Glue versus tackers for mesh fixation in laparoscopic inguinal hernia repair: a meta-analysis and trial sequential analysis

Open Access
01.12.2025
Original Article

Erschienen in:

Verfasst von: Samuel Kitching; Agastya Patel; Jacob Tan; Jacob Kadamapuzah; Thomas Satyadas
Erschienen in: Hernia | Ausgabe 1/2025

Abstract

Purpose

Mesh fixation in laparoscopic inguinal hernia repair has improved patient outcomes compared to natural tissue repair. The method of fixation of the mesh to the abdominal wall and its impact on patient outcomes has not been determined as part of a trial sequential analysis. The aim of this study is to compare the use of glue and tackers in mesh fixation of inguinal and femoral hernia repair by meta-analysis and trial sequential analysis (TSA).

Method

Medline, Cochrane Library, Scopus, Web of Science, and EMBASE were searched to retrieve relevant randomised controlled trials (RCT) comparing glue and tacker fixation in laparoscopic inguinal and femoral hernia repair, resulting in 648 studies, of which 18 met the inclusion criteria. This data was systematically analysed using RevMan and TSA software.

Results

2312 patients were included in the 18 RCTs used in this study, with 1149 in the glue cohort and 1163 in the tacker cohort. Glue fixation significantly reduced risk of haematoma formation [MD (95% CI): 0.35 (0.17–0.73), P < 0.01]. Glue fixation resulted in significantly less acute pain [MD (95% CI): − 1.80 (− 2.71 to − 0.89), P < 0.01] and chronic pain [MD (95% CI): 0.42 (0.27–0.64), P < 0.01]. Glue fixation also allowed significantly quicker return to normal activity/work compared to tacker fixation [MD (95% CI): − 1.92 (− 3.17 to − 0.67), P < 0.01]. TSA confirmed that glue fixation significantly reduced early pain scores (< 3 months) and haematoma incidence compared to tacker fixation.

Conclusion

Mesh fixation with glue is superior to tackers in reducing post-operative pain and haematomas, which means patients return to work/activity significantly faster. Surgeons should be aware of these benefits when consenting the patient for laparoscopic inguinal and femoral hernia repair.

Hinweise

Samuel Kitching and Agastya Patel equally contributed to the work.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Introduction

In laparoscopic inguinal hernia repair, glue or tackers are being used for the fixation of the mesh [1]. It is widely accepted that the laparoscopic approach to inguinal hernia repair provides better outcomes in terms of chronic pain compared to open hernia repair. [2, 3]. However, 5–6% of patients continue to experience chronic post-operative pain after inguinal hernia repair, but the effect of different fixation methods (glue versus tackers) on surgical outcomes is debated [4].

Fibrin glue was initially used in 1998 and is being increasingly used as a non-invasive approach, thought to increase wound healing via biodegradability, haemostatic properties and flexibility in the adhesive [5], distributing stress across the surface of the tissue compared to tackers which insert into the tissue in which they are placed. In addition, the application of fibrin glue avoids risk to neurovascular supply to the surrounding tissue in opposition to tackers.

Fixation of mesh is associated with postoperative pain caused by irritation of the surrounding nerves, bone and peritoneum [6], the difference in pain between fixation with glue or tackers has been explored in the literature by randomised control trial but no trial sequential analysis has been completed on all post-operative outcomes [7‐20]. This study aims to perform a trial-sequential analysis of randomised controlled trials comparing postoperative outcomes following glue versus tacker mesh fixation.

Methods

This study was designed according to an agreed protocol, which complied with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards [21]. The protocol for the study detailing the research question, search strategy, criteria for inclusion and risk of bias assessment was established a priori.

Eligibility criteria

Randomised controlled trials (RCTs), including patients undergoing laparoscopic inguinal hernia repair with glue and tacker mesh fixation, were considered eligible for inclusion. The intervention of interest was mesh fixation with glue. The comparison of interest was mesh fixation with tackers. The primary outcomes were acute and chronic postoperative pain and recurrence. Secondary outcomes were rates of postoperative complications (seroma, hematoma, surgical site infection), operative time, return to work/activity, and length of hospital stay.

