a high-cost yet robust and effective biologic mesh. CASE PRESENTATION A 38-year-old obese female with multiple comorbidities developed an LIH and an incarcerated left-sided inguinal hernia following a kidney transplantation. The surgical approach involved a two-layer mesh reconstruction, combining a biologic intraperitoneal mesh and an absorbable onlay mesh. To reduce the risk of infection and provide extra reinforcement, the hernia sac was preserved and sutured over the biologic mesh. Postoperative complications, including infection and seroma formation, were managed effectively with negative pressure wound therapy. The wound closed after seven months, with no recurrence observed during follow-up. DISCUSSION The biologic mesh, combined with the well-vascularized sac, demonstrated integration with vascularized tissue, minimizing infection risk, and providing natural reinforcement and enhanced healing. Advanced wound management, including negative pressure wound therapy, effectively resolved postoperative complications such as infection and seroma. CONCLUSION This case demonstrates the use of a multilayer reconstruction approach that combines a biologic mesh and the reuse of the hernia sac, offering a viable option for managing complex hernias in high-risk, immunosuppressed patients. This technique minimizes infection risk and provides stable long-term outcomes, even in challenging clinical settings.
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Affiliation(s)
- E A J Alkemade
- Leiden University Medical Center, Leiden, the Netherlands.
| | - A G Baranski
- Abdominal Organ Transplant Centre, Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.
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Rancke-Madsen P, Öberg S, Rosenberg J. Mesh fixation in laparoscopic groin hernia repair: a comprehensive review of techniques and devices. Hernia 2025; 29:105. [PMID: 39969637 DOI: 10.1007/s10029-025-03276-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2024] [Accepted: 01/19/2025] [Indexed: 02/20/2025]
Abstract
PURPOSE Laparoscopic groin hernia repair has increased in popularity in recent years. Many laparoscopic mesh fixation techniques and devices are available, but there is a lack of high-certainty evidence favoring one fixation technique over another. This narrative review aimed to provide a comprehensive summary detailing the available mesh fixation techniques and devices used in laparoscopic groin hernia repair. METHODS Information about mesh fixation techniques and devices was searched in PubMed, groin hernia guidelines, and medical technology companies webpages. RESULTS This review outlines various mesh fixation techniques, materials, and their features in laparoscopic groin hernia repair. We have summarized and presented in detail the available information on both penetrating and non-penetrating mesh fixation techniques, including the option of not fixating the mesh. Penetrating mesh fixation includes tacks, staples, and sutures. Tacks vary in size, absorption time, and shape and can be further categorized into absorbable and permanent materials. Additionally, this review describes two types of permanent titanium staples and the use of permanent and absorbable sutures as mesh fixation. Non-penetrating mesh fixation includes self-fixating mesh and glue. The types of glue are cyanoacrylate glue and fibrin sealant. While fibrin sealant requires careful thawing from a frozen state before use, cyanoacrylate glue offers easier storage but poses a risk of exothermic reaction with the surrounding tissue. Self-fixating meshes have an adhesive side made of microgrips or adhesive material, and a permanent side. CONCLUSION This review provided a comprehensive overview of the various mesh fixation techniques and devices in laparoscopic groin hernia repair.
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Affiliation(s)
- Patricia Rancke-Madsen
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Stina Öberg
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Rosenberg
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
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Nguyen M, Tran L, Foreman A, Lockwood C. The effectiveness of fibrin sealants in head and neck surgery: a systematic review and meta-analysis. Syst Rev 2024; 13:246. [PMID: 39342380 PMCID: PMC11439234 DOI: 10.1186/s13643-024-02634-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 08/08/2024] [Indexed: 10/01/2024] Open
Abstract
BACKGROUND Fibrin sealants are increasingly used in head and neck surgery to aid hemostasis, but individual studies lack conclusive evidence. This systematic review investigates their effectiveness compared to placebo or usual care in head and neck surgery. METHODS Studies comparing fibrin sealant to placebo or usual care in patients 18 years or older who have undergone soft tissue surgery of the head and neck with drain placement were included. Primary outcomes include wound complications and time to surgical drain removal postoperatively. Secondary outcomes include length of hospital stay, drain volume output, surgical management of hematoma, blood transfusion rates, and adverse reactions. Electronic databases were searched on October 2023 for randomized controlled and quasi-experimental studies. Studies underwent independent screening, review, and appraisal by two reviewers using JBI appraisal tools. Certainty was assessed with GRADE, and meta-analysis was conducted using JBI SUMARI, presenting effect sizes as relative risk ratios or mean differences with 95% confidence intervals. RESULTS Fourteen studies were included examining 904 patients. The fibrin sealant group exhibited reduced postoperative wound complications (hematoma, seroma, wound dehiscence, wound infection) (RR = 0.64, 95% CI = 0.45-0.92), shorter drain removal times (MD = - 0.49 days, 95% CI = - 0.68 to - 0.29), decreased drain output (MD = - 16.52 mL, 95% CI = - 18.56 to - 14.52), and shorter hospital stay (MD = - 0.84 days, 95% CI = - 1.11 to - 0.57) compared to controls. There was no statistically significant difference on the rate of intervention for postoperative hematoma and the rate of adverse reactions. DISCUSSION Evidence demonstrates with low certainty that fibrin sealant use is associated with a modest reduction in the rate of wound complications, drain duration, and length of stay, and a small reduction in drain volume output. Methodological weaknesses and clinical heterogeneity limit these findings. Further research should focus on enhancing methodological quality and exploring the cost-effectiveness of fibrin sealant use in surgery. SYSTEMATIC REVIEW REGISTRATION CRD42023412820. FUNDING Nil.
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Affiliation(s)
- Marie Nguyen
- JBI, School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia.
- Department of Otorhinolaryngology, Head and Neck Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
| | - Liem Tran
- JBI, School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | - Andrew Foreman
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
- Department of Otorhinolaryngology, Head and Neck Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Craig Lockwood
- JBI, School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
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Ang EWJ, Djordjevic I, Solic I, Goh CY, Steele TWJ. Tougher Bioadhesives through Dual Stimulation Strategies. Adv Healthc Mater 2024; 13:e2303666. [PMID: 38431774 PMCID: PMC11469300 DOI: 10.1002/adhm.202303666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/26/2024] [Indexed: 03/05/2024]
Abstract
Carbene-based bioadhesives have favourable attributes for tissue adhesion, including non-specific bonding to wet and dry tissues, but suffer from relatively weak fracture strength after photocuring. Light irradiation of carbene-precursor (diazirine) also creates inert side products that are absent under thermal activation. Herein, a dual activation method combines light irradiation at elevated temperatures for the evaluation of diazirine depletion and effects on cohesive properties. A customized photo/thermal-rheometer evaluates viscoelastic properties, correlated to the kinetics of carbene:diazoalkane ratios via 19F NMR). The latter exploits the sensitive -CF3 functional group to determine joule-based light/temperature kinetics on trifluoroaryl diazirine consumption. The combination of heat and photoactivation produced bioadhesives that are 3× tougher compared to control. Dual thermal/light irradiation may be a strategy to improve viscoelastic dissipation and toughness of photo-activated adhesive resins.
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Affiliation(s)
- Elwin W. J. Ang
- Nanyang Environment and Water Research InstituteInterdisciplinary Graduate SchoolNanyang Technological UniversitySingapore637553Singapore
- School of Materials Science and EngineeringNanyang Technological UniversitySingapore639798Singapore
| | - Ivan Djordjevic
- School of Materials Science and EngineeringNanyang Technological UniversitySingapore639798Singapore
| | - Ivan Solic
- School of Materials Science and EngineeringNanyang Technological UniversitySingapore639798Singapore
| | - Chen Yee Goh
- School of Materials Science and EngineeringNanyang Technological UniversitySingapore639798Singapore
| | - Terry W. J. Steele
- School of Materials Science and EngineeringNanyang Technological UniversitySingapore639798Singapore
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Nguyen M, Foreman A, Lockwood C. Effectiveness of fibrin sealants in head and neck surgery: a systematic review protocol. JBI Evid Synth 2024; 22:1151-1160. [PMID: 38015095 DOI: 10.11124/jbies-23-00142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
OBJECTIVE This review will investigate the effectiveness of fibrin sealants in adult patients who underwent head and neck surgery. INTRODUCTION Controlling bleeding is important in head and neck surgery. Complications involving nearby vital structures increase the risk of morbidity and mortality. Surgical tissue adhesives are used in addition to other traditional hemostatic methods to reduce surgical site bleeding. Fibrin sealants have shown some success compared with other tissue adhesives, but individual studies have been inconclusive. INCLUSION CRITERIA We will include studies comparing fibrin sealants with placebo or usual care in patients 18 years or older who have undergone soft tissue surgery of the head and neck with drain placement. Primary outcomes include wound complications and time to surgical drain removal. Secondary outcomes include length of hospital stay, drain volume output, surgical management of postoperative hematoma, rate of blood transfusions, and adverse reactions. METHODS We will search electronic databases (PubMed, Embase, Cochrane Central Register of Controlled Trials CINAHL, Scopus, Web of Science) for studies published from 1975 onwards. Sources to be search for unpublished literature will include ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, MedNar, and ProQuest Dissertations and Theses. Titles, abstracts, and full-text papers will be assessed against the inclusion criteria by 2 independent reviewers. Study screening and selection will be performed, and critical appraisal conducted using the standardized JBI appraisal tools. Data will be extracted by 2 independent reviewers. Meta-analysis will be conducted for all outcomes where appropriate, with weighted mean differences for continuous data. Risk ratios will be used for dichotomous data. Certainty will be reported using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. REVIEW REGISTRATION PROSPERO CRD42023412820.
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Affiliation(s)
- Marie Nguyen
- JBI, School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
- Department of Otorhinolaryngology, Head and Neck Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Andrew Foreman
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
- Department of Otorhinolaryngology, Head and Neck Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Craig Lockwood
- JBI, School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
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Thompson JL, Miller L, Bowlt Blacklock K. Effects of cyanoacrylate on leakage pressures of cooled canine cadaveric jejunal enterotomies. Vet Surg 2024; 53:367-375. [PMID: 38071682 DOI: 10.1111/vsu.14059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 10/31/2023] [Accepted: 11/24/2023] [Indexed: 02/16/2024]
Abstract
OBJECTIVE To compare the intraluminal initial and maximal pressures of enterotomies closed using three different techniques (single-layer appositional continuous closure; closure with cyanoacrylate; a single-layer appositional closure augmented with cyanoacrylate) in a cooled canine cadaveric jejunal model and to report the initial leak location in all samples. STUDY DESIGN Experimental, ex-vivo study. SAMPLE POPULATION Grossly normal chilled small intestine segments from three canine cadavers. METHODS A total of 45 chilled jejunal segments (n = 15 segments/group) were assigned to a handsewn group (HSE), a cyanoacrylate only group (CE) and a handsewn and cyanoacrylate group (HS + CE). A 2 cm antimesenteric enterotomy was performed and closure with one of the above techniques. Initial leakage pressures (ILP), maximal intraluminal pressures (MIP) and initial leakage location were recorded by a single observer. RESULTS Handsewn enterotomies leaked at higher ILP when augmented with cyanoacrylate (83.3 ± 4.6 mmHg, p < .001) compared to both the HSE group (43.8 ± 5.3 mmHg) and the CE group (18.6 ± 3.5 mmHg). Those sealed with cyanoacrylate only leaked at a lower MIP compared with the other groups (p < .001). Maximal intraluminal pressures did not differ between handsewn enterotomies, whether augmented or not (p = .19). CONCLUSION Reinforcement of a sutured enterotomy closure with cyanoacrylate was easy to perform and resulted in significantly increased initial leak pressures in cadaveric jejunum. CLINICAL SIGNIFICANCE The increased leakage pressures achieved by reinforcing enterotomies with cyanoacrylate could consequently reduce the incidence of postoperative intestinal leakage following an enterotomy and may result in reduced patient morbidity or mortality.
