JOURNAL CLUB

Presenter : Dr. Sukhesh Holla

Moderator : [Link] B Pai

 Articles Shortlisted
[Link] chemotherapy for luminal a breast
cancer: Factors predictive of histopathologic response
and oncologic outcome.

[Link] topical application of tranexamic acid to control

bleeding in inguinal hernia surgery candidate patients: A
randomized controlled trial.
3. Early positive fluid balance is predictive for venous
thromboembolism in critically ill surgical patients.

4. Transformation of acute cholecystitis to acute

choledocholithiasis in COVID-19 patient.

5. Comparing suture with N-Hexyl Cyanoacrylate glue

for mesh fixation in inguinal hernia repair, a
randomised clinical trial
 Article of interest

Comparing suture with N-Hexyl

Cyanoacrylate glue for mesh fixation in
inguinal hernia repair, a randomised clinical
trial
Arash Mohammadi Tofigh,Milad Karimian
Ghadim, Mehrdad Bohlooli

The American Journal of Surgery( Volume

222,number 1-July 2021) is the journal reffered
• Type of study: Randomised controlled trial.

• Reason for choosing the article:

Inguinal hernia is one of the most common
surgical procedures in our hospital and
elsewhere.
Post operative complications of pain,damage to
neurological and vascular structures are mostly
secondary to sutures.
There is a need for improvising the technique to
overcome these problems.

Hence this article was chosen; as it focuses on

using an alternative method to suture fixation.
 Lichtenstein’s tension free hernioplasty

• Direct hernia, the posterior

wall is invaginated;

• Indirect hernia, after the

peritoneal sac is inverted or
transected, the internal ring is
narrowed.

• A piece of prosthetic mesh is

sutured as an onlay patch to
the transverses arch
superiorly, the inguinal
ligament inferiorly, and the
pubis medially.
• Mesh placement: tailored to the
shape and size of the patient’s
anatomy to facilitate overlap of 2
cm onto the pubic tubercle, 4 cm
above Hesselbach triangle, and 5
to 6 cm lateral to the deep ring.

• Two tails are created in the mesh

by incising it from the lateral
edge to create a slit that encircles
the spermatic cord and
reconstructs the internal ring.
(upper 2/3rd and lower 1/3rd
junction)
• This technique does not
require opening the
posterior wall, and after the
prosthetic patch is
incorporated with posterior
wall, it acts like a
reinforcing barrier.

• Fibrotic reaction between

the inguinal floor and the
posterior surface of the
mesh, forming scar and
strengthening the closure of
the hernia defect.
 Article summary
• Authors aims and objective:
To compare therapeutic outcomes of mesh
fixation with suture and N-Hexyl Cyanoacrylate
glue in inguinal hernia repair with the
Linchtenstein method.

• Medical outcomes:
Lower postoperative pain.
Less Duration of surgery .
 Materials and methods
• Randomised controlled trail.
• Conducted in one institution-*(Shahid
Beheshti University of medical
sciences,Tehran,Iran)
The inclusion criteria The exclusion criteria
• All hernia patients with age • Recurrent hernia.
group of 20-65 years. • Impossible to follow up.
• Long term preoperative use
of anti-inflammatory
• Phyical status classification
grade 3 and higher.
• Patient addicted to
alcohol,opium and drugs
were excluded.
 Surgical steps
Lichtenstein tension free hernioplasty
• Anaesthesia- Spinal
• Supine position
• Paint and drape the groin
• An oblique incision was made in the skin.
• Incise subcutaneous tissue and external
oblique aponeurosis
• Elevate Spermatic cord from the posterior
wall of the inguinal canal.
• Identify the hernial sac and dissect till the
internal ring.
• Then it was opened and ligated.
• In large indirect inguinal hernias, the distal
part of the sac may be left open to prevent the
formation of a hydrocele.
• In direct hernias, the sac contents were
imbricated with non-absorbable sutures.
• A mesh was trimmed to fit the floor of the canal and an
opening was made into its lower edge to accommodate the
spermatic cord.
• In the control group, the apex of the mesh was first
sutured over the public tubercle using a Prolene 3-0
suture.
• The same continuous suture then sutures the lower border
of the mesh to the free edge of the inguinal ligament.
• The continuous suture extends up just medial to the
anterior superior iliac spine.
• Interrupted Prolene sutures then suture the two
cut edges of the mesh together around the
spermatic cord.
• The mesh was then sutured to the conjoined
tendon by interrupted sutures (Prolene 3-0).
• The aponeurosis of external oblique was closed
using absorbable sutures (Vicryl 2-0).
• The skin was then subcutaneously repaired
using Monocryl 3-0 sutures
• In the intervention group - N-Hexyl
Cyanoacrylate glue (IFABOND, Peters
Surgical, France) was sprayed on the edges
and the center of the mesh.
• Adhesive dry time – 2min then wound was
closed same as above
• The data collected included
A. Length of the operation
B. Acute and Chronic pain
C. Hospital stay days,
D. Recurrence rate
E. Complications including
Seroma
Hematoma
Infection
Urinary problems.
• Acute pain was assessed in 8th hour, 24th
hour, one week and one month after the
surgery by the numerical rating scale (NRS).
• The presence or absence of chronic pain and
then the severity of chronic pain (according to
the NRS) was questioned and recorded in 3, 6,
and 12 months after the surgery.
• Recurrence rate was assessed by sonography
which was done by a radiologist unaware of
the patient group, one year after the surgery.
 Statistical analysis
• SPSS version 25.0 software(IBM, Inc.,
Armonk NY, USA)
• Kolmogorov-Smirnov test
• Chi-Square test
• Fisher test
• Independent-Sample-T test
• The P values less than 0.05 were considered
significant.
 RESULTS
SUTURE GLUE P-VALUE

