Cyanoacrylate glue for hernia mesh fixation

Study size and design

A systematic review including 15 RCTs with a total of 2,109 participants. Five RCTs used cyanoacrylate glue as 1 of the treatment arms (Brugger et al. 2011; Jani 2016; Liew et al. 2017; Moreno-Egea 2014; Subwongcharoen and Ruksakul 2013). There was a total of 552 people in these 5 studies, 275 of whom were randomised to treatment using cyanoacrylate glue.

Intervention and comparator(s)

The systematic review compared all types of glue (including cyanoacrylate glue) with mechanical mesh fixation (sutures, tacks or staples). A subgroup analysis of chronic postoperative inguinal pain reported separate results for fibrin sealant and cyanoacrylate glue. Two studies used Histoacryl glue, 1 used Glubran (GEM), 1 used Endocryl (Samarth Life Sciences), and 1 used Ifabond (Peter's Surgical).

Key outcomes

The incidence of chronic postoperative inguinal pain was reported in 13 of the included studies. There was no significant difference in chronic postoperative inguinal pain between cyanoacrylate glue and mechanical fixation methods (relative risk [RR] 0.68, 95% confidence interval [CI] 0.38 to 1.22; p=0.19).

Strengths and limitations

The systematic review included 15 RCTs. Laparoscopic procedures included both transabdominal preperitoneal (TAPP) and total extraperitoneal repair (TEP) approaches. Results specific to cyanoacrylate glue were only available for 1 outcome (chronic postoperative pain). Length of follow up was only reported for recurrence rates (median 12 months) and not specifically for the cyanoacrylate glue group; the length of follow up for chronic pain was not reported.

Study size and design

Systematic review including 13 RCTs. Five studies included cyanoacrylate glue as 1 of the treatment arms (Brugger et al. 2011; Jani 2016; Liew et al. 2017; Moreno-Egea 2014; Subwongcharoen and Ruksakul 2013). A total of 1,947 hernia repair procedures were included in the full review, 275 of which used cyanoacrylate-based glue. Median follow up was 12 months (range 1 to 38).

Intervention and comparator(s)

Cyanoacrylate-based glue was compared with fibrin-based glue. The study also reported results of meta-analyses within glue subtypes (which compared each type of glue with a range of mechanical fixation methods). Two studies used Histoacryl glue, 1 used Glubran, 1 used Endocryl and 1 used Ifabond.

Key outcomes

When comparing cyanoacrylate glue with mechanical fixation, there was no difference in the rate of hernia recurrence (odds ratio [OR] 1.05, CI 0.18 to 6.18, p=0.96), postoperative haematoma or seroma (OR 0.78, CI 0.41 to 1.50, p=0.46), or urinary retention (OR 0.51, CI 0.05 to 5.68, p=0.58). There were no significant differences in these outcomes when cyanoacrylate was compared with fibrin glues.

Strengths and limitations

Both TAPP and TEP procedures were included. Mechanical fixation methods included sutures, tacks and staples. Indirect methods were used when comparing cyanoacrylate-based glues with fibrin-based glues. Results were detailed enough to report some outcomes from studies that directly compared cyanoacrylate glue with mechanical fixation methods, but may have been statistically underpowered.

Study size, design and location

An RCT including 3 treatment arms with a total of 798 people who had TAPP procedures in Egypt.

Intervention and comparator(s)

The study compared mesh fixation using Histoacryl cyanoacrylate glue (n=266) and tacks (n=266) with no fixation (n=266).

Key outcomes

The authors report that there were no statistically significant differences between cyanoacrylate glue and no fixation for postoperative pain, postoperative complications, length of procedure, length of hospital stay or chronic groin pain at 18‑month follow up. Postoperative pain and complications were more common with tacks than with cyanoacrylate glue. Chronic pain was reported by 19 people (7%) in the cyanoacrylate group, 53 people (20%) in the tacks group, and by 5 people (2%) in the no fixation group.