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Affiliation(s)
- Jamie-Leigh Thompson
- Department of Small Animal Surgery, The Royal Dick School of Veterinary Studies, Edinburgh, Scotland
| | - Lucy Miller
- Department of Anesthesia and Analgesia, The Royal Dick School of Veterinary Studies, Edinburgh, Scotland
| | - Kelly Bowlt Blacklock
- Department of Small Animal Surgery, The Royal Dick School of Veterinary Studies, Edinburgh, Scotland
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Raab S, Huber L, Fortelny R, Shamiyeh A. Laparoscopic transabdominal preperitoneal (TAPP) groin hernia repair using n-butyl-2-cyanoacrylate (LiquiBandFIX8) for mesh fixation and peritoneal closure: case report about extraperitoneal hematoma. Ann Med Surg (Lond) 2024; 86:481-484. [PMID: 38222725 PMCID: PMC10783228 DOI: 10.1097/ms9.0000000000001439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/17/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction A symptomatic inguinal hernia is a prevalent condition that typically requires surgical intervention. Various surgical approaches have been established for hernia repair, including several techniques for peritoneal closure and mesh fixation in laparoscopic surgery. N-butyl-2-cyanoacrylate, such as LiquiBandFIX8, offers a time-saving alternative to invasive methods for both mesh fixation and peritoneal closure. While n-butyl-2-cyanoacrylate is employed in various closure procedures, LiquiBandFIX8 is specifically designed for mesh fixation in inguinal hernia repair. Case presentation We present a case of a 68-year old man undergoing transabdominal preperitoneal inguinal hernia repair under full heparinization. LiquiBandFIX8 was employed for mesh fixation and peritoneal closure. Upon conducting a revision laparoscopy due to a significant postoperative hematoma, we found that the mesh and peritoneum remained undamaged and fully sealed, indicating an effective fixing technique. Both the initial repair and the subsequent revision surgery were documented and the videos were subsequently analyzed. Conclusion LiquiBandFIX8 provides a reliable adhesive strength and appropriate application for peritoneal closure and mesh fixation. When encountering extraperitoneal fluid collection, there is no anticipation of intraabdominal complications.
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Affiliation(s)
- Sandra Raab
- Department of General and Visceral Surgery, Kepler University Hospital
- Johannes Kepler University, Linz
| | - Livia Huber
- Department for Urology, Hospital Baden-Mödling, Baden, Austria
| | - René Fortelny
- Private Clinic Confraternity, General, and Visceral Surgery, Vienna, Austria
| | - Andreas Shamiyeh
- Department of General and Visceral Surgery, Kepler University Hospital
- Johannes Kepler University, Linz
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Koerniawan HS, Candrawinata VS, Tjahyanto T, Wijaya NJ, Putra AW, Wijaya JH. The safety and efficacy of fibrin sealant for thyroidectomy: a systematic review and meta-analysis of randomized controlled trials. Front Surg 2023; 10:1149882. [PMID: 37409068 PMCID: PMC10318191 DOI: 10.3389/fsurg.2023.1149882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/18/2023] [Indexed: 07/07/2023] Open
Abstract
Fibrin sealants have recently been thoroughly studied in several surgical specialties; however, results are conflicting. We aimed to examine the safety and efficacy of fibrin sealant patients having thyroidectomies. A thorough, systematic literature search was carried out using the terms thyroidectomy and fibrin sealant using PubMed, Cochrane Library, and Clinicaltrials.gov on December 25, 2022. The primary outcome of interest in this review was the amount of drainage, whereas hospitalization, the length of drain retention, and temporary dysphonia were secondary outcomes. Our meta-analysis (n = 249) showed that application of fibrin sealant is associated with lesser total drainage [SMD -2.76 (-4.83, -0.69); P = 0.009; I2 97%], but not with retention time of drainage [SMD -2.35 (-4.71, 0.01); P = 0.05; I2 98%], hospitalization time [SMD -1.65 (-3.70, 0.41); P = 0.12; I2 97%], and transient dysphonia [RR 1.01 (0.27, 3.82); P = 0.99; I2 0%]. The systematic review found that the use of fibrin sealant in thyroid surgery is positive in total volume drainage but not with the retention time of drainage, hospitalization time, and transient dysphonia. It is notable to remember that this interpretation is complicated by uneven, occasionally subpar technique and trial reporting, according to this systematic review's findings.
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Affiliation(s)
| | | | - Teddy Tjahyanto
- Department of Medicine, Universitas Tarumanagara, Jakarta, Indonesia
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Harman M, Champaigne K, Cobb W, Lu X, Chawla V, Wei L, Luzinov I, Mefford OT, Nagatomi J. A Novel Bio-Adhesive Mesh System for Medical Implant Applications: In Vivo Assessment in a Rabbit Model. Gels 2023; 9:372. [PMID: 37232966 PMCID: PMC10217475 DOI: 10.3390/gels9050372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/08/2023] [Accepted: 04/13/2023] [Indexed: 05/27/2023] Open
Abstract
Injectable surgical sealants and adhesives, such as biologically derived fibrin gels and synthetic hydrogels, are widely used in medical products. While such products adequately adhere to blood proteins and tissue amines, they have poor adhesion with polymer biomaterials used in medical implants. To address these shortcomings, we developed a novel bio-adhesive mesh system utilizing the combined application of two patented technologies: a bifunctional poloxamine hydrogel adhesive and a surface modification technique that provides a poly-glycidyl methacrylate (PGMA) layer grafted with human serum albumin (HSA) to form a highly adhesive protein surface on polymer biomaterials. Our initial in vitro tests confirmed significantly improved adhesive strength for PGMA/HSA grafted polypropylene mesh fixed with the hydrogel adhesive compared to unmodified mesh. Toward the development of our bio-adhesive mesh system for abdominal hernia repair, we evaluated its surgical utility and in vivo performance in a rabbit model with retromuscular repair mimicking the totally extra-peritoneal surgical technique used in humans. We assessed mesh slippage/contraction using gross assessment and imaging, mesh fixation using tensile mechanical testing, and biocompatibility using histology. Compared to polypropylene mesh fixed with fibrin sealant, our bio-adhesive mesh system exhibited superior fixation without the gross bunching or distortion that was observed in the majority (80%) of the fibrin-fixed polypropylene mesh. This was evidenced by tissue integration within the bio-adhesive mesh pores after 42 days of implantation and adhesive strength sufficient to withstand the physiological forces expected in hernia repair applications. These results support the combined use of PGMA/HSA grafted polypropylene and bifunctional poloxamine hydrogel adhesive for medical implant applications.
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Affiliation(s)
- Melinda Harman
- 301 Rhodes Engineering Research Center, Bioengineering Department, Clemson University, Clemson, SC 29634, USA
- School of Medicine Greenville, Prisma Health Upstate, University of South Carolina, Greenville, SC 29605, USA
| | - Kevin Champaigne
- 301 Rhodes Engineering Research Center, Bioengineering Department, Clemson University, Clemson, SC 29634, USA
- Circa Bioscience, Charleston, SC 29412, USA
| | - William Cobb
- School of Medicine Greenville, Prisma Health Upstate, University of South Carolina, Greenville, SC 29605, USA
| | - Xinyue Lu
- 301 Rhodes Engineering Research Center, Bioengineering Department, Clemson University, Clemson, SC 29634, USA
| | | | - Liying Wei
- Materials Science & Engineering Department, Clemson University, Clemson, SC 29634, USA
| | - Igor Luzinov
- Materials Science & Engineering Department, Clemson University, Clemson, SC 29634, USA
| | - O. Thompson Mefford
- 301 Rhodes Engineering Research Center, Bioengineering Department, Clemson University, Clemson, SC 29634, USA
- Materials Science & Engineering Department, Clemson University, Clemson, SC 29634, USA
| | - Jiro Nagatomi
- 301 Rhodes Engineering Research Center, Bioengineering Department, Clemson University, Clemson, SC 29634, USA
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Szymanski L, Gołaszewska K, Małkowska J, Gołębiewska M, Kaczyńska J, Gromadka B, Matak D. Safety and performance of surgical adhesives. PLoS One 2022; 17:e0271531. [PMID: 36006958 PMCID: PMC9409600 DOI: 10.1371/journal.pone.0271531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 07/05/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Tissue adhesives are an alternative to conventional surgical sutures to reduce the time and cost of wound closure and to improve patient comfort. The use of tissue adhesives does not require any subsequent intervention and significantly lowers the volume and rate of blood loss, and reduces the need for transfusions during and after surgery. However, based on their formulation, tissue adhesives' safety profile and functional properties may differ. Therefore, this study aimed to evaluate the basic safety and performance of NE'X Glue® Surgical Sealant, BioGlue® Surgical Sealant, and PREVELEAKTM Surgical Sealant in vitro. METHODS The basic safety of commercially available tissue adhesives was evaluated using MEM elution assay according to ISO 10993-5 and endotoxin level according to 85. USP. The in vitro performance was evaluated using lap-shear by tension loading test, burst strength test, degradation, and swelling assays. RESULTS NE'X Glue®, BioGlue®, and PREVELEAKTM did not cause cytotoxicity in MEM elution assay. All surgical adhesives are below the general limit of endotoxin contamination of 20 EU/device. NE'X Glue® and BioGlue® showed the highest and comparable strength properties in lap shear and burst strength tests compared to PREVELEAKTM. NE'X Glue® and PREVELEAKTM are characterized by lower degradation potential than BioGlue®. PREVELEAKTM is characterized by the highest swelling when compared to NE'X Glue® and BioGlue®. CONCLUSIONS NE'X Glue® is most versatile in terms of functional properties while maintaining the same safety profile as BioGlue® and PREVELEAKTM.
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Affiliation(s)
- Lukasz Szymanski
- Department of Molecular Biology, Institute of Genetics and Animal Biotechnology, Polish Academy of Science, Magdalenka, Poland
- European Biomedical Institute, Jozefow, Poland
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12
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Alabi A, Haladu N, Scott NW, Imamura M, Ahmed I, Ramsay G, Brazzelli M. Mesh fixation techniques for inguinal hernia repair: an overview of systematic reviews of randomised controlled trials. Hernia 2022; 26:973-987. [PMID: 34905142 PMCID: PMC9334446 DOI: 10.1007/s10029-021-02546-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/24/2021] [Indexed: 11/12/2022]
Abstract
PURPOSE Inguinal hernia repair using surgical mesh is a very common surgical operation. Currently, there is no consensus on the best technique for mesh fixation. We conducted an overview of existing systematic reviews (SRs) of randomised controlled trials to compare the risk of chronic pain and recurrence following open and laparoscopic inguinal hernia repairs using various mesh fixation techniques. METHODS We searched major electronic databases in April 2020 and assessed the methodological quality of identified reviews using the AMSTAR-2 tool. RESULTS We identified 20 SRs of variable quality assessing suture, self-gripping, glue, and mechanical fixation. Across reviews, the risk of chronic pain after open mesh repair was lower with glue fixation than with suture and comparable between self-gripping and suture. Incidence of chronic pain was lower with glue fixation than with mechanical fixation in laparoscopic repairs. There were no significant differences in recurrence rates between fixation techniques in open and laparoscopic mesh repairs, although fewer recurrences were reported with suture. Many reviews reported wide confidence intervals around summary estimates. Despite no clear evidence of differences among techniques, two network meta-analyses (one assessing open repairs and one laparoscopic repairs) ranked glue fixation as the best treatment for reducing pain and suture for reducing the risk of recurrence. CONCLUSION Glue fixation may be effective in reducing the incidence of chronic pain without increasing the risk of recurrence. Future research should consider both the effectiveness and cost-effectiveness of fixation techniques alongside the type of mesh and the size and location of the hernia defect.