MEAN 53.1 ± 10.9 55.8 ± 6.9 > 0.05

AGE Years Years
MEAN 25.4 ± 2.03 26.2 ± 2.07 > 0.05
BMI kg/m2 kg/m2

All cases were male.

Acute pain distribution across the groups.
Fixation Pain score Std. Deviation

8 Hour Glue 8.05 1.071

Suture 8.68 0.749

24 Hour Glue 7.57 1.076

Suture 7.95 1.079

1 week Glue 4.67 1.017

Suture 5.58 2.090

1 month Glue 2.76 1.044

Suture 3.79 2.226
• According to NRS, the mean acute pain
severity (8th, 24th hours, 1 week, 1 month
after the surgery) in the N-Hexyl
cyanoacrylate glue group was 5.7 ± 0.9 versus
6.5 ± 0.8 in the suture group, and the
difference was significant (P - 0.006)
 Chronic pain scores in suture and glue groups

Fixation Mean pain Std

score deviation
Chronic Suture 4.99 0.75
pain score
(NRS)
Glue 4.74 0.87
• According to NRS, the mean chronic pain
severity (3, 6 and 12 months after the surgery)
in the N-Hexyl cyanoacrylate glue group was
4.74 ± 0.87 versus 4.99 ± 0.75 in the suture
group, and the difference was not significant
(P > 0.05)
• The length of operation was 64.5 ± 11.2 min in
the glue group versus 73.3 ± 10.6 min in the
suture group that was significantly Fig. 1.
Formula for sample size determination. shorter
in the glue group (P - 0.014).
• The hospital stay was the same across the
groups (1.6 ± 0.7 days versus 1.4 ± 0.6 days, P
- 0.323).
• There was no complicated case in the glue
group but one case of hematoma in the suture
group was seen (P > 0.05).
• There was no recurrence after one year
according to the sonography report in either
group.
Variable Suture group Glue group P Value

Mean acute 6.5 ± 0.8 5.7 ± 0.9 0.006

pain (NRS)

Operation 73.3 ± 10.6 64.5 ± 11.2 0.014

length (min)

Stay (day) 1.6 ± 0.7 1.4 ± 0.6 0.323

Recurrence 0 0 -
after One year
 Discussion
• In this study, N-Hexyl Cyanoacrylate glue was
compared to suture for mesh fixation in hernia
repair with the Lichtenstein method.
• Acute pain, chronic pain, recurrence rate and lengh
of operation and hospital stay were compared.
• The acute pain severity and length of surgery were
less in the glue group (P - 0.006, P -0.014).
• The hospital stay, chronic pain, and complication
rates were the same across the groups.
 Conclusion
• Using N-Hexyl Cyanoacrylate glue for mesh
fixation in hernia repair with the Lichtenstein
method can lower postoperative pain and duration
of the surgery.
• It might be safely used as a substitute for suture and
can increase patient satisfaction.
• More studies with larger sample size and
assessment of the other surgical methods and mesh
fixation techniques are required to attain more
definite results.
MY OPINION ABOUT THE ARTICLE
• Commonly practiced elective surgery in SDM.

• N-Hexyl Cyanoacrylate glue for mesh fixation

in inguinal hernia repair can be considered and
adopted in our hospital.
• Strenghts:
-short duration of surgery.
-lower post operative pain.

• Weakness:
-Sample size is less.
-Data and results are single hospital based.
 Other studies
• Ladwa N, Sajid MS, Sains P, Baig MK. Suture mesh
fixation versus glue mesh fixation in open inguinal
hernia repair: a systematic review and meta-analysis.
Int J Surg. 2013;11(2):128e135.
• Colvin HS, Rao A, Cavali M, Campanelli G, Amin
AI. Glue versus suture fixation of mesh during open
repair of inguinal hernias: a systematic review and
metaanalysis. World J Surg. 2013
Oct;37(10):2282e2292.
• Matikainen M, Kossi J, Silvasti S, Hulmi T, Paajanen H.
Randomized clinical trial comparing cyanoacrylate glue
versus suture fixation in Lichtenstein hernia repair: 7-year
outcome analysis. World J Surg. 2017;41(1):108e113.
• Liu H, Zheng X, Gu Y, Guo S. A meta-analysis examining the
use of fibrin glue mesh fixation versus suture mesh fixation in
open inguinal hernia repair. Dig Surg. 2014;31(6):444e451.
14.
• De Goede B, Klitsie PJ, Van Kempen BJH, et al. Meta-
analysis of glue versus sutured mesh fixation for Lichtenstein
inguinal hernia repair. Br J Surg. 2013 May;100(6):735e742.
• Thank you