Search strategy and selection process

A comprehensive literature search of Embase, MEDLINE, Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases was performed from inception to April 2024 to identify full-text articles related to the research question. The following search strategy, without any filters, was utilised: ("laparoscopic" OR "transabdominal preperitoneal repair" OR "TAPP" OR "total extraperitoneal repair" OR "TEP" OR "hernioplasty" OR "mesh fixation") AND ("glue" OR "fibrin" OR "tissue adhesive") AND ("staple*" OR "tack*"). The PRISMA flowchart describing the results of the search and screening process is provided in Fig. 1. The initial search process provided 677 articles, which were screened based on titles and abstracts by two independent authors (SK, AP). Additionally, five articles were identified via backward citation searching of the included studies. The full text of 50 eligible articles was reviewed against pre-specified inclusion criteria for the meta-analysis. Any disagreements between the reviewers were resolved through discussion to consensus (Table 1).

Fig. 1

PRISMA flowchart

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Table 1

Baseline patient characteristics, surgical intervention and intraoperative details of included studies

Author	Grouping	N patients	Male%	Age (years)	Hernia size	Laparoscopic technique	Operative time	Surgeons
Issa et al. 2021	Glue	46	96	48.5 (± 14.0)	NR	TEP	NR	13
Issa et al. 2021	Tackers	54	96	57.9 (± 15.2)	NR	TEP	NR	16
Lovisetto et al. 2007	Glue	99	89	52.9 (± 14.6)	NR	NR	53.6 (± 7.6)	4
Lovisetto et al. 2007	Tackers	98	87	53.2 (± 12.6)	NR	NR	39.6 (± 7.6)	4
Tolver et al. 2013	Glue	50	100	NR	NR	TAPP	39.3 (± 38.2)	2
Tolver et al. 2013	Tackers	50	100	NR	NR	TAPP	51.3 (± 78.6)	2
Brügger et al. 2003	Glue	40	100	NR	NR	TAPP	105.0 (± 103.8)	NR
Brügger et al. 2003	Tackers	40	98	NR	NR	TAPP	106.7 (± 96.1)	NR
Ambore et al. 2017	Glue	30	NR	NR	2.8 (± 1.0)	NR	NR	> 1
Ambore et al. 2017	Tackers	30	NR	NR	3.2 (± 0.7)	NR	NR	> 1
Nizam et al. 2021	Glue	30	90	NR	NR	TEP	90.1 (± 5.6)	> 1
Nizam et al. 2021	Tackers	30	90	NR	NR	TEP	88.3 (± 5.1)	> 1
Fortelny et al. 2012	Glue	44	100	45.5 (± 11.3)	NR	TAPP	70.0 (± 19.0)	1
Fortelny et al. 2012	Tackers	45	100	45.0 (± 14.0)	NR	TAPP	69.0 (± 23.0)	1
Lau et al. 2005	Glue	46	98	NR	NR	TEP	75.2 (± 18)	> 1
Lau et al. 2005	Tackers	47	100	NR	NR	TEP	76.7 (± 19.1)	> 1
Bunkar et al. 2021	Glue	30	NR	49.6 (± 16.9)	NR	TEP	NR	1
Bunkar et al. 2021	Tackers	30	NR	48.8 (± 13.2)	NR	TEP	NR	1
Melissa et al. 2014	Glue	64	NR	52.8 (± 10.3)	1.6 (± 0.6)	TEP	75.8 (± 19.0)	2
Melissa et al. 2014	Tackers	65	NR	53.3 (± 11.8)	1.5 (± 0.6)	TEP	73 (± 21.3)	2
Boldo et al. 2008	Glue	22	NR	NR	NR	TAPP	NR	1
Boldo et al. 2008	Tackers	20	NR	NR	NR	TAPP	NR	1
Olmi et al. 2007	Glue	150	98	NR	NR	TAPP	53.3 (± 29.9)	2
Olmi et al. 2007	Tackers	150	97	NR	NR	TAPP	51.7 (± 33.7)	2
Chandra et al. 2015	Glue	50	76	40.6 (± 8.4)	3.0 (± 0.7)	TEP	50.3 (± 4.1)	> 1
Chandra et al. 2015	Tackers	50	70	41.7 (± 8.5)	3.2 (± 0.8)	TEP	54.9 (± 5.8)	> 2
Azevedo et al. 2022	Glue	21	100	NR	NR	TAPP	NR	> 1
Azevedo et al. 2022	Tackers	21	100	NR	NR	TAPP	NR	> 1
Habeeb et al. 2020	Glue	266	97	NR	NR	TAPP	NR	> 1
Habeeb et al. 2020	Tackers	266	95	NR	NR	TAPP	NR	> 1
Manish et al. 2023	Glue	27	19	NR	NR	TAPP	71.0 (± 3.2)	1
Manish et al. 2023	Tackers	27	22	NR	NR	TAPP	70.0 (± 3.0)	1
Liew et al. 2017	Glue	32	NR	52.2 (± 19.0)	NR	TEP	70.0 (± 24.0)	4
Liew et al. 2017	Tackers	34	NR	57.0 (± 17.0)	NR	TEP	65.0 (± 15.0)	4
Jeroukhimov et al. 2023	Glue	102	94	54.5 (± 16.3)	NR	TEP	NR	5
Jeroukhimov et al. 2023	Tackers	106	93	54.5 (± 16.0)	NR	TEP	NR	5