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Affiliation(s)
- A Alabi
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.,Luton and Dunstable University Hospital, Luton, UK
| | - N Haladu
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.,Emergency Department, Southend University Teaching Hospital, Westcliff-on-Sea, UK
| | - N W Scott
- Medical Statistics Team, University of Aberdeen, Aberdeen, UK
| | - M Imamura
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - I Ahmed
- Department of Surgery, NHS Grampian, Aberdeen, UK
| | - G Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.,Department of Surgery, NHS Grampian, Aberdeen, UK
| | - M Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
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13
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Kapoulas S, Papalois A, Papadakis G, Tsoulfas G, Christoforidis E, Papaziogas B, Schizas D, Chatzimavroudis G. Safety and efficacy of absorbable and non-absorbable fixation systems for intraperitoneal mesh fixation: an experimental study in swine. Hernia 2022; 26:567-579. [PMID: 33400026 DOI: 10.1007/s10029-020-02352-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 12/02/2020] [Indexed: 02/05/2023]
Abstract
PURPOSE Choice of the best possible fixation system in terms of safety and effectiveness for intraperitoneal mesh placement in hernia surgery remains controversial. The aim of the present study was to compare the performance of four fixation systems in a swine model of intraperitoneal mesh fixation. METHODS Fourteen Landrace swine were utilized in the study. The experiment included two stages. Initially, four pieces of mesh (Ventralight ™ ST) sizing 10 × 5 cm were placed and fixed intraperitoneally to reinforce 4 small full thickness abdominal wall defects created with diathermy. These defects were repaired primarily with absorbable suture before mesh implantation. Each mesh was anchored with a different tack device between Absorbatack™, Protack™, Capsure™, or Optifix™. The second stage took place after 60 days and included euthanasia, laparoscopy, and laparotomy via U-shaped incision to obtain the measurements for the outcome parameters. The primary endpoint of the study was to compare the peel strength of the compound tack/mesh from the abdominal wall. Secondary parameters were the extent and quality of visceral adhesions to the mesh, the degree of mesh shrinkage and the histological response around the tacks. RESULTS Thirteen out of 14 animals survived the experiment and 10 were included in the final analysis. Capsure™ tacks had higher peel strength when compared to Absorbatack™ (p = 0.028); Protack™ (p = 0.043); and Optifix™ (p = 0.009). No significant differences were noted regarding the extent of visceral adhesions (Friedman's test p value 0.854), the adhesion quality (Friedman's test p value 0.506), or the mesh shrinkage (Friedman's test p value = 0.827). Four out of the ten animals developed no adhesions at all 2 months after implantation. CONCLUSION Capsure™ fixation system provided higher peel strength that the other tested devices in our swine model of intraperitoneal mesh fixation. Our findings generate the hypothesis that this type of fixation may be superior in a clinical setting. Clinical trials with long-term follow-up are required to assess the safety and efficacy of mesh fixation systems in hernia surgery.
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Affiliation(s)
- S Kapoulas
- 2nd Department of Surgery, Aristotle University of Thessaloniki, G. Gennimatas General Hospital, Thessaloniki, Greece.
- Department of Upper Gastrointestinal and Bariatric Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
- , Flat 318, Centenary Plaza, 18 Holliday Street, Birmingham, B11TW, UK.
| | - A Papalois
- ELPEN Pharmaceuticals Research and Experimental Centre, Pikermi, Greece
| | - G Papadakis
- Department of Renal Transplant and Access Surgery, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - G Tsoulfas
- 1st Department of Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - E Christoforidis
- 2nd Department of Surgery, Aristotle University of Thessaloniki, G. Gennimatas General Hospital, Thessaloniki, Greece
| | - B Papaziogas
- 2nd Department of Surgery, Aristotle University of Thessaloniki, G. Gennimatas General Hospital, Thessaloniki, Greece
| | - D Schizas
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - G Chatzimavroudis
- 2nd Department of Surgery, Aristotle University of Thessaloniki, G. Gennimatas General Hospital, Thessaloniki, Greece
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14
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Self-adhesive hydrogel meshes reduce tissue incorporation and mechanical behavior versus microgrips self-fixation: a preclinical study. Hernia 2022; 26:543-555. [PMID: 34994950 PMCID: PMC9012769 DOI: 10.1007/s10029-021-02552-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/11/2021] [Indexed: 11/15/2022]
Abstract
Purpose Atraumatic mesh fixation for abdominal hernia repair has been developed to avoid the disadvantages of classical fixation with sutures, which is considered a cause of chronic pain and discomfort. This study was designed to analyze, in the short and medium term, the biological and mechanical behavior of two self-fixing meshes compared to that of a polypropylene (PP) mesh fixed with a cyanoacrylate (CA) tissue adhesive. Methods Partial abdominal wall defects (6 × 4 cm) were created in New Zealand rabbits (n = 36) and repaired using a self-adhesive hydrogel mesh (Adhesix™), a self-gripping mesh (ProGrip™) or a PP mesh fixed with CA (Surgipro™ CA). After 14 and 90 days, the host tissue incorporation, macrophage response and biomechanical strength were examined. Results At 14 and 90 days, the ProGrip and Surgipro CA meshes showed good host tissue incorporation; however, the Adhesix implants presented poor integration, seroma formation and a higher degree of shrinkage. The Adhesix hydrogel was completely reabsorbed at 14 days, whereas ProGrip microhooks were observed at all study times. The macrophage response was higher in the ProGrip and Surgipro CA groups at 14 and 90 days, respectively, and decreased over time. At 90 days, the ProGrip implants showed the highest tensile strength values and the Adhesix implants showed the highest failure stretch. Conclusion Meshes with mechanical microgrip self-fixation (ProGrip) show better biological and mechanical behavior than those with adhesive hydrogel (Adhesix) in a preclinical model of abdominal hernia repair in rabbits.
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15
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Bunkar SK, Verma K, Jhunjhunwala A, Singh A. A Randomized Controlled Clinical Trial of N-Butyl Cyanoacrylate Glue Fixation Versus Tacker Fixation of Mesh in Endoscopic Totally Extraperitoneal Hernia Repair. Indian J Surg 2021. [DOI: 10.1007/s12262-021-03118-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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16
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Nie Y, Xiong Y, Guan L, Yuan X, Chen F, Chen J, Yang H. Laparoscopic fixation of biological mesh at hiatus with glue and suture during hiatal hernia repair. BMC Surg 2021; 21:158. [PMID: 33752652 PMCID: PMC7983393 DOI: 10.1186/s12893-021-01151-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Laparoscopic paraesophageal hernia repair is associated with higher recurrence rate. Mesh is used to reduce the recurrence rate. This retrospective study is to review our experience of biological mesh fixed with suture and medical glue in hiatal hernias repairs. METHODS A retrospective chart review was conducted for a consecutive series of patients undergoing laparoscopic hiatal herniorrhaphy between January 2018 and January 2019. After hiatus closure, a piece of biological prosthesis was fixed with medical glue and suture for reinforcement of the crural closure. Clinical outcomes were reviewed, and data were collected regarding operative details, complications, symptoms, and follow-up imaging. Radiological evidence of any size of hiatal hernia was considered to indicate a recurrence. RESULTS Thirty-six patients underwent surgery uneventfully without any serious complication. There was no mortality. The follow-up was, on average, 18.4 months, and there was no symptomatic recurrence. There was one anatomical recurrence without any related presentation. The method of mesh fixation with medical glue and suture took 12 min on average, and the handling was fairly easy. CONCLUSIONS Biological mesh fixed with suture and medical glue was safe and effective for repairing large hiatal hernias. Of course, a longer follow-up is still needed for determining long-term outcomes.
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Affiliation(s)
- Yusheng Nie
- Department of Hernia and Abdominal Wall Surgery, The Capital Medical University Beijing Chaoyang Hospital, Jingyuan Road No.5, Shijingshan District, Beijing, 100043, China
| | - Yao Xiong
- Department of Hernia and Abdominal Wall Surgery, The Capital Medical University Beijing Chaoyang Hospital, Jingyuan Road No.5, Shijingshan District, Beijing, 100043, China
| | - Lei Guan
- Department of Hernia and Abdominal Wall Surgery, The Capital Medical University Beijing Chaoyang Hospital, Jingyuan Road No.5, Shijingshan District, Beijing, 100043, China
| | - Xin Yuan
- Department of Hernia and Abdominal Wall Surgery, The Capital Medical University Beijing Chaoyang Hospital, Jingyuan Road No.5, Shijingshan District, Beijing, 100043, China
| | - Fuqiang Chen
- Department of Hernia and Abdominal Wall Surgery, The Capital Medical University Beijing Chaoyang Hospital, Jingyuan Road No.5, Shijingshan District, Beijing, 100043, China
| | - Jie Chen
- Department of Hernia and Abdominal Wall Surgery, The Capital Medical University Beijing Chaoyang Hospital, Jingyuan Road No.5, Shijingshan District, Beijing, 100043, China
| | - Huiqi Yang
- Department of Hernia and Abdominal Wall Surgery, The Capital Medical University Beijing Chaoyang Hospital, Jingyuan Road No.5, Shijingshan District, Beijing, 100043, China.
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17
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Badiani S, Cooper EA, Diab J, Berney CR. Occult Para-Psoas Hernia during Routine Endoscopic Totally Extraperitoneal Inguinal Hernia Repair. JSLS 2021; 25:JSLS.2021.00033. [PMID: 34354336 PMCID: PMC8325482 DOI: 10.4293/jsls.2021.00033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background and Objectives: Advantage of the total extraperitoneal (TEP) technique over open inguinal hernia repair allows for exploration of other anatomical regions in search for occult hernias (OH). Methods: Our institutional practice is to routinely explore the obturator and femoral regions for occult hernias. In addition to this technique, we routinely expose the psoas muscle extensively to perfect mesh placement followed by fibrin glue fixation on both ‘triangles of doom and pain’. The use of this technique has led to the identification of three incidental occult para-psoas hernias (PPH) out of a total of 800 TEP repairs performed in a high-volume specialist hernia center. Conclusions: The purpose of this article is to demonstrate that occult parapsoas hernias (PPH) can be easily identified and safely repaired with mesh glue fixation, using the standard TEP technique during inguinal hernia repair.
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Affiliation(s)
- Sarit Badiani
- Bankstown Lidcombe Hospital, Bankstown, NSW, Australia
| | | | - Jason Diab
- University of Sydney, School of Medicine, Sydney, Australia
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18
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Chen YS, Loh EW, Shen SC, Su YH, Tam KW. Efficacy of Fibrin Sealant in Reducing Complication Risk After Bariatric Surgery: a Systematic Review and Meta-analysis. Obes Surg 2020; 31:1158-1167. [PMID: 33145716 DOI: 10.1007/s11695-020-05098-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Complications including staple-line leakage and bleeding may occur after sleeve gastrectomy and Roux-en-Y gastric bypass. In this meta-analysis, the efficacy of fibrin sealant in strengthening the staple line and reducing complication risk after bariatric surgery was evaluated. METHODS We searched PubMed, Embase, and Cochrane Library databases for randomized controlled trials (RCTs) published up to October 2020. Pooled estimates of the outcomes were computed using a random effects model. The primary outcomes were bleeding and leakage; secondary outcomes were gastric stricture, length of hospital stay, reoperation rate, and total operation time. RESULTS In total, 9 RCTs including 2136 patients were reviewed. Our meta-analysis revealed that compared with controls, fibrin sealants decreased incidence of bleeding significantly (risk ratio [RR] = 0.42; 95% confidence interval [CI], 0.18-0.97), but did not demonstrate significant differences in reducing the incidence of leakage (RR = 0.62; 95% CI, 0.23-1.73), gastric stricture (RR = 1.16; 95% CI, 0.46-2.91), reoperation rate (RR = 0.85; CI, 0.14-5.14), or length of hospital stay (weighted mean difference = 0.62; 95% CI, - 0.31 to 1.55). Compared with oversewing, fibrin sealant use reduced the operation time; however, their efficacies in reducing the incidence of postoperative bleeding and leakage did not differ significantly. CONCLUSIONS Although applying fibrin sealants to the staple line in bariatric surgery may provide favorable results, but it may not reduce postoperative leakage and stricture incidence significantly. Nevertheless, the application of fibrin sealants as a method for reducing risks of complications after bariatric surgery warrant further investigation.
