Cyanoacrylate glue for hernia mesh fixation

Level of innovation

One expert described mesh fixation using cyanoacrylate glue as a major innovation compared with tacking devices. Another described it as a novel approach that enables a move away from traumatic, mechanical mesh fixation methods. One expert felt it was only a minor variation, noting that different forms of glue (fibrin) have been used for many years. They explained that the operation and mesh remained the same, and that the difference was in the way that the mesh was fixed in place.

Potential patient impact

Experts advised that at least 70,000 inguinal hernia repairs are done in the UK each year, and most would be eligible for cyanoacrylate glue use. One expert estimated that less than 10% of NHS hospitals currently use cyanoacrylate glue for hernia mesh fixation.

All 4 experts agreed that there would be a reduced risk of complications compared with mechanical mesh fixation methods. Three of the experts noted the reduced risk of chronic pain, with 2 commenting that the incidence of nerve damage would be reduced. One also mentioned that immediate postoperative pain was likely to be reduced. Two experts advised that the risk of hernia recurrence is reduced when using glue; 1 explained that it is possible to extend the mesh across a wider area in laparoscopic transabdominal preperitoneal (TAPP) and extraperitoneal (TEP) inguinal hernia repairs. The other expert suggested that chronic pain is a greater concern than hernia recurrence because it is possible to carry out another hernia repair, but not always to resolve chronic pain. One expert thought that thin people who have a low body mass index may particularly benefit from glue use, because they have a greater risk of nerve damage from mechanical mesh fixation methods. Another expert commented that young people tend to have a higher rate of chronic pain, and probably have more chance of benefit from cyanoacrylate glue use.

One of the experts noted that evidence suggests that improved clinical outcomes associated with cyanoacrylate glue may lead to a shortened length of hospital stay, and a quicker return to normal activities. Two experts commented that avoiding complications such as pain and recurrence could reduce the need for further management, avoiding visits to primary and secondary care, potential reoperation and absences from the workplace.

Potential system impact

All 4 experts agreed that adopting cyanoacrylate glue has little impact on staff resources, equipment or care setting. Applicator devices were considered by 2 experts to be simple to use for mesh fixation (1 said that peritoneal closure using glue can be technically challenging in TAPP repairs). All experts agreed that minimal training is needed. One said that this can be achieved on the job. One said 20 cases or less would be needed to get the required experience but another believed that up to 50 cases may be needed before the operator can apply the glue efficiently. One expert emphasised that nurses also need minimal training to understand how to prepare the device for use.

Two experts indicated that the length of procedure may be shortened if glue is used for both mesh fixation and peritoneal closure. Lessening the need for ongoing management of complications, and avoiding recurrence, could slightly reduce the overall burden on the healthcare system.

All experts indicated that cyanoacrylate glue has the potential to replace the routine use of tacks and other mechanical fixation devices. The potential economic impact depends very much on the standard care comparator. As highlighted by 1 of the experts, cyanoacrylate glue would inevitably cost more than no mesh fixation. Another advised that cyanoacrylate glue costs substantially less than fibrin glue. Two experts believed that cyanoacrylate glue is likely to cost about the same as current standard care, when the whole care pathway is taken into consideration. One expert suggested that cyanoacrylate glue may ultimately prove less costly than tacks because of reduced long-term resource use. One expert commented that cyanoacrylate glue products are easy to store and do not require refrigeration; another suggested that shelf life should be taken into consideration.

General comments

The experts confirmed that a variety of mesh fixation methods are commonly used in the NHS. The decision on which 1 to use is likely influenced by the procedural approach and which technologies are available locally. Three experts described using tacks for laparoscopic procedures, and 2 referred to using sutures for open surgery. One of the experts routinely used fibrin glue.

In hernia repair procedures, cyanoacrylate glue can be used for both mesh fixation and for peritoneal closure. One expert believed that the glue's main advantages (such as speed of use) are most evident when used for these 2 purposes within a single procedure. One expert was uncertain about the relative effectiveness of mesh fixation with cyanoacrylate glue when compared with self-gripping mesh (which similarly has the benefit of avoiding tissue trauma). However, when self-gripping mesh is used, it takes more time to suture the peritoneum (than when the peritoneum is glued).

Although not reported in the included studies, anecdotal evidence from 1 expert suggests that some clinicians are reluctant to use cyanoacrylate glue because they are not sure whether the fixation is as strong as with tacks, and are concerned about the risk of hernia recurrence.

One expert considered that the evidence could be strengthened by additional high-quality randomised controlled trials comparing recurrence rates. Another suggested further research comparing cyanoacrylate with more established glues. Three experts noted that the length of study follow up should extend to at least 1 year after the procedure (to evaluate prevalence of chronic pain). One expert suggested that longer studies (up to 10 years) are needed for a better understanding of relative rates of recurrence. One of the experts considered the design of the applicator device to be 'key', and implied that a comparative evaluation of device functioning would be helpful. Three experts emphasised that applicators must be easy to use; 1 provided a further explanation that this could affect how quickly the operation could be done (and so the number of procedures that could be completed in a day). Cost comparisons should consider the frequency of applicator device malfunctioning, which can result if glue is not loaded correctly or a blockage occurs. Three experts reported that they sometimes needed to replace LiquiBand Fix8 devices because of problems with glue delivery; this adds to the cost and can add a few extra minutes to the length of the procedure.

One of the experts commented that their experience and research (based on the laparoscopic LiquiBand Fix8 device) had led to them to no longer using tacks in TAPP repairs and laparoscopic intraperitoneal onlay mesh (IPOM) repairs. Another expert noted that all of the procedures they had carried out using Histoacryl had been day cases, with no reports of chronic pain.