NR not reported or in the correct format, TEP total extraperitoneal repair, TAPP transabdominal peritoneal repair

A structured data collection form was used by two independent reviewers (SK, AP) to extract data from included studies. Data were retrieved regarding baseline study and patient characteristics, surgical and repair technique (Glue or Tackers), intraoperative outcomes, and postoperative outcomes (Table 2).

Table 2

Data on postoperative outcomes from the included studies

Author		VAS < 3 months	VAS > 3 months	Surgical site infection	Seroma	Haematoma	Recurrence	Return to work/activity	Stay in hospital	Chronic pain
Issa et al. 2021	Glue	3.6 (± 3.2)	0.8 (± 1.9)	NR	0	4	0	NR	NR	1
Issa et al. 2021	Tackers	4.1 (± 3.0)	0.6 (± 1.7)	NR	0	4	0	NR	NR	0
Lovisetto et al. 2007	Glue	19.3 (± 5.3)	NR	0	0	3	1	7.9 (± 1.3)	NR	1
Lovisetto et al. 2007	Tackers	26.0 (± 5.3)	NR	0	0	3	0	9.1 (± 2.0)	NR	5
Tolver et al. 2013	Glue	34.3 (± 61.1)	NR	NR	NR	NR	2	NR	NR	NR
Tolver et al. 2013	Tackers	45.7 (± 74.8)	NR	NR	NR	NR	0	NR	NR	NR
Brügger et al. 2003	Glue	4.7 (± 3.1)	5.3 (± 3.1)	0	0	3	2	19.7 (± 23.1)	5.3 (± 5.4)	NR
Brügger et al. 2003	Tackers	5.3 (± 3.8)	5.3 (± 3.8)	0	0	3	1	28.0 (± 37.7)	5.3 (± 5.4)	NR
Ambore et al. 2017	Glue	1.0 (± 0.5)	0	NR	0	0	0	1.0 (± 0.6)	2.0 (± 1.6)	NR
Ambore et al. 2017	Tackers	2.2 (± 1.4)	0	NR	1	0	0	3.0 (± 0.6)	3.0 (± 1.6)	NR
Nizam et al. 2021	Glue	4.7 (± 1.4)	1.5 (± 1.2)	NR	3	0	0	NR	49.3 (± 4.6)	NR
Nizam et al. 2021	Tackers	7.5 (± 1.5)	3.3 (± 1.8)	NR	10	0	0	NR	57.1 (± 6.0)	NR
Fortelny et al. 2012	Glue	2.1 (± 3.8)	2.3 (± 4.6)	NR	NR	NR	1	NR	4.5 (± 0.8)	NR
Fortelny et al. 2012	Tackers	2.1 (± 3.8)	1.5 (± 2.7)	NR	NR	NR	1	NR	4.2 (± 0.9)	NR
Lau et al. 2005	Glue	3.7 (± 2.3)	NR	0	16	0	0	3.3 (± 2.3)	1.0 (± 0.0)	5
Lau et al. 2005	Tackers	3.7 (± 2.3)	NR	0	5	0	0	3.0 (± 1.5)	1.3 (± 0.8)	8
Bunkar et al. 2021	Glue	1.9 (± 1.1)	0	1	1	0	0	NR	NR	0
Bunkar et al. 2021	Tackers	2.5 (± 1.6)	0.1 (± 0.5)	0	1	0	0	NR	NR	1
Melissa et al. 2014	Glue	NR	NR	5	11	0	0	NR	NR	3
Melissa et al. 2014	Tackers	NR	NR	2	7	0	0	NR	NR	1
Boldo et al. 2008	Glue	1.6 (± 2.4)	NR	NR	9	0	3	NR	NR	NR
Boldo et al. 2008	Tackers	5.0 (± 2.8)	NR	NR	8	0	2	NR	NR	NR
Olmi et al. 2007	Glue	NR	NR	NR	5	0	0	5.3 (± 3.7)	1.7 (± 1.5)	0
Olmi et al. 2007	Tackers	NR	NR	NR	12	0	0	11.3 (± 11.2)	1.7 (± 1.5)	3
Chandra et al. 2015	Glue	2.3 (± 1.0)	5.4 (± 1.6)	NR	10	0	0	NR	2.1 (± 0.4)	NR
Chandra et al. 2015	Tackers	5.8 (± 1.4)	2.1 (± 0.6)	NR	31	0	4	NR	2.4 (± 0.6)	NR
Azevedo et al. 2022	Glue	0	0	NR	1	NR	0	NR	NR	0
Azevedo et al. 2022	Tackers	0	0	NR	2	NR	0	NR	NR	0
Habeeb et al. 2020	Glue	NR	NR	0	NR	NR	2	NR	NR	19
Habeeb et al. 2020	Tackers	NR	NR	1	NR	NR	1	NR	NR	53
Manish et al. 2023	Glue	1.5 (± 0.5)	0	NR	1	0	NR	NR	NR	0
Manish et al. 2023	Tackers	2.2 (± 0.7)	0	NR	1	4	NR	NR	NR	0
Liew et al. 2017	Glue	NR	NR	NR	7	1	0	NR	NR	2
Liew et al. 2017	Tackers	NR	NR	NR	8	0	0	NR	NR	0
Jeroukhimov et al. 2023	Glue	NR	NR	NR	NR	0	1	NR	NR	NR
Jeroukhimov et al. 2023	Tackers	NR	NR	NR	NR	1	9	NR	NR	NR