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Affiliation(s)
- Yi-Shyue Chen
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - El-Wui Loh
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
| | - Shih-Chiang Shen
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, 291, Zhongzheng Road, Zhonghe District, New Taipei City, 23561, Taiwan
| | - Yen-Hao Su
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, 291, Zhongzheng Road, Zhonghe District, New Taipei City, 23561, Taiwan
- Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan
| | - Ka-Wai Tam
- Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, 291, Zhongzheng Road, Zhonghe District, New Taipei City, 23561, Taiwan.
- Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan.
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19
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Li D, Chen J, Wang X, Zhang M, Li C, Zhou J. Recent Advances on Synthetic and Polysaccharide Adhesives for Biological Hemostatic Applications. Front Bioeng Biotechnol 2020; 8:926. [PMID: 32923431 PMCID: PMC7456874 DOI: 10.3389/fbioe.2020.00926] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 07/20/2020] [Indexed: 11/13/2022] Open
Abstract
Rapid hemostasis and formation of stable blood clots are very important to prevent massive blood loss from the excessive bleeding for living body, but their own clotting process cannot be completed in time for effective hemostasis without the help of hemostatic materials. In general, traditionally suturing and stapling techniques for wound closure are prone to cause the additional damages to the tissues, activated inflammatory responses, short usage periods and inevitable second operations in clinical applications. Especially for the large wounds that require the urgent closure of fluids or gases, these conventional closure methods are far from enough. To address these problems, various tissue adhesives, sealants and hemostatic materials are placed great expectation. In this review, we focused on the development of two main categories of tissue adhesive materials: synthetic polymeric adhesives and naturally derived polysaccharide adhesives. Research of the high performance of hemostatic adhesives with strong adhesion, better biocompatibility, easy usability and cheap price is highly demanded for both scientists and clinicians, and this review is also intended to provide a comprehensive summarization and inspiration for pursuit of more advanced hemostatic adhesives for biological fields.
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Affiliation(s)
- Dawei Li
- Eighth Medical Center of the General Hospital of the Chinese People’s Liberation Army, Beijing, China
| | - Jing Chen
- Department of Orthopedics, Aerospace Center Hospital, Beijing, China
| | - Xing Wang
- Beijing National Laboratory for Molecular Sciences, Institute of Chemistry, Chinese Academy of Sciences, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Mingming Zhang
- The People’s Liberation Army Strategic Support Force Characteristic Medical Center, Beijing, China
| | - Chunlin Li
- Eighth Medical Center of the General Hospital of the Chinese People’s Liberation Army, Beijing, China
| | - Jin Zhou
- Eighth Medical Center of the General Hospital of the Chinese People’s Liberation Army, Beijing, China
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20
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Ranjan SR, Majumdar S, Manickavasagam J, Flach S. Tissue glue: a potential role in the management of intraoperative oesophageal perforation. BMJ Case Rep 2020; 13:13/7/e232568. [PMID: 32737024 DOI: 10.1136/bcr-2019-232568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
An 85-year-old man suffering from oropharyngeal dysphagia due to a pharyngeal pouch and cricopharyngeal spasm underwent endoscopic stapling of the pouch under general anaesthesia. During the procedure, an iatrogenic perforation of the oesophagus was noticed. After considering several options, 5 mL of Tisseel tissue glue was used to seal the perforation intraoperatively. The patient was started on intravenous co-amoxiclav, kept nil by mouth and fed via a nasogastric tube. After 4 days of observation mediastinal collection and any leakage was ruled out with a gastrografin contrast swallow procedure. At this point he was considered safe for oral intake.
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Affiliation(s)
| | | | - Jaiganesh Manickavasagam
- Department of Otorhinolaryngology, Ninewells Hospital, Dundee, UK .,Tayside Academic Science Centre, University of Dundee, Dundee, UK
| | - Susanne Flach
- Otorhinolaryngology and Head & Neck Surgery, Hospital of the Ludwig-Maximilians-University, Munich, Germany
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21
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Jasmine S, Thangavelu A, Krishnamoorthy R, Alshatwi AA. Platelet Concentrates as Biomaterials in Tissue Engineering: a Review. REGENERATIVE ENGINEERING AND TRANSLATIONAL MEDICINE 2020. [DOI: 10.1007/s40883-020-00165-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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22
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Tsai CP, Kao HF, Liu CK, Shen PS, Chen MJ, Hung MJ. One-year outcomes of a suture-less laparoscopic sacral hysteropexy using polypropylene Y-mesh grafts and fibrin sealant spray: A prospective comparative study. J Chin Med Assoc 2020; 83:484-490. [PMID: 31904661 DOI: 10.1097/jcma.0000000000000253] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Laparoscopic sacral hysteropexy (SH) is a minimally invasive and effective treatment for uterovaginal prolapse in women who wish to retain the uterus. However, this procedure is limited by a steep learning curve and a long operating time. In this study, we aim to evaluate the surgical outcomes of a modified laparoscopic SH procedure using innovative methods of vaginal mesh attachment, which we hypothesized to be equally effective and time-saving. METHODS This was a prospective, parallel, comparative study conducted at a tertiary referral hospital. A total of 34 women with advanced (POPQ [Pelvic Organ Prolapse Quantification] stages ≧ 2) uterine prolapse, who underwent a laparoscopic SH procedure using lightweight polypropylene Y-mesh grafts (ALYTE), were studied. In half (n = 17) of the cases, fibrin sealant spray (TISSEEL) was applied to the meshes fixed at the anterior and posterior vaginal wall with fewer (six vs at least ten) sutures. A detailed comparison of one-year outcomes between groups was performed. RESULTS Patient characteristics and perioperative results were comparable between groups with the exception of a significantly shorter total operating time (247.0 vs 292.9 minutes, p = 0.04) noted in the fibrin group. At 1 year, anatomic success (POPQ stage ≦1) rates (76.5% vs 76.5%) were not different between groups. There were eight patients, with four in each group, who had surgical failure. Notably, most (7/8; 87.5%) surgical failures were at the anterior compartment (i.e, recurrent cystocele). No vaginal mesh extrusions were noted. After statistical analysis, we found "cystocele as the dominant prolapse before operation" was a significant predisposing factor for prolapse recurrence (p = 0.019; odds ratio = 8.04). CONCLUSION The modified laparoscopic SH procedure using Y-mesh grafts and fibrin sealant spray with fewer vaginal sutures was equally effective as conventional methods but saved time. Laparoscopic SH using Y-mesh grafts might not be as effective in repairing a concomitant dominant cystocele.
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Affiliation(s)
- Ching-Pei Tsai
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Hui-Fen Kao
- Department of Obstetrics and Gynecology, Asia University Hospital, Taichung, Taiwan, ROC
- College of Medical and Health Science, Asia University, Taichung, Taiwan, ROC
| | - Chih-Ku Liu
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Pao-Sheng Shen
- Department of Statistics, Tunghai University, Taichung, Taiwan, ROC
| | - Ming-Jer Chen
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Man-Jung Hung
- Department of Obstetrics and Gynecology, Asia University Hospital, Taichung, Taiwan, ROC
- College of Medical and Health Science, Asia University, Taichung, Taiwan, ROC
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23
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Roberts IV, Bukhary D, Valdivieso CYL, Tirelli N. Fibrin Matrices as (Injectable) Biomaterials: Formation, Clinical Use, and Molecular Engineering. Macromol Biosci 2019; 20:e1900283. [PMID: 31769933 DOI: 10.1002/mabi.201900283] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/14/2019] [Indexed: 12/19/2022]
Abstract
This review focuses on fibrin, starting from biological mechanisms (its production from fibrinogen and its enzymatic degradation), through its use as a medical device and as a biomaterial, and finally discussing the techniques used to add biological functions and/or improve its mechanical performance through its molecular engineering. Fibrin is a material of biological (human, and even patient's own) origin, injectable, adhesive, and remodellable by cells; further, it is nature's most common choice for an in situ forming, provisional matrix. Its widespread use in the clinic and in research is therefore completely unsurprising. There are, however, areas where its biomedical performance can be improved, namely achieving a better control over mechanical properties (and possibly higher modulus), slowing down degradation or incorporating cell-instructive functions (e.g., controlled delivery of growth factors). The authors here specifically review the efforts made in the last 20 years to achieve these aims via biomimetic reactions or self-assembly, as much via formation of hybrid materials.
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Affiliation(s)
- Iwan Vaughan Roberts
- Division of Pharmacy and Optometry, School of Health Science, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
| | - Deena Bukhary
- Division of Pharmacy and Optometry, School of Health Science, University of Manchester, Oxford Road, Manchester, M13 9PT, UK.,Department of Pharmaceutical Science, Faculty of Pharmacy, Umm Al-Qura University, Makkah, 21955, Saudi Arabia
| | | | - Nicola Tirelli
- Division of Pharmacy and Optometry, School of Health Science, University of Manchester, Oxford Road, Manchester, M13 9PT, UK.,Laboratory of Polymers and Biomaterials, Fondazione Istituto Italiano di Tecnologia, via Morego 30, 16163, Genova, Italy
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24
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Villalobos RN, Mias MC, Gas C, Maestre Y, Nogués M, Vilardell F, Olsina JJ. Atraumatic laparoscopic intraperitoneal mesh fixation using a new laparoscopic device: an animal experimental study. Hernia 2019; 23:1123-1132. [PMID: 31325053 DOI: 10.1007/s10029-019-02008-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 07/11/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE Laparoscopic ventral and incisional hernia repair (LVIHR) has become a common procedure because of its feasibility and safety, but it is not free of complications. Acute and chronic post-operative pain and bleeding caused by traumatic fixation of the mesh are frequently prolonging the hospital stay. The aim of this study was to analyze the behavior of n-butyl-cyanoacrylate (GLUBRAN® 2) as only mesh fixation METHODS: Ten female pigs were involved in the study and were divided into two groups of five (A and B). Animals in each group underwent a laparoscopic procedure in which two meshes were placed intraperitoneally and fixed with the same synthetic glue only. Animals in group A were sacrificed after 3 weeks, and those in group B were sacrificed after 12 weeks. We studied the morphological, biomechanical, and histological characteristics of the intraperitoneal mesh-tissue interface RESULTS: No disruption, migration or folding was observed in any of the pigs. In group A, the mean tensile strength was 1.4 N/cm (± 0.2) while in group B, the mean tensile strength was 2.5 N/cm (± 0.8). Histological analyses, in areas where mesh was fixed using the glue, showed a chronic lymphocytic inflammatory reaction with a granulomatous component and a marked desmoplastic reaction made up of immature collagen and numerous fibroblasts acquiring myofibroblastic characteristics. In some areas corresponding to fixation, the desmoplastic reaction originated from mature lamellar bone tissue with osteocytes and osteoblasts. CONCLUSION Laparoscopic mesh fixation with only the synthetic comonomer glue GLUBRAN® 2 is feasible, effective, and safe in intraperitoneal incisional/ventral hernia repair in this animal model.
