Retrorectus Mesh Fixation Using Fibrin Glue: Early Outcomes of an Evolving Technique

Purpose: The retrorectus approach to abdominal wall hernia repair has led to superior post-operative outcomes. However, this technique has been associated with long hospital lengths of stay (LOS), long operative times, long time to drain removal, and more frequent 30-day post-operative visits (POV). Additionally, there is substantial effect on patient well-being with high pain scores and low activity levels. The aim of our study was to determine the effect of fibrin glue fixation (FGF) of mesh when compared to suture fixation (SF) on early post-operative outcomes after retrorectus hernia repair.

Methods: Patients undergoing retrorectus abdominal wall hernia repairs (n=87) by the senior author between June 1, 2015 and December 31, 2017 were retrospectively assessed. 28 patients (32.2%) received FGF, whereas 59 (67.8%) received SF. Demographic factors, intraoperative details, and early post-operative outcomes were identified through the electronic medical record. The two cohorts were then matched based on the type of mesh, number of prior repairs, average defect size, age, BMI, and wound class. Statistical analyses were performed using chi-square tests for categorical variables and Students T-tests for continuous variables.

Results: After matching the two cohorts based on the 6 variables listed above, 21 patients remained in the FGF group and 21 remained in the SF group. All patients had retrorectus repairs with biosynthetic mesh. No statistically significant differences were identified in percentage of females (43% FGF vs. 48% SF, p=0.757), mean age (57 FGF vs. 56 SF, p=0.890), mean BMI (34 kg/m² FGF vs. 35 kg/m² SF, p=0.575), and average number of prior hernia repairs (0.81 FGF vs 0.76 SF, p=0.883). Intraoperative factors were similar as well with average wound class (1.33 FGF vs 1.38 SF, p=0.848), mean defect size (326 cm² FGF vs. 334 cm² SF), use of epidural and patient-controlled analgesics (p=1), concomitant procedures (p=0.756) including specifically panniculectomies (p=0.758), use of anterior component separation (p=0.4690), and use of transversus abdominis release (p=1). Surgical site occurrences between the two groups were not statistically significant except for a trend towards higher rates of seromas in the SF cohort (3 vs. 0 in FGF, p=0.072). Statistical significance was observed for LOS (3.7 days FGF vs. 7.1 days SF, p=0.032), time to drain removal (17 days FGF vs. 27 days SF, p-0.020), 30 day POV (2 visits FGF vs 3 visits SF, p=0.007), 24-hour pain scores (3 FGF vs 5 SF, p=0.021) and Braden activity scores (walking at 24 hours for FGF compared to sitting in a chair at 24 hours for SF, p=0.004). There was a trend towards decreased operative time (193 minutes FGF vs 217 minutes SF, p=0.352) and decreased narcotics being re-prescribed post-operatively (3 patients FGF vs 7 patients SF, p=0.272)

Conclusion: Compared to SF, FGF can improve pain and activity scores while reducing LOS, time to drain removal, and 30 day POV. This study shows that FGF is a safe and useful alternative to SF in the immediate post-operative period and lays the foundation for future studies to assess long-term outcomes related to hernia recurrence.