NR not reported or in the correct format, VAS visual analogue score

Risk of bias assessment

The Cochrane Risk of Bias 2.0 (RoB 2.0) Tool was used to assess the risk of bias within included RCT studies. Two authors (SK, AP) carried out the risk of bias assessment independently, with any disagreements resolved by consensus.

Statistical analysis

Pooled summary estimates for continuous variables were performed using mean difference (MD) and for categorical variables using odds ratio (OR) with respective 95% confidence interval (CI). All statistical analyses were modelled based on a 95% confidence level to demonstrate statistical significance. If studies reported continuous variables as median (interquartile range), Wang et al.’s method was utilised for conversion into estimated mean ± standard deviation and used in the statistical analysis [22]. Heterogeneity between studies was measured using the I² statistic, with I² > 50% considered to indicate significant statistical heterogeneity. Summary estimates were produced using a random-effects model (in case of significant heterogeneity) or a fixed-effects model. Forest plots were generated for visual representation of analysed outcomes to assess publication bias. The Review Manager (RevMan, version 5.0. Copenhagen, 2014) software was used for data synthesis.

Trial sequential analysis (TSA) software (0.9.5.5 Beta, Copenhagen Trial Unit, Denmark) was used to perform trial sequential analysis. TSA of data from randomised controlled trials was conducted when an outcome was reported by at least two randomised trials. To assess the likelihood of type 1 error, the O’Brien-Fleming α-spending function was used to adjust the thresholds for the Z-values. Furthermore, the Z values were penalised using the iterated logarithm law. To assess the likelihood of type 2 error, the β-spending function and futility boundaries were used. Random effects models were used for TSA, and constant continuity correction was used to deal with the no-event RCTs.

Results

In total, 18 RCTs were eligible for inclusion in the meta-analysis (Fig. 1). Overall, 2312 patients were included in this study, of whom 1149 underwent glue fixation and 1163 underwent tacker fixation. Figure 2 highlights the outcomes of the methodological quality assessment based on the Cochrane tool.

Fig. 2

Risk of bias assessment

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Both groups included participants with a hernia of less than 5 cm, with a mean size of 2.46 cm and 2.63 cm for Glue and Tacker groups, respectively. The included studies only treated inguinal hernias, with three studies treating femoral hernias in addition. Eight studies performed totally extraperitoneal repair (TEP) [7, 13, 14, 18, 19, 23‐25], eight studies did transabdominal pre-peritoneal repair (TAPP) [9, 10, 12, 16, 17, 26‐28], and two studies did not describe the technique used [8, 11]. Four studies used data from a single surgeon [12, 14, 16, 27], 13 studies reported data from more than one surgeon [7, 8, 11, 13, 17‐19, 23‐26, 28, 29], and one did not report the number of surgeons involved in the study [10].