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Affiliation(s)
- R N Villalobos
- Abdominal Wall Surgery Unit, General Surgery Department, Arnau de Vilanova University Hospital, 80 Rovira Roure Avenue, 25198, Lleida, Catalonia, Spain.
| | - M C Mias
- General Surgery Department, Arnau de Vilanova University Hospital, Lleida, Spain
| | - C Gas
- General Surgery Department, Arnau de Vilanova University Hospital, Lleida, Spain
| | - Y Maestre
- General Surgery Department, Arnau de Vilanova University Hospital, Lleida, Spain
| | - M Nogués
- Engineering Faculty, University of Lleida, Lleida, Spain
| | - F Vilardell
- Pathology Department, Arnau de Vilanova University Hospital, Lleida, Spain
| | - J J Olsina
- Abdominal Wall Surgery Unit, General Surgery Department, Arnau de Vilanova University Hospital, 80 Rovira Roure Avenue, 25198, Lleida, Catalonia, Spain
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25
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To Glue or Not to Glue? Analysis of Fibrin Glue for Split-thickness Skin Graft Fixation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2187. [PMID: 31333930 PMCID: PMC6571290 DOI: 10.1097/gox.0000000000002187] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 01/25/2019] [Indexed: 12/03/2022]
Abstract
Background: Split-thickness skin grafting (STSG) is a commonly used tool in the plastic surgeon’s reconstructive armamentarium. Fibrin glue (FG) consists of a combination of clotting factors and thrombin whose key properties include adherence and hemostasis. This preliminary study aimed to assess clinical outcomes and cost of FG for STSG fixation in a general wound reconstruction. Methods: A retrospective review was conducted in all patients undergoing STSG placement by a single surgeon (JPF) from January 2016 to March 2018. Twenty patients were identified and matched by wound location and wound size. Patients were then divided into 2 groups based on the method of STSG fixation: FG (n = 10) or suture only (SO) (n = 10). Results: In patients with FG fixation, we observed trends of decreased adjusted operative times (34.9 versus 49.4 minutes, P = 0.612), a similar length of stay (2.8 versus 3.5 days, P = 0.306), and liberation from the use of negative pressure wound therapy (0 versus 10 wounds, P < 0.0001). There were no observed differences between the 2 groups in terms of graft-related complications at 180 days (1 complication FG versus 0 complications SO). Time to 100% graft take was also not different (20.2 versus 29.4 days, P = 0.405). Additionally, total direct cost ($16,542 FG versus $24,266 SO; P = 0.545) and total charges ($120,336 FG versus $183,750 SO; P = 0.496) were not statistically different between the FG and SO groups. Conclusions: In this preliminary comparative assessment, FG for STSG fixation has shown no difference in clinical outcomes to SO fixation, trends of decreased operative time, and afforded complete liberation from negative pressure wound therapy dressings.
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Barchi LC, Franciss MY, Zilberstein B. Subcutaneous Videosurgery for Abdominal Wall Defects: A Prospective Observational Study. J Laparoendosc Adv Surg Tech A 2019; 29:523-530. [DOI: 10.1089/lap.2018.0697] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
| | | | - Bruno Zilberstein
- Digestive Surgery Department, Gastromed Institute, São Paulo, Brazil
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Totally extraperitoneal inguinal hernia repair with or without fixation leads to similar results. Outcome of randomized prospective trial. Wideochir Inne Tech Maloinwazyjne 2019; 15:1-10. [PMID: 32117479 PMCID: PMC7020706 DOI: 10.5114/wiitm.2019.83611] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 02/03/2019] [Indexed: 01/14/2023] Open
Abstract
Introduction The use of implants in inguinal hernia repair has reduced its recurrence rate. However, postoperative groin pain still remains an unresolved problem. There are suggestions that in totally extraperitoneal inguinal hernia repair (TEP-IHR) two of the likely factors responsible for pain are use of fixation and the type of fixation used. Aim To evaluate the impact of mesh fixation on the incidence of postoperative pain, restriction of physical activities, hernia recurrence risk, return to normal activities and demand for analgesics in patients after unilateral TEP-IHR. Material and methods Unilateral TEP-IHR was performed in 139 male patients randomized to three groups: self-gripping mesh (SG), lightweight mesh (L) and lightweight mesh with fixation (LF). Full study-inclusion criteria were met by 110 patients; 43, 18 and 49 in groups SG, L and LF respectively. Follow-up occurred on the 1st, 2nd, and 7th day and 3, 6, 12 months postoperatively. The numeric rating scale (NRS) was used to assess pain and the EuraHS-QoL (European Registry for Abdominal Wall Hernias Quality of Life Score) questionnaire to compare quality of life (QoL) prior to surgery and one year later. Results No statistically significant differences were observed between study groups with regard to the incidence rate and intensity of acute post-operative pain, chronic pain, analgesic demand, return to normal activity, hernia recurrence rate and post-operative QoL. Conclusions Lack of fixation in TEP-IHR does not increase the risk of hernia recurrence, and its presence does not significantly worsen the treatment results; especially it does not increase the incidence of chronic pain.
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Furtado M, Claus CMP, Cavazzola LT, Malcher F, Bakonyi-Neto A, Saad-Hossne R. SYSTEMIZATION OF LAPAROSCOPIC INGUINAL HERNIA REPAIR (TAPP) BASED ON A NEW ANATOMICAL CONCEPT: INVERTED Y AND FIVE TRIANGLES. ACTA ACUST UNITED AC 2019; 32:e1426. [PMID: 30758474 PMCID: PMC6368153 DOI: 10.1590/0102-672020180001e1426] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 09/25/2018] [Indexed: 12/12/2022]
Abstract
Background: Laparoscopic inguinal hernia repair has been shown to be superior than open repairs with faster return to daily activities and decrease in the occurrence of chronic pain. However, higher direct costs and mandatory use of general anesthesia are arguments against their use. In addition, increased complexity of surgery resulting from an anatomy that is unusual to general surgeons prevents the widespread adoption of laparoscopic approach. Aim: To propose a technical systematization for transabdominal laparoscopic repair (TAPP) of inguinal hernias based on anatomical concepts. Method: To offer a systematization of TAPP repair based on well defined anatomic landmarks, describing the concept of “inverted Y”, identification of five triangles and three zones of dissection, to achieve the “critical view of safety” for laparoscopic inguinal hernia repair. Results: Since this standardization was developed five years ago, many surgeons were trained following these precepts. Reproducibility is high, as far as, it´s rate of adoption among surgeons. Conclusion: The concept of the “inverted Y”, “Five triangles” and the dissection based in “Three Zones” establish an effective and reproducible standardization of the TAPP technique.
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Affiliation(s)
- Marcelo Furtado
- Videolaparoscopic Surgery Service, Pintagueiras Hospital, Jundiaí, São Paulo, Brazil
| | - Christiano M P Claus
- Department of Surgical Clinic and Post-Graduation in Mini Invasive Surgery, Positivo University - Jacques Perissat Institute, Curitiba, PR, Brazil
| | | | - Flavio Malcher
- Department of Surgery, Celebration Health Florida Center, Florida, USA
| | - Alexandre Bakonyi-Neto
- Department of Surgery, Hospital das Clínicas, Botucatu Medical School, Botucatu, SP, Brazil)
| | - Rogério Saad-Hossne
- Department of Surgery, Hospital das Clínicas, Botucatu Medical School, Botucatu, SP, Brazil)
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Damiano G, Palumbo VD, Fazzotta S, Buscemi S, Ficarella S, Maffongelli A, Buscemi G, Lo Monte AI. Laparoscopic Repair of Boundary Incisional Hernia in a Kidney Transplant Patient: A Safe Tacks-Fibrin Glue Combined Mesh Fixation Technique. Transplant Proc 2019; 51:215-219. [PMID: 30655152 DOI: 10.1016/j.transproceed.2018.04.084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 04/13/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Incisional hernia in renal transplant patients is a complication that negatively affects the global outcome of transplant and quality of life. The repair of this condition was classically made by open repair with mesh. Increasing evidence suggests that laparoscopic repair could be advocated as the technique of choice in these patients with optimal results. However, the fixation of mesh should be performed by a mixed combination of fibrin sealant (lateral margin of wall defect) and tacks (medial margin). The tacks fixation of the mesh along the lateral margin of the wall defect, close to the graft, is generally difficult for the small size of the remaining aponeurotic plane and dangerous for the underlying presence of the graft. MATERIALS AND METHODS A case of incisional hernia in a kidney transplant recipient was repaired by laparoscopic mesh technique. The polypropylene-polyglycolic acid composite mesh was fastened with a mixed technique of absorbable tacks for medial margin of the defect and fibrin sealant for the lateral side in contiguity with graft surface. RESULTS The patient was discharged after 4 days. The 6-month follow-up did not show mesh displacement or recurrence of hernia. CONCLUSIONS The laparoscopic mesh repair may become the criterion standard for kidney transplant patients affected by incisional hernia. The difficulties of mesh fixation close to the graft can be overcome by the combination of fibrin sealant glue and absorbable tacks at different margins of the wall defect. This technique may offer advantages for this population of patients.
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Affiliation(s)
- G Damiano
- Department of Surgical, Oncological and Oral Sciences, Università degli Studi di Palermo, Palermo, Italy.
| | - V D Palumbo
- Department of Surgical, Oncological and Oral Sciences, Università degli Studi di Palermo, Palermo, Italy
| | - S Fazzotta
- Department of Surgical, Oncological and Oral Sciences, Università degli Studi di Palermo, Palermo, Italy
| | - S Buscemi
- Department of Surgical, Oncological and Oral Sciences, Università degli Studi di Palermo, Palermo, Italy
| | - S Ficarella
- Department of Surgical, Oncological and Oral Sciences, Università degli Studi di Palermo, Palermo, Italy
| | - A Maffongelli
- Department of Surgical, Oncological and Oral Sciences, Università degli Studi di Palermo, Palermo, Italy
| | - G Buscemi
- Department of Surgical, Oncological and Oral Sciences, Università degli Studi di Palermo, Palermo, Italy
| | - A I Lo Monte
- Department of Surgical, Oncological and Oral Sciences, Università degli Studi di Palermo, Palermo, Italy
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Georgiou E, Schoina E, Markantonis SL, Karalis V, Athanasopoulos PG, Chrysoheris P, Antonakopoulos F, Konstantinidis K. Laparoscopic total extraperitoneal inguinal hernia repair: Retrospective study on prosthetic materials, postoperative management, and quality of life. Medicine (Baltimore) 2018; 97:e13974. [PMID: 30593223 PMCID: PMC6314767 DOI: 10.1097/md.0000000000013974] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Laparoscopic inguinal hernia repair is one of the most frequently performed operations. However, the search for the most appropriate prosthetic materials continues to occupy the surgical community. The purpose of this study was to evaluate the postoperative short- and mid-term effects (like duration of stay, number and type of complications, and inguinal pain) of laparoscopic inguinal hernia repair using the total extraperitoneal (TEP) approach. The evaluation encompassed different types of mesh and fixation devices, as well as medications prescribed during hospitalization.This retrospective study was conducted at the General, Laparoendoscopic, Bariatric, and Robotic Surgical Clinic of the Athens Medical Center. Clinical data from 524 patients were evaluated. The answers from an appropriately designed questionnaire completed from each individual were used to obtain information about their postoperative course. The statistical analysis was implemented in SPSS v 23.Analysis revealed that pain sensation on discharge decreased with increasing age (P < .05). No clear relationship was found between surgical clips and pain (P = .292), as well as mesh absorbability and chronic pain (P = .539). The major postoperative complications were annoyance and discomfort (15.9%). The recurrence rate was 1.7%.Postoperative complications following the TEP approach were mostly found to be minor; chronic pain, as an aspect of impaired quality of life, was not experienced in the majority (89.08%). The properties of prosthetic materials used and the type of medications prescribed were not found to exert a significant role in satisfactory postoperative outcomes.