Procedure length was greater than 60 minutes for 32 people (12%) in the cyanoacrylate group, compared with 98 people (37%) in the tacks group and 24 people (9%) in the no fixation group. Hospital stay was greater than 1 day for 28 people (11%) in the cyanoacrylate group, 62 people (23%) in the tacks group and 14 people (5%) in the no fixation group. The proportions of people able to return to work and normal activity within 1 week were 83% (221 out of 266) of those treated with cyanoacrylate, 43% (115 out of 266) of those treated with tacks and 90% (238 out of 266) of those who had no mesh fixation.

Hernia recurrence rates were low, with 2 in each of the cyanoacrylate and non-fixation groups, and 1 in the tacks group. Haematoma or seroma was most commonly reported in the cyanoacrylate group (14 people, 5%), compared with 3 people (1%) in the tacks group and only 1 (0.4%) in the no fixation group. There was 1 wound infection in a patient in the tacks group; no mesh infections were reported.

Strengths and limitations

This was an RCT with a large sample size. Multiple outcome measures were considered, but statistical comparison was summarised across all 3 treatment arms (not reported separately for cyanoacrylate glue compared with tacks). In the abstract the authors claim there were no significant differences between cyanoacrylate glue and no fixation for several measures, but did not provide supporting data for this direct comparison. Although immediate postoperative pain scores were referenced in the abstract and methods, they were not clearly reported in the results. Several continuous measures were reported as binary outcomes (grouped according to values above and below a threshold), reducing the value of the available data.

Study size and design

A systematic review including 23 RCTs. Eight studies included cyanoacrylate glue as 1 of the treatment arms (Dabrowieki et al. 2012; Hoyuela et al. 2017; Kim-Fuchs et al. 2011; Moreno-Egea 2014; Nowobilski et al. 2004; Paajanen et al. 2011; Ronka et al. 2015; Shen et al. 2011). The total number of participants in these 8 RCTs was 1,832, with 833 randomised to treatment using cyanoacrylate glue.

Intervention and comparator(s)

The main study compared adhesional or self-gripping fixation methods (including cyanoacrylate glue, fibrin glue and self-gripping mesh) with sutures. Subgroup analyses compared cyanoacrylate glue with sutures for postoperative pain, chronic pain and rate of recurrence. Three of the 8 studies used Histoacryl glue, with the remainder each using Glubran (GEM), Glubran2, Ifabond, Indermil (Loctite) and Compont (Beijing Compont Medical Devices).

Key outcomes

Postoperative pain scores were lower with cyanoacrylate compared with sutures after 1 week (mean difference -0.77, CI -1.48 to -0.05, p=0.04) and 1 month (-0.43, CI -0.72 to -0.14, p=0.004). After 12 months there were no significant differences between cyanoacrylate glue and sutures for chronic pain (OR 1.36, CI 0.77 to 2.42, p=0.29), and hernia recurrence (OR 1.53, CI 0.48 to 4.86, p=0.47). Overall, the length of procedure was approximately 6 minutes shorter for self-adhering or self-gripping methods when compared with suturing.

Strengths and limitations

This was a systematic review, which included 23 RCTs with some relevant subgroup analyses (including cyanoacrylate-based glues).

Study size, design and location

An RCT including 3 treatment arms with a total of 625 people who had Lichtenstein hernioplasty in Finland.

Intervention and comparator(s)

Histoacryl cyanoacrylate glue was used for mesh fixation (n=216). Comparators were non-absorbable sutures (n=216) or self-gripping mesh (n=202). After 5 years, the numbers of people remaining in the trial were 177 in the cyanoacrylate glue group, 170 in the sutures group and 167 in the self‑gripping mesh group.

Key outcomes

After 5 years of follow up, there were no significant differences between the 3 treatment groups in the incidence of chronic pain, recurrence requiring reoperation, overall reoperations or patient satisfaction.

Strengths and limitations

This multicenter trial had a large sample size with long-term follow up. A similar proportion of people in each group was lost to follow up. People were not clinically examined at final follow up so results rely on patient-reported outcomes. Statistical comparisons were across all 3 treatment arms; no subgroup analyses were reported. This study was previously reported by Ronka et al. (2015) at 1‑year follow up, and the same people had been included in the Van Steensel et al. (2019) systematic review.