Intraoperative outcomes

The only intraoperative outcome included in the trial sequential analysis was operative time, with 11 studies reporting operative time with an average operative time of 68.52 ± 24.76 min and 67.90 ± 28.03 min for the glue and tacker cohort, respectively (n = 1268) [8‐10, 12, 13, 15, 17‐19, 25, 27]. The utilization of glue compared to tacker fixation showed no significant difference in operative time [MD (95% CI): 1.90 (− 3.06 to 6.85), P = 0.45, I² = 94%] (Fig. 3a).

Fig. 3

Forest plot of operative time (a), haematoma (b), VAS pain after < 3 months (c), recurrence (d), return to work/activity (e) and seroma (f)

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The information size for operative time was calculated at 15,589 patients. The information size was not reached for this outcome, and the Z-curve did not cross the conventional, alpha-spending, and futility boundaries; therefore, the meta-analysis was inconclusive, and the risk of type 2 error cannot be excluded ****(Fig. 4a, Fig. 5a).

Fig. 4

Forest plot of surgical site infection (a), VAS pain after > 3 months (b), chronic pain (c), stay in hospital (d)

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Fig. 5

Trial sequential analysis of operative time (a), haematoma (b), VAS pain after < 3 months (c), recurrence (d)

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Postoperative outcomes

Early pain VAS (< 3 months)

Twelve studies reported on postoperative pain VAS scores at < 3 months (n = 1035) [7‐14, 16, 18, 19, 27]. Patients who underwent glue fixation reported significantly lower VAS scores before 3 months compared to tacker fixation group [MD (95% CI): − 1.80 (− 2.71 to − 0.89), P < 0.01, I² = 94%] (Fig. 3c).

The information size for VAS less than three months postoperatively was calculated at 583 patients. The Z-curve crossed the conventional boundaries in favour of the glue technique after the information size was reached and the penalised Z value remained greater than 1.96; therefore, the meta-analysis was conclusive, and the risk of type 1 error was minimal (Fig. 5c).

Length of hospital stay

Seven studies reported data on length of hospital stay (n = 782) [10‐13, 17‐19]. There was no significant difference between groups [MD (95% CI): − 0.17 (− 0.42 to 0.08), P = 0.18, I² = 65%] (Fig. 4d).

The information size for the length of hospital stay postoperatively was calculated at 4540 patients. The information size was not reached for this outcome, and the Z-curve did not cross the conventional, alpha-spending, and futility boundaries; therefore, the meta-analysis was inconclusive, and the risk of type 2 error cannot be excluded (Fig. 6b).

Fig. 6

Trial sequential analysis of chronic pain (a) and hospital stay (b)

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Return to work/activity

Five studies provided information on a return to work/activity (n = 730) [10‐12, 14, 19]. The glue fixation cohort had a significantly shorter time to return to work/activity compared to tacker fixation cohort [MD (95% CI): − 1.92 (− 3.17 to − 0.67), P < 0.01, I² = 93%] (Fig. 3e).

The information size for return to work/activity postoperatively was calculated at 870 patients. The Z-curve crossed the conventional boundaries in favour of the glue technique before the information size was reached, and the penalised Z value remained less than 1.96; therefore, the meta-analysis was inconclusive, and the risk of type 1 error cannot be excluded (Fig. 7a).

Fig. 7

Trial sequential analysis of return to work/activity (a), seroma (b), surgical site infection (c), VAS pain > 3 months (d)

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Chronic pain VAS (> 3 months post operation)

Seven studies provided data on VAS pain scores > 3 months post-operation (n = 549) [7, 10‐12, 14, 18, 19]. There was no significant difference between groups [MD (95% CI): 0.70 (− 0.87 to 2.28), P = 0.38, I² = 98%] (Fig. 4b).

The information size for chronic pain VAS (> 3 months) postoperatively could not be calculated. The Z-curve did not cross the conventional, alpha-spending, and futility boundaries; therefore, the meta-analysis was inconclusive, and the risk of type 2 error cannot be excluded (Fig. 7d).