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Affiliation(s)
- Efi Georgiou
- Department of Pharmacy, National and Kapodistrian University of Athens, Athens
| | - Elina Schoina
- Department of Pharmacy, National and Kapodistrian University of Athens, Athens
| | | | - Vangelis Karalis
- Department of Pharmacy, National and Kapodistrian University of Athens, Athens
| | | | - Periklis Chrysoheris
- Department of General, Laparoscopic, Robotic and Bariatric Surgery, Athens Medical Center, Marousi, Greece
| | - Fotis Antonakopoulos
- Department of General, Laparoscopic, Robotic and Bariatric Surgery, Athens Medical Center, Marousi, Greece
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Wilson P, Hickey L. Laparoscopic transabdominal preperitoneal (TAPP) groin hernia repair using n-butyl-2-cyanoacrylate (Liquiband®Fix8™) for mesh fixation and peritoneal closure: learning experience during introduction into clinical practice. Hernia 2018; 23:601-613. [PMID: 30506242 PMCID: PMC6586721 DOI: 10.1007/s10029-018-1861-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 11/19/2018] [Indexed: 12/15/2022]
Abstract
Introduction In a single centre evaluation of a novel hernia repair device, 200 consecutive patients underwent 247 laparoscopic (TAPP) groin hernia repairs (47 bilateral) using n-butyl-2-cyanoacrylate (Liquiband®Fix8™) for mesh fixation and peritoneal closure over a 2-year period by a single experienced laparoscopic surgeon. Patients and methods All groin hernia patients requiring TAPP repair were included in the study: Inguinal 142, Femoral 14, Spigelian 4, and Inguinal disruption 40. A retrospective review of the data was performed. There were 161 males and 39 females, mean age 55 years (range 20–89 years). Mesh fixation was successful in all 247 TAPP repairs, and 90% of patients had a successful peritoneal closure using the device (20 patients required the use of conventional tacks to complete closure). Follow-up Patients were followed up with an out-patient visit at 6 weeks post-op, followed by a Patient Initiated Follow Up programme, and a final Telephone follow-up. To date all patients have completed 1 year of follow-up, and 70% of patients 2 years of follow-up (median 29 months, range 14 to 40 months). Results There were very few procedure-related adverse events: groin seromas 6 (2.4%), port site bleeding 2 (0.3%), port site hernia 2 (0.3%), and only 1 groin hernia recurrence (0.4%). Prospective surgeon scoring of satisfaction for mesh fixation, peritoneal closure, and device clogging was favourable and increased following the initial learning phase. Changes in the device design during the study period improved the efficacy of the device significantly. Conclusion This retrospective study shows that mesh fixation and peritoneal closure using the Liquiband®Fix8™ device is feasible, safe, practical, and is easy to learn.
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Affiliation(s)
- P Wilson
- University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, UK. .,Department of General Surgery, Royal Lancaster Infirmary, Lancaster, LA1 4RP, UK.
| | - L Hickey
- University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, UK
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Abstract
Objectives The incidence of acute Achilles tendon rupture appears to be increasing. The aim of this study was to summarize various therapies for acute Achilles tendon rupture and discuss their relative merits. Methods A PubMed search about the management of acute Achilles tendon rupture was performed. The search was open for original manuscripts and review papers limited to publication from January 2006 to July 2017. A total of 489 papers were identified initially and finally 323 articles were suitable for this review. Results The treatments of acute Achilles tendon rupture include operative and nonoperative treatments. Operative treatments mainly consist of open repair, percutaneous repair, mini-open repair, and augmentative repair. Traditional open repair has lower re-rupture rates with higher risks of complications. Percutaneous repair and mini-open repair show similar re-rupture rates but lower overall complication rates when compared with open repair. Percutaneous repair requires vigilance against nerve damage. Functional rehabilitation combining protected weight-bearing and early controlled motion can effectively reduce re-rupture rates with satisfactory outcomes. Biological adjuncts help accelerating tendon healing by adhering rupture ends or releasing highly complex pools of signalling factors. Conclusion The optimum treatment for complete rupture remains controversial. Both mini-open repair and functional protocols are attractive alternatives, while biotherapy is a potential future development. Cite this article: X. Yang, H. Meng, Q. Quan, J. Peng, S. Lu, A. Wang. Management of acute Achilles tendon ruptures: A review. Bone Joint Res 2018;7:561–569. DOI: 10.1302/2046-3758.710.BJR-2018-0004.R2.
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Affiliation(s)
- X Yang
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - H Meng
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Q Quan
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - J Peng
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - S Lu
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - A Wang
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
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Long-term outcomes after prophylactic use of onlay mesh in midline laparotomy. Hernia 2018; 22:1113-1122. [DOI: 10.1007/s10029-018-1833-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 09/24/2018] [Indexed: 10/28/2022]
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Shahan CP, Stoikes NF, Roan E, Reese P, Webb DL, Voeller GR. Biomechanical Comparison of Fibrin Sealants for Mesh Fixation. Am Surg 2018. [DOI: 10.1177/000313481808400512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Adhesive use for fixation in hernia repair allows for complete and immediate mesh surface area adherence. Little is known about the fixation strengths of the products and application methods available. The purpose of this study was to compare the immediate and early strength of fixation of Tisseel™ and Evicel™ using hand and spray application techniques. Sixteen Mongrel swine underwent implantation of large-pore, mid-weight polypropylene mesh fixated with either Tisseel™ or Evicel™, applied by hand or with a spray apparatus. Time points studied were zero and four days. All samples underwent lap shear testing to quantify the strength of the mesh–tissue interface as an indicator of mesh fixation strength. Thirty Day 4 and 16 Day 0 samples were tested. Manually applied Tisseel™ mean fixation strength was 2.05 N/cm at Day 0 and 6.02 N/cm at Day 4. Sprayed Tisseel™ had mean fixation strength of 1.22 N/cm at Day 0 and 7.21 N/cm at Day 4. Manually applied Evicel™ showed mean fixation strength of 0.92 N/cm at Day 0 and 6.73 N/cm at Day 4. Mean fixation strength of sprayed Evicel™ was 0.72 N/cm at Day 0 and 6.70 N/cm at Day 4. Analysis of variance showed no difference between groups at Day 0 or Day 4. Immediate strength of mesh fixation could have significant implications for early recurrence and mesh contraction. This study demonstrates that no difference exists in immediate or early fixation strength between these two brands of sealants or their method of application.
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Affiliation(s)
- Charles P. Shahan
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee and
| | - Nathaniel F. Stoikes
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee and
| | - Esra Roan
- Department of Biomedical Engineering, University of Memphis, Memphis, Tennessee
| | - Patrick Reese
- Department of Biomedical Engineering, University of Memphis, Memphis, Tennessee
| | - David L. Webb
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee and
| | - Guy R. Voeller
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee and
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Fibrin glue mesh fixation combined with mesenchymal stem cells or exosomes modulates the inflammatory reaction in a murine model of incisional hernia. Acta Biomater 2018; 71:318-329. [PMID: 29462710 DOI: 10.1016/j.actbio.2018.02.014] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/09/2018] [Accepted: 02/12/2018] [Indexed: 02/07/2023]
Abstract
Surgical meshes are effective and frequently used to reinforce soft tissues. Fibrin glue (FG) has been widely used for mesh fixation and is also considered an optimal vehicle for stem cell delivery. The aim of this preclinical study was to evaluate the therapeutic effect of MSCs and their exosomes combined with FG for the treatment of incisional hernia. A murine incisional hernia model was used to implant surgical meshes and different treatments with FG, MSCs and exo-MSCs were applied. The implanted meshes were evaluated at day 7 by anatomopathology, cellular analysis of infiltrating leukocytes and gene expression analysis of TH1/TH2 cytokines, MMPs, TIMPs and collagens. Our results demonstrated a significant increase of anti-inflammatory M2 macrophages and TH2 cytokines when MSCs or exo-MSCs were used. Moreover, the analysis of MMPs, TIMPs and collagen exerted significant differences in the extracellular matrix and in the remodeling process. Our in vivo study suggests that the fixation of surgical meshes with FG and MSCs or exo-MSCs will have a beneficial effect for the treatment of incisional hernia in terms of improved outcomes of damaged tissue, and especially, in the modulation of inflammatory responses towards a less aggressive and pro-regenerative profile. STATEMENT OF SIGNIFICANCE The implantation of surgical meshes is the standard procedure to reinforce tissue defects such as hernias. However, an exacerbated and persistent inflammatory response secondary to this implantation is frequently observed, leading to a strong discomfort and chronic pain in the patients. In many cases, an additional surgical intervention is needed to remove the mesh. This study shows that mesenchymal stem cells and their exosomes, combined with a fibrin sealant, can be used for the successful fixation of these meshes. This new therapeutic approach, assayed in a murine model of incisional hernia, favors the modulation of the inflammatory response towards a less aggressive and pro-regenerative profile.
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Shahan CP, Stoikes NN, Roan E, Tatum J, Webb DL, Voeller GR. Biomechanical and Histologic Evaluation of LifeMesh™: A Novel Self-Fixating Mesh Adhesive. Am Surg 2018. [DOI: 10.1177/000313481808400424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mesh fixation with the use of adhesives results in an immediate and total surface area adhesion of the mesh, removing the need for penetrating fixation points. The purpose of this study was to evaluate LifeMesh™, a prototype mesh adhesive technology which coats polypropylene mesh. The strength of the interface between mesh and tissue, inflammatory responses, and histology were measured at varying time points in a swine model, and these results were compared with sutures. Twenty Mongrel swine underwent implantation of LifeMesh™ and one piece of bare polypropylene mesh secured with suture (control). One additional piece of either LifeMesh™ or control was used for histopathologic evaluation. The implants were retrieved at 3, 7, and 14 days. Only 3- and 7-day specimens underwent lap shear testing. On Day 3, LifeMesh™ samples showed considerably less contraction than sutured samples. The interfacial strength of Day 3 LifeMesh™ samples was similar to that of sutured samples. At seven days, LifeMesh™ samples continued to show significantly less contraction than sutured samples. The strength of fixation at seven days was greater in the control samples. The histologic findings were similar in LifeMesh™ and control samples. LifeMesh™ showed significantly less contraction than sutured samples at all measured time points. Although fixation strength was similar at three days, the interfacial strength of LifeMesh™ remained unchanged, whereas sutured controls increased by day 7. With histologic equivalence, considerably less contraction, and similar early fixation strength, LifeMesh™ is a viable mesh fixation technology.
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Affiliation(s)
- Charles P. Shahan
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee and
| | - Nathaniel N. Stoikes
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee and
| | - Esra Roan
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee and
- Department of Biomedical Engineering, University of Memphis, Memphis, Tennessee
| | - James Tatum
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee and
- Department of Biomedical Engineering, University of Memphis, Memphis, Tennessee
| | - David L. Webb
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee and
| | - Guy R. Voeller
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee and
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Abstract
INTRODUCTION Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery. METHODS An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients. CONCLUSIONS The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.
