Advice

The technology

The technology

Cyanoacrylate glue is a synthetic adhesive with various uses. This briefing reviews 3 types of cyanoacrylate glue for medical use for hernia mesh fixation.

All 3 glues have good tensile strength. They polymerise rapidly on contact with tissue fluids then degrade slowly until they are fully absorbed by the body. Each has a different applicator for mesh fixation.

Histoacryl LapFix

Histoacryl (B Braun Surgical) consists of n‑butyl‑2-cyanoacrylate (a pure butyl ester) and is used for open and laparoscopic procedures. The Histoacryl LapFix applicator (designed for laparoscopic surgery) includes Histoacryl glue and a syringe and cannula.

LiquiBand Fix8

The LiquiBand Fix8 device (Advanced Medical Solutions) consists of n‑butyl‑2-cyanoacrylate adhesive in liquid form, preloaded into an applicator device. Two versions are available; 1 designed for laparoscopic procedures and another for open surgery. LiquiBand Fix8 devices are also indicated for secondary use for peritoneal closure and topical wound closure.

Glubran2

Glubran2 (GEM/Sela Medical UK), also known as Glubran, is synthetic biodegradable cyanoacrylate-based glue (an n‑butyl-cyanoacrylate) modified by the addition of a monomer synthesised by the company. The Glutack device has been designed to apply Glubran2 in precise drops. Two versions of Glutack are available; 1 designed for laparoscopic procedures and another (Glutack Short) for open surgery.

Innovations

Using glue instead of mechanical mesh fixation methods aims to avoid the trauma associated with tissue penetration.

Potential benefits include:

  • reduced postoperative and chronic pain

  • fewer postoperative complications, such as seroma formation or nerve injury

  • reduced risk of hernia recurrence

  • reduced length of hospital stay

  • earlier return to work and usual activities

  • improved patient quality of life.

Compared with fibrin-based (biologic) glues, which have lower adhesive strengths, synthetic cyanoacrylate-based technologies use less glue and need less time for setting. Fibrin glues must also be refrigerated during storage, whereas cyanoacrylate glue can be stored at room temperature.

There have also been innovative developments in the tools used to apply the glues to make them easier to use and make delivery more accurate. Some applicators require manual assembly before use. Others are preloaded and only require activation or priming before use.

Current care pathway

Standard mesh fixation methods in the NHS vary according to the surgeon's preferences and the requirements of each procedure (for example, hernia size and location, surgical approach and type of mesh). Sutures and other mechanical methods such as tacks have traditionally been used for mesh fixation, but traumatic penetration of the abdominal wall can damage blood vessels and nerves. Some types of tacks remain as permanent foreign bodies, and they have been reported to migrate, resulting in chronic pain and other complications.

The choice of mesh fixation method is not likely to significantly affect the broader care pathway, although it may affect operative and recovery times. Post-procedural complications such as chronic pain may need ongoing management.

The following publications have been identified as relevant to this care pathway:

Population, setting and intended user

The technologies are intended to be used in people having abdominal hernia repair with mesh. Cyanoacrylate glue may be contraindicated in:

  • people with known hypersensitivity to cyanoacrylate or formaldehyde

  • people with known preoperative systemic infections or uncontrolled diabetes

  • conditions known to interfere with wound healing

  • pregnancy.

It is incompatible with certain types of mesh (such as biological or bioabsorbable meshes).

When used for mesh fixation, cyanoacrylate glue is prepared by nurses and applied by experienced surgeons in the operating theatre in secondary care. Introductory training may be needed on first use, including in how to prime applicator devices.

Costs

When the cost of the fixation technologies is excluded, the associated cost of the hernia repair procedure itself is expected to be similar regardless of fixation method. A single procedure (unilateral or bilateral) typically requires only 1 applicator device for glue or tacks.

Technology costs

All costs exclude VAT.

Histoacryl LapFix

Histoacryl LapFix is available as:

  • a single set, which includes a cannula, a syringe, and two 0.5 ml ampoules of Histoacryl glue and costs £134.34

  • a box of 5, which includes 5 cannulas, 5 syringes and 5 ampoules of 0.5 ml Histoacryl glue and costs £482.42.

Extra glue is available separately as a box of 5 ampoules at £59.59 or a box of 10 at £110.13.

LiquiBand Fix8

LiquiBand Fix8 is supplied in boxes of 6. The version for laparoscopic procedures costs £1,199.94 and the version for open procedures costs £390.

Both are pre-assembled and terminally sterilised and do not require any additional consumable products.

A single laparoscopic Fix8 device contains 1.5 ml adhesive, enough for at least 40 applications of 12.5 mg adhesive each. The minimum number of 12.5 mg applications for the LiquiBand Fix8 open device is 45.

Glubran2

Glubran2 adhesive is available in boxes of 10, with glue volumes of either 0.5 ml at a total cost of £900 or 1.0 ml at a total cost of £1,200.

The Glutack applicator (for either laparoscopic or open procedures) is available separately at a cost of £110 each.

Costs of standard care

There is no consensus about standard mesh fixation methods in the NHS. There is no fixation cost when no fixation method is used.

  • Tacking devices (complete with tacks) were estimated to cost approximately £206 (ranging from £160 to £241) by clinical experts; and £1,400 to £2,190 by 1 of the cyanoacrylate glue companies.

  • One expert suggested costs for fibrin glue of approximately £150 to £300 per procedure.

  • One of the companies reported that a box of 12 sutures costs around £60 to £90; a clinical expert estimated between £23 and £92.

  • Cost estimates for stapling devices were less clear but costs of £145 or £312 were proposed by 1 of the experts.

Resource consequences

Cyanoacrylate glue is currently used in the NHS as 1 of the options for hernia mesh fixation. There are unlikely to be significant resource consequences of adopting the technology. No changes in facilities or infrastructure are needed. Minimal training is necessary.

There may be implications for resource use if chronic pain management is not needed (because glue causes less trauma to tissues than mechanical fixation methods), if length of hospital stay is reduced, or if recurrence is avoided.