Chronic pain incidence

Ten studies reported data regarding post-operative chronic pain (n = 1573) [7, 8, 13‐15, 17, 25‐28]. The glue cohort had a significantly lower incidence of chronic pain compared to the tacker cohort [MD (95% CI): 0.42 (0.27–0.64), P < 0.01, I² = 28%] (Fig. 4c).

The information size for chronic pain incidence postoperatively was calculated at 4856 patients, which was not reached. The Z-curve crossed the conventional boundaries in favour of the glue technique before the information size was reached, and the penalised Z value remained greater than 1.96; therefore, the risk of type 1 error cannot be excluded (Fig. 6a).

Haematoma

Twelve studies provided data on postoperative haematoma (n = 1272) [7, 11, 13‐19, 24, 25, 27]. Glue fixation was found to significantly reduce postoperative haematoma in comparison to tacker fixation [MD (95% CI): 0.35 (0.17–0.73), P < 0.01, I² = 27%] (Fig. 3b).

The information size for haematoma was calculated at 828 patients. The Z-curve crossed the conventional boundaries in favour of the glue technique after the information size was reached and the penalised Z value remained greater than 1.96; therefore, the meta-analysis was conclusive, and the risk of type 1 error was minimal (Fig. 5b).

Seroma

Twelve studies reported on the incidence of postoperative seroma (n = 1106) [7, 11, 13‐19, 25‐27]. There was no significant difference between the two groups in terms of seroma incidence [MD (95% CI): 0.72 (0.33–1.57), P = 0.41, I² = 66%] (Fig. 3f).

The information size for seroma postoperatively was calculated at 7857 patients. The information size was not reached for this outcome, and the Z-curve did not cross the conventional, alpha-spending, and futility boundaries; therefore, the meta-analysis was inconclusive, and the risk of type 2 error cannot be excluded (Fig. 7b).

Surgical site infection

Six studies reported surgical site infection incidence (n = 1091) [8, 10, 13‐15, 28]. There was no significant difference between groups [MD (95% CI): 1.80 (0.52–6.27), P = 0.35, I² = 0%] (Fig. 4a).

The information size for surgical site infection postoperatively was calculated at 1994 patients. The information size was not reached for this outcome, and the Z-curve did not cross the conventional, alpha-spending, and futility boundaries; therefore, the meta-analysis was inconclusive, and the risk of type 2 error cannot be excluded (Fig. 7c).

Hernia recurrence

Seventeen studies provided data on hernia recurrence (n = 2258) [7‐19, 24‐26, 28]. The incidence of hernia recurrence was similar between the glue and tacker fixation cohorts [MD (95%): 0.68 (0.34–1.38), P = 0.29, I² = 25%] (Fig. 3d).

The information size for hernia recurrence postoperatively was calculated at 3146 patients, which was not reached. The Z-curve did not cross the conventional, alpha-spending, and futility boundaries; therefore, the meta-analysis was inconclusive, and the risk of type 2 error cannot be excluded (Fig. 5d).

Discussion

This trial sequential analysis (TSA) compares the effectiveness of glue versus tacker mesh fixation during laparoscopic repair of inguinal hernias. This TSA shows that glue fixation reduces early pain scores, and haematoma incidence compared to tacker fixation. The required sample sizes for the TSA of early pain scores and haematoma were reached suggesting that the use of glue provides superior outcomes to tackers in laparoscopic inguinal hernia repair. Tacker use may complicate mesh fixation due to compression of tissue, damaging surrounding lymphatics and vasculature, resulting in post-operative complications such as seroma and haematoma [30, 31]. Fibrin glue applies equivalent adhesive force across the surface of the tissue which may explain the reduction in haematoma formation and early pain.

Interpretation of meta-analyses can result in false positive and negative findings. Trial sequential analysis provides a means of determining significance based on multiple tests, better controlling type I and II errors than traditional meta-analysis. TSA analysis calculates the required number of randomised participants to detect or reject a specific assumed effect. The required information size is defined as the number of participants and events necessary to detect or reject an intervention effect in a meta-analysis. The plotted result of a TSA meta-analysis is displayed on a TSA diagram with four outcome zones including “benefit” and “harm” areas which show statistical significance, and the “not significantly affected” area. The data plotted within the inner wedge area suggests there is strong evidence that further studies will not change the no-effect results [32, 33].

The meta-analysis of 11 randomised controlled trials in this study found no significant difference in operative time between glue and tackers, which is in concordance with the literature [34, 35]. Given cost is a driving factor influencing the use of glue versus tackers, it is interesting Lovisetto et al. found, based on 1 ml of glue usage, that tackers were 70% more expensive; considerable cost savings would be gained from reduced post-operative pain and complications with the use of glue [8].