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Seroma following transabdominal preperitoneal patch plasty (TAPP): incidence, risk factors, and preventive measures. Surg Endosc 2017; 32:2222-2231. [PMID: 29075973 PMCID: PMC5897456 DOI: 10.1007/s00464-017-5912-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 10/03/2017] [Indexed: 01/23/2023]
Abstract
Background The reported range of seroma formation in the literature after TEP repair is between 0.5 and 12.2% and for TAPP between 3.0 and 8.0%. Significant clinical factors associated with seroma formation include old age, a large hernia defect, an extension of the hernia sac into the scrotum, as well as the presence of a residual indirect sac. Seroma formation is a frequent complication of laparoendoscopic mesh repair of moderate to large-size direct (medial) inguinal hernia defects. This present analysis of data from the Herniamed Hernia Registry now explores the influencing factors for seroma formation in male patients after TAPP repair of primary unilateral inguinal hernia. Methods In total, 20,004 male patients with TAPP repair of primary unilateral inguinal hernia were included in uni- and multivariable analysis. Results Univariable analysis revealed the highly significant impact of the fixation technique on the seroma rate (non-fixation 0.7% vs. tacks 2.1% vs. glue 3.9%; p < 0.001). Multivariable analysis showed that glue compared to tacks (OR 2.077 [1.650; 2.613]; p < 0.001) and non-fixation (OR 5.448 [4.056; 7.317]; p < 0.001) led to an increased seroma rate. A large hernia defect (III vs. I: OR 2.868 [1.815; 4.531]; p < 0.001; II vs. I: OR 2.157 [1.410; 3.300]; p < 0.001) presented a significantly higher risk of seroma formation. Likewise, medial compared to lateral inguinal hernias had a higher seroma rate (OR 1.272 [1.020; 1.585]; p = 0.032). Conclusions Mesh fixation with tacks or glue, a larger hernia defect, and medial defect localization present a higher risk for seroma development in TAPP inguinal hernia repair.
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Moazzez A, Dubina ED. A Novel Approach to Mesh Fixation in Retrorectus Ventral Hernia Repair Using Fibrin Sealant. J Am Coll Surg 2017; 225:e1-e4. [PMID: 28606483 DOI: 10.1016/j.jamcollsurg.2017.05.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/30/2017] [Accepted: 05/31/2017] [Indexed: 11/22/2022]
Affiliation(s)
- Ashkan Moazzez
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA
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Jairam AP, Timmermans L, Eker HH, Pierik REGJM, van Klaveren D, Steyerberg EW, Timman R, van der Ham AC, Dawson I, Charbon JA, Schuhmacher C, Mihaljevic A, Izbicki JR, Fikatas P, Knebel P, Fortelny RH, Kleinrensink GJ, Lange JF, Jeekel HJ. Prevention of incisional hernia with prophylactic onlay and sublay mesh reinforcement versus primary suture only in midline laparotomies (PRIMA): 2-year follow-up of a multicentre, double-blind, randomised controlled trial. Lancet 2017. [PMID: 28641875 DOI: 10.1016/s0140-6736(17)31332-6] [Citation(s) in RCA: 211] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Incisional hernia is a frequent long-term complication after abdominal surgery, with a prevalence greater than 30% in high-risk groups. The aim of the PRIMA trial was to evaluate the effectiveness of mesh reinforcement in high-risk patients, to prevent incisional hernia. METHODS We did a multicentre, double-blind, randomised controlled trial at 11 hospitals in Austria, Germany, and the Netherlands. We included patients aged 18 years or older who were undergoing elective midline laparotomy and had either an abdominal aortic aneurysm or a body-mass index (BMI) of 27 kg/m2 or higher. We randomly assigned participants using a computer-generated randomisation sequence to one of three treatment groups: primary suture; onlay mesh reinforcement; or sublay mesh reinforcement. The primary endpoint was incidence of incisional hernia during 2 years of follow-up, analysed by intention to treat. Adjusted odds ratios (ORs) were estimated by logistic regression. This trial is registered at ClinicalTrials.gov, number NCT00761475. FINDINGS Between March, 2009, and December, 2012, 498 patients were enrolled to the study, of whom 18 were excluded before randomisation. Therefore, we included 480 patients in the primary analysis: 107 were assigned primary suture only, 188 were allocated onlay mesh reinforcement, and 185 were assigned sublay mesh reinforcement. 92 patients were identified with an incisional hernia, 33 (30%) who were allocated primary suture only, 25 (13%) who were assigned onlay mesh reinforcement, and 34 (18%) who were assigned sublay mesh reinforcement (onlay mesh reinforcement vs primary suture, OR 0·37, 95% CI 0·20-0·69; p=0·0016; sublay mesh reinforcement vs primary suture, 0·55, 0·30-1·00; p=0·05). Seromas were more frequent in patients allocated onlay mesh reinforcement (34 of 188) than in those assigned primary suture (five of 107; p=0·002) or sublay mesh reinforcement (13 of 185; p=0·002). The incidence of wound infection did not differ between treatment groups (14 of 107 primary suture; 25 of 188 onlay mesh reinforcement; and 19 of 185 sublay mesh reinforcement). INTERPRETATION A significant reduction in incidence of incisional hernia was achieved with onlay mesh reinforcement compared with sublay mesh reinforcement and primary suture only. Onlay mesh reinforcement has the potential to become the standard treatment for high-risk patients undergoing midline laparotomy. FUNDING Baxter; B Braun Surgical SA.
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Affiliation(s)
- An P Jairam
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands.
| | - Lucas Timmermans
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands; Department of Surgery, Maasstad Ziekenhuis, Rotterdam, Netherlands
| | - Hasan H Eker
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands; Department of Surgery, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - David van Klaveren
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Reinier Timman
- Department of Medical Psychology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | | | - Imro Dawson
- Department of Surgery, IJsselland Ziekenhuis, Capelle aan de IJssel, Netherlands
| | - Jan A Charbon
- Department of Surgery, Maxima Medisch Centrum, Veldhoven, Netherlands
| | | | - André Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Jakob R Izbicki
- Department of Surgery, Universitätsklinikum Hamburg Eppendorf, Hamburg, Germany
| | | | - Philip Knebel
- Department of Surgery, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | - Gert-Jan Kleinrensink
- Department of Neuroscience, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Johan F Lange
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Hans J Jeekel
- Department of Neuroscience, Erasmus University Medical Centre, Rotterdam, Netherlands
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Sutures versus new cyanoacrylates in prosthetic abdominal wall repair: a preclinical long-term study. J Surg Res 2017; 220:30-39. [PMID: 29180195 DOI: 10.1016/j.jss.2017.06.074] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/04/2017] [Accepted: 06/28/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND As an alternative to sutures, meshes used for hernia repair can be fixed using cyanoacrylate-based adhesives. Attempts to improve these adhesives include alkyl-chain lengthening to reduce their toxicity. This preclinical study compares the long-term behavior of cyanoacrylates of different chain lengths already used in hernia repair and new ones for this application. MATERIALS AND METHODS Partial abdominal wall defects were repaired using a Surgipro mesh in 18 New Zealand White rabbits, and groups were established according to the mesh fixation method: sutures (control), Glubran 2 (n-butyl), Ifabond (n-hexyl), and the new adhesives SafetySeal (n-butyl), and Evobond (n-octyl). Six months after surgery, recovered implants were examined to assess adhesive degradation, host tissue reaction, and biomechanical strength. RESULTS All the cyanoacrylate groups showed good host tissue incorporation in the meshes. Macrophage responses to Glubran and Ifabond were quantitatively greater compared with sutures. Cell damage caused by the adhesives was similar, and only Glubran induced significantly more damage than sutures. Significantly lower collagen 1/3 messenger RNA expression was induced by Ifabond than the remaining fixation materials. No differences were observed in collagen expression except slightly reduced collagen I deposition in Glubran/Ifabond and collagen III deposition in the suture group. Mechanical strengths failed to vary between the suture and cyanoacrylate groups. CONCLUSIONS All cyanoacrylates showed good long-term behavior and tolerance irrespective of their long or intermediate chain length. Cyanoacrylate residues persisted at 6 mo, indicating their incomplete degradation. Biomechanical strengths were similar both for the adhesives and sutures.
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Bittner JG, Alrefai S, Vy M, Mabe M, Del Prado PAR, Clingempeel NL. Comparative analysis of open and robotic transversus abdominis release for ventral hernia repair. Surg Endosc 2017; 32:727-734. [PMID: 28730275 DOI: 10.1007/s00464-017-5729-0] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 07/13/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Transversus abdominis release (TAR) is a safe, effective strategy to repair complex ventral incisional hernia (VIH); however, open TAR (o-TAR) often necessitates prolonged hospitalization. Robot-assisted TAR (r-TAR) may benefit short-term outcomes and shorten convalescence. This study compares 90-day outcomes of o-TAR and r-TAR for VIH repair. METHODS A single-center, retrospective review of patients who underwent o-TAR or r-TAR for VIH from 2015 to 2016 was conducted. Patient and hernia characteristics, operative data, and 90-day outcomes were compared. The primary outcome was hospital length of stay, and secondary metrics were morbidity, surgical site events, and readmission. RESULTS Overall, 102 patients were identified (76 o-TAR and 26 r-TAR). Patients were comparable regarding age, gender, body mass index, and the presence of co-morbidities. Diabetes was more common in the open group (22.3 vs. 0%, P = 0.01). Most VIH defects were midline (89.5 vs. 83%, P = 0.47) and recurrent (52.6 vs. 58.3%, P = 0.65). Hernia characteristics were similar regarding mean defect size (260 ± 209 vs. 235 ± 107 cm2, P = 0.55), mesh removal, and type/size mesh implanted. Average operative time was longer in the r-TAR cohort (287 ± 121 vs. 365 ± 78 min, P < 0.01) despite most receiving mesh fixation with fibrin sealant alone (18.4 vs. 91.7%, P < 0.01). r-TAR trended toward lower morbidity (39.2 vs. 19.2%, P = 0.09), less severe complications, and similar rates of surgical site events and readmission (6.6 vs. 7.7%, P = 1.00). In addition, r-TAR resulted in a significantly shorter median hospital length of stay compared to o-TAR (6 days, 95% CI 5.9-8.3 vs. 3 days, 95% CI 3.2-4.3). CONCLUSIONS In select patients, the robotic surgical platform facilitates a safe, minimally invasive approach to complex abdominal wall reconstruction, specifically TAR. Robot-assisted TAR for VIH offers the short-term benefits of low morbidity and decreased hospital length of stay compared to open TAR.
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Affiliation(s)
- James G Bittner
- Department of Surgery, Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. .,Department of Surgery, Division of Bariatric and Gastrointestinal Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA.
| | - Sameer Alrefai
- Department of Surgery, Division of Bariatric and Gastrointestinal Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Michelle Vy
- Department of Surgery, Division of Bariatric and Gastrointestinal Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Micah Mabe
- Department of Surgery, Division of Bariatric and Gastrointestinal Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Paul A R Del Prado
- Department of Surgery, Division of General Surgery, Maricopa Medical Center, Phoenix, AZ, USA
| | - Natasha L Clingempeel
- Department of Surgery, Division of Bariatric and Gastrointestinal Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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Hirsch H, Nagatomo K, Gefen J. Mesh Fixation with Fibrin Sealant in Totally Extraperitoneal Hernia Repair. J Laparoendosc Adv Surg Tech A 2017; 27:259-263. [PMID: 27893306 PMCID: PMC5369384 DOI: 10.1089/lap.2016.0555] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Repair of inguinal hernia is a common procedure, but there is a lack of consensus as to the optimal repair technique along with the use of mesh and methods of mesh fixation. The objective of this study was to evaluate the efficacy and safety of fibrin sealant for mesh fixation in laparoscopic totally extraperitoneal (TEP) inguinal hernia repair. MATERIALS AND METHODS A study was conducted of the first 200 patients undergoing TEP hernia repair with mesh fixation using fibrin sealant between March 2012 and January 2014. The primary outcome measures were (1) chronic pain (persisting for >3 months), (2) persistence of hernia (recurrence identified within first 2 weeks postoperatively), (3) hernia recurrence, and (4) any additional perioperative complications. The mean follow-up in the series was 34.4 ± 6.1 months (range 22.2-44.1). RESULTS Of the 278 hernias repaired in 204 patients (74 bilateral, 130 unilateral), 38 were recurrent and 240 were primary. Three patients (1.5%) had a persistent hernia, including one with a planned return to the operating room the next day due to poor visualization. Three patients (1.5%) had a hernia recurrence. Twelve patients (5.9%) reported experiencing chronic pain. The remaining complications were minor and resolved over time. CONCLUSIONS TEP repair of inguinal hernia using mesh secured with fibrin sealant can be effectively used to treat primary, recurrent, unilateral, and bilateral inguinal hernias in adults with minimal recurrence rates and complications during almost 3 years of follow-up.