The recurrence rate for inguinal hernias varies depending on location and type of repair, with 12.3% recurrence over 10 years for open repair [36]. Laparoscopic hernia repair significantly reduces the risk of recurrence compared to open repair (P < 0.01), with a rate at two years of 3.8% [37], to 6.3% over four years [1, 38]. The recurrence rate in this study was 2.0% and 1.8% for glue and tackers respectively, at two years. We have importantly shown that there is no difference in risk of recurrence with glue and tackers, as this would negate any benefit found regarding recovery. Previous meta-analyses have shown similarly that there is no difference in recurrence rate when comparing glue and tackers [34, 39].

The limitations of this study include the lack of detail regarding the method of randomisation in five studies, increasing the potential risk of bias in patient selection. In addition, six studies used alternative pain scales to VAS scores or provided time points not consistent with this study's collection of less than three months and greater than three months, which increases the heterogeneity of results. Chronic pain incidence was defined differently between studies and was followed up over different time frames making the comparison less accurate. TSA of return to activity and chronic pain incidence found the cumulative z-line crossed the boundary for effect but did not reach the required sample size. This indicates that although mesh fixation with glue significantly reduces the return to activity time and chronic pain incidence, further studies are required to obtain definitive evidence on the benefit of glue in these aspects. No significant difference was found in seroma formation due to the sample size for seroma not reaching the minimum threshold. Studies did not consistently report size of hernia and the type, size and weight of mesh used which may contribute to post-operative pain.

In conclusion, the trial-sequential analysis showed that glue fixation reduced early pain scores and haematoma formation; the remaining tested variables did not meet the required minimum information size for TSA with further randomised control trial evidence needed. The meta-analysis of these variables showed that glue fixation may reduce the time for a patient to return to normal activity, with less pain and reduced complications.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Not required.

Human and animal rights

This article does not contain any studies with human participants or animals performed by any of the authors.

For this type of study formal consent is not required.

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Metadaten
Literatur

Titel: Glue versus tackers for mesh fixation in laparoscopic inguinal hernia repair: a meta-analysis and trial sequential analysis
Verfasst von: Samuel Kitching
Agastya Patel
Jacob Tan
Jacob Kadamapuzah
Thomas Satyadas
Publikationsdatum: 01.12.2025
Verlag: Springer Paris
Erschienen in: Hernia / Ausgabe 1/2025
Print ISSN: 1265-4906
Elektronische ISSN: 1248-9204
DOI: https://doi.org/10.1007/s10029-025-03315-w

Collaboration EHT (2002) Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials. Ann Surg 235:322–332. https://doi.org/10.1097/00000658-200203000-00003CrossRef

Lundström K-J, Holmberg H, Montgomery A, Nordin P (2018) Patient-reported rates of chronic pain and recurrence after groin hernia repair. Br J Surg 105:106–112. https://doi.org/10.1002/bjs.10652CrossRefPubMed

Kumar S, Wilson RG, Nixon SJ, Macintyre IMC (2002) Chronic pain after laparoscopic and open mesh repair of groin hernia. BJS (Br J Surg) 89:1476–1479. https://doi.org/10.1046/j.1365-2168.2002.02260.xCrossRefPubMed

Öberg S, Andresen K, Rosenberg J (2018) Decreasing prevalence of chronic pain after laparoscopic groin hernia repair: a nationwide cross-sectional questionnaire study. Surg Today 48:796–803. https://doi.org/10.1007/s00595-018-1664-5CrossRefPubMed

Jourdan IC, Bailey ME (1998) Initial experience with the use of N-butyl 2-cyanoacrylate glue for the fixation of polypropylene mesh in laparoscopic hernia repair. Surg Laparosc Endosc 8:291–293PubMed

Novik B, Hagedorn S, Mork UB et al (2006) Fibrin glue for securing the mesh in laparoscopic totally extraperitoneal inguinal hernia repair. Surg Endosc Other Interv Tech 20:462–467. https://doi.org/10.1007/s00464-005-0391-3CrossRef

Issa M, Tacey M, Geraghty J et al (2021) Cyanoacrylate glue versus absorbable tacks in mesh fixation for laparoscopic extraperitoneal inguinal hernia repair: a randomized controlled trial. Surg Laparosc Endosc Percutan Tech 31:291–297. https://doi.org/10.1097/SLE.0000000000000915CrossRefPubMed