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Affiliation(s)
- Hank Hirsch
- Lankenau Medical Center , General Surgery, Wynnewood, Pennsylvania
| | - Kei Nagatomo
- Lankenau Medical Center , General Surgery, Wynnewood, Pennsylvania
| | - Jonathan Gefen
- Lankenau Medical Center , General Surgery, Wynnewood, Pennsylvania
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Sun P, Cheng X, Deng S, Hu Q, Sun Y, Zheng Q, Cochrane Colorectal Cancer Group. Mesh fixation with glue versus suture for chronic pain and recurrence in Lichtenstein inguinal hernioplasty. Cochrane Database Syst Rev 2017; 2:CD010814. [PMID: 28170080 PMCID: PMC6464532 DOI: 10.1002/14651858.cd010814.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Chronic pain following mesh-based inguinal hernia repair is frequently reported, and has a significant impact on quality of life. Whether mesh fixation with glue can reduce chronic pain without increasing the recurrence rate is still controversial. OBJECTIVES To determine whether tissue adhesives can reduce postoperative complications, especially chronic pain, with no increase in recurrence rate, compared with sutures for mesh fixation in Lichtenstein hernia repair. SEARCH METHODS We searched the following electronic databases with no language restrictions: the Cochrane Central Register of Controlled Trials (CENTRAL; issue 4, 2016) in the Cochrane Library (searched 11 May 2016), MEDLINE Ovid (1986 to 11 May 2016), Embase Ovid (1986 to 11 May 2016), Science Citation Index (Web of Science) (1986 to 11 May 2016), CBM (Chinese Biomedical Database), CNKI (China National Knowledge Infrastructure), VIP (a full-text database in China), Wanfang databases. We also checked reference lists of identified papers (included studies and relevant reviews). SELECTION CRITERIA We included all randomised and quasi-randomised controlled trials comparing glue versus sutures for mesh fixation in Lichtenstein hernia repair. Cluster-RCTs were also eligible. DATA COLLECTION AND ANALYSIS Two review authors extracted data and assessed the risk of bias independently. Dichotomous outcomes were expressed as odds ratio (OR) with 95% confidence intervals (CI). Continuous outcomes were expressed as mean differences (MD) with 95% CIs. MAIN RESULTS Twelve trials with a total of 1932 participants were included in this review. The overall postoperative chronic pain in the glue group was reduced by 37% (OR 0.63, 95% CI 0.44 to 0.91; 10 studies, 1418 participants, low-quality evidence) compared with the suture group. However, the results changed when we conducted subgroup analysis with regard to the type of mesh. Subgroup analysis of included studies using lightweight mesh showed the reduction of chronic pain was less profound and insignificant (OR 0.77, 95% CI 0.50 to 1.17). Subgroup analysis of included studies using heavyweight mesh resulted in a significant benefit from the fixation with glue (OR 0.38, 95% CI 0.17 to 0.82).Hernia recurrence was similar between the two groups (OR 1.44, 95% CI 0.63 to 3.28; 12 studies, 1932 participants, low-quality evidence). Fixation with glue was superior to suture regarding duration of the operation (MD -3.13, 95% CI -4.48 to -1.78; 9 studies, 1790 participants, low-quality evidence); haematoma (OR 0.52, 95% CI 0.31 to 0.86; 10 studies, 1384 participants, moderate-quality evidence); and recovery time to daily activities (MD -1.26, 95% CI -1.89 to -0.63; 3 studies, 403 participants, low-quality evidence).We also investigated adverse events. There were no significant differences between the two groups. For superficial wound infection pooled analyses showed OR 1.23, 95% CI 0.37 to 4.11; 7 studies, 763 participants (low-quality evidence); for mesh/deep infection OR 0.67, 95% CI 0.16 to 2.83; 8 studies, 1393 participants (low-quality evidence). Furthermore, we investigated seroma (a postoperative swelling caused by fluid) (OR 0.83, 95% CI 0.51 to 1.33); and persisting numbness (OR 0.81, 95% CI 0.57 to 1.14).Finally, six trials involving 1009 participants reported postoperative length of stay, resulting in non-significant difference between the two groups (MD -0.12, 95% CI: -0.35 to 0.10)Due to the lack of data, it was impossible to draw any distinction between synthetic glue and biological glue.Eight out of 12 trials showed high risk of bias in at least one of the investigated domains. Two studies were quasi-randomised controlled trials and the allocation sequence of one trial was not concealed. Nearly half of the included trials either did not provide adequate information or had high risk of bias regarding blinding processes. The risk of bias for incomplete outcome data of all the included studies varied from low to high risk of bias. Two trials did not report on some important outcomes. One study was funded by the manufacturer producing the fibrin sealant. Therefore, according to the 'Summary of findings' tables, the quality of the evidence (GRADE) for the outcomes is moderate to low. AUTHORS' CONCLUSIONS Based on the short-term results, glue may reduce postoperative chronic pain and not simultaneously increase the recurrence rate, compared with sutures for mesh fixation in Lichtenstein hernia repair. Glue may therefore be a sensible alternative to suture for mesh fixation in Lichtenstein repair. Larger trials with longer follow-up and high quality are warranted. The difference between synthetic glue and biological glue should also be assessed in the future.
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Affiliation(s)
- Ping Sun
- Union Hospital, Tongji Medical College, Huazhong University of Science and TechnologyDepartment of Hepatobiliary Surgery1277 Jiefang Avenue.WuhanHubei ProvinceChina430022
| | - Xiang Cheng
- Union Hospital, Tongji Medical College, Huazhong University of Science and TechnologyDepartment of Hepatobiliary Surgery1277 Jiefang Avenue.WuhanHubei ProvinceChina430022
| | - Shichang Deng
- Union Hospital West Campus, Tongji Medical College, Huazhong University of Science and TechnologyDepartment of Gastrointestinal Surgery58 Shenlong Avenue.WuhanHubeiChina430056
| | - Qinggang Hu
- Union Hospital, Tongji Medical College, Huazhong University of Science and TechnologyDepartment of Hepatobiliary Surgery1277 Jiefang Avenue.WuhanHubei ProvinceChina430022
| | - Yi Sun
- Huazhong University of Science and TechnologySchool of Public Health, Tongji Medical CollegeHangkong Street, No. 13WuhanHubei ProvinceChina430030
| | - Qichang Zheng
- Union Hospital, Tongji Medical College, Huazhong University of Science and TechnologyDepartment of Hepatobiliary Surgery1277 Jiefang Avenue.WuhanHubei ProvinceChina430022
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Bellón JM, Fernández-Gutiérrez M, Rodríguez M, Pérez-López P, Pérez-Köhler B, Kühnhardt A, Pascual G, San Román J. Behavior of a new long-chain cyanoacrylate tissue adhesive used for mesh fixation in hernia repair. J Surg Res 2017; 208:68-83. [DOI: 10.1016/j.jss.2016.09.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 07/29/2016] [Accepted: 09/09/2016] [Indexed: 10/21/2022]
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Yang X, Liu W, Li N, Wang M, Liang B, Ullah I, Luis Neve A, Feng Y, Chen H, Shi C. Design and development of polysaccharide hemostatic materials and their hemostatic mechanism. Biomater Sci 2017; 5:2357-2368. [DOI: 10.1039/c7bm00554g] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The formation of stable blood clots or hemostasis is essential to prevent major blood loss and death from excessive bleeding.
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Incidence of chronic pain after single stitch mesh fixation in open inguinal hernia repair: An observational prospective study, a case series. INTERNATIONAL JOURNAL OF SURGERY OPEN 2017. [DOI: 10.1016/j.ijso.2017.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Lasses Martínez B, Peña Soria MJ, Cabeza Gómez JJ, Jiménez Valladolid D, Flores Gamarra M, Fernández Pérez C, Torres García A, Delgado Lillo I. Surgical treatment of large incisional hernias with intraperitoneal composite mesh: a cohort study. Hernia 2016; 21:253-260. [PMID: 28008551 DOI: 10.1007/s10029-016-1557-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 11/25/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE Patients with large incisional hernias have significant morbidity and their management is a challenge for the surgical team because of the large abdominal wall involvement. The choice of surgical technique is still controversial. The purpose of this study is to analyze the predictive factors for recurrence after intraperitoneal mesh repair in patients with large incisional hernias. METHODS A retrospective cohort observational study with a prospectively collected database was performed in the Hospital Clinico San Carlos (Madrid, Spain). All consecutive patients operated on from January 2009 to December 2014 with incisional hernia of 10 or more centimeters in its transverse diameter were included. An intraperitoneal repair with a composite mesh fixed with discontinuous absorbable suture and fibrin sealant was performed. Demographic data, comorbidities, and early and long term outcomes were analyzed. The primary outcome was the presence of recurrence. RESULTS One hundred and twenty patients were included. Mean age was 63.3 years (SD 12.9) and sex ratio was 1.4:1. Seventy-two patients (60%) were ASA III-IV. Forty-five patients (37.5%) had recurrent ventral hernias. Mean defect size was 14.7 cm (SD 3.21) of width. Overall postoperative morbidity rate was 25%. Median hospital stay was 6 days (IQR 4-8). Recurrence rate was 8.3%, after a median follow-up of 16 months (IQR 10-25). Multivariate analysis showed significant association between ASA III-IV, use of Composix Kugel™ mesh, superficial surgical site infection, and the presence of recurrence. CONCLUSIONS The recurrence rate after intraperitoneal mesh repair in patients with large incisional hernias might be associated with ASA III-IV, use of Composix Kugel™ mesh, and superficial surgical site infection.
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Affiliation(s)
- B Lasses Martínez
- Surgery Department, Hospital Clinico San Carlos, Universidad Complutense de Madrid, Calle Profesor Martin Lagos s/n, 28040, Madrid, Spain.
| | - M J Peña Soria
- Surgery Department, Hospital Clinico San Carlos, Universidad Complutense de Madrid, Calle Profesor Martin Lagos s/n, 28040, Madrid, Spain
| | - J J Cabeza Gómez
- Surgery Department, Hospital Clinico San Carlos, Universidad Complutense de Madrid, Calle Profesor Martin Lagos s/n, 28040, Madrid, Spain
| | - D Jiménez Valladolid
- Surgery Department, Hospital Clinico San Carlos, Universidad Complutense de Madrid, Calle Profesor Martin Lagos s/n, 28040, Madrid, Spain
| | - M Flores Gamarra
- Surgery Department, Hospital Clinico San Carlos, Universidad Complutense de Madrid, Calle Profesor Martin Lagos s/n, 28040, Madrid, Spain
| | - C Fernández Pérez
- Preventive Medicine Department, Hospital Clinico San Carlos, Universidad Complutense de Madrid, Calle Profesor Martin Lagos s/n, 28040, Madrid, Spain
| | - A Torres García
- Surgery Department, Hospital Clinico San Carlos, Universidad Complutense de Madrid, Calle Profesor Martin Lagos s/n, 28040, Madrid, Spain
| | - I Delgado Lillo
- Surgery Department, Hospital Clinico San Carlos, Universidad Complutense de Madrid, Calle Profesor Martin Lagos s/n, 28040, Madrid, Spain
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Dauser B, Szyszkowitz A, Seitinger G, Fortelny RH, Herbst F. A novel glue device for fixation of mesh and peritoneal closure during laparoscopic inguinal hernia repair: short- and medium-term results. Eur Surg 2016. [DOI: 10.1007/s10353-016-0450-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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