Lovisetto F, Zonta S, Rota E et al (2007) Use of human fibrin glue (Tissucol) versus staples for mesh fixation in laparoscopic transabdominal preperitoneal hernioplasty: a prospective, randomized study. Ann Surg 245:222–231. https://doi.org/10.1097/01.sla.0000245832.59478.c6CrossRefPubMedPubMedCentral

Tolver MA, Rosenberg J, Juul P, Bisgaard T (2013) Randomized clinical trial of fibrin glue versus tacked fixation in laparoscopic groin hernia repair. Surg Endosc 27:2727–2733. https://doi.org/10.1007/s00464-012-2766-6CrossRefPubMed

10.

Brugger L, Bloesch M, Ipaktchi R et al (2012) Objective hypoesthesia and pain after transabdominal preperitoneal hernioplasty: a prospective, randomized study comparing tissue adhesive versus spiral tacks. Surg Endosc Other Interv Tech 26:1079–1085. https://doi.org/10.1007/s00464-011-2003-8CrossRef

11.

Ambore VK, More JP, Bhandarwar AH et al (2017) Comparative study of tacker vs glue fixation of mesh in laparoscopic intraperitoneal onlay mesh repair of ventral hernias. World J Laparosc Surg 10:87–90. https://doi.org/10.5005/jp-journals-10033-1312CrossRef

12.

Fortelny RH, Petter-Puchner AH, May C et al (2012) The impact of atraumatic fibrin sealant vs. staple mesh fixation in TAPP hernia repair on chronic pain and quality of life: results of a randomized controlled study. Surg Endosc 26:249–254. https://doi.org/10.1007/s00464-011-1862-3CrossRefPubMed

13.

Lau H (2005) Fibrin sealant versus mechanical stapling for mesh fixation during endoscopic extraperitoneal inguinal hernioplasty: a randomized prospective trial. Ann Surg 242:670–675. https://doi.org/10.1097/01.sla.0000186440.02977.deCrossRefPubMedPubMedCentral

14.

Bunkar SK, Verma K, Jhunjhunwala A, Singh A (2021) A randomized controlled clinical trial of n-butyl cyanoacrylate glue fixation versus tacker fixation of mesh in endoscopic totally extraperitoneal hernia repair. Indian J Surg. https://doi.org/10.1007/s12262-021-03118-0CrossRef

15.

Melissa CS, Bun TAY, Wing CK et al (2014) Randomized double-blinded prospective trial of fibrin sealant spray versus mechanical stapling in laparoscopic total extraperitoneal hernioplasty. Ann Surg 259:432–437. https://doi.org/10.1097/SLA.0b013e3182a6c513CrossRef

16.

Boldo E, Armelles A, Perez De Lucia G, et al (2008) Pain after laparascopic bilateral hernioplasty: early results of a prospective randomized double-blind study comparing fibrin versus staples (Surgical Endoscopy https://doi.org/10.1007/s00464-007-9587-z). Surg Endosc Other Interv Tech 22:1210. https://doi.org/10.1007/s00464-008-9802-6

17.

Olmi S, Scaini A, Erba L et al (2007) Quantification of pain in laparoscopic transabdominal preperitoneal (TAPP) inguinal hernioplasty identifies marked differences between prosthesis fixation systems. Surgery 142:40–46. https://doi.org/10.1016/j.surg.2007.02.013CrossRefPubMed

18.

Chandra P, Phalgune D, Shah S (2016) Comparison of the clinical outcome and complications in laparoscopic hernia repair of inguinal hernia with mesh fixation using fibrin glue vs tacker. Indian J Surg 78:464–470. https://doi.org/10.1007/s12262-015-1410-9CrossRefPubMed

19.

Nizam S, Saxena N, Yelamanchi R et al (2021) Mesh fixation with fibrin glue versus tacker in laparoscopic totally extraperitoneal inguinal hernia repair. ANZ J Surg 91:2086–2090. https://doi.org/10.1111/ans.17165CrossRefPubMed

20.

Habib Bedwani NAR, Kelada M, Smart N et al (2021) Glue versus mechanical mesh fixation in laparoscopic inguinal hernia repair: meta-analysis and trial sequential analysis of randomized clinical trials. Br J Surg 108:14–23. https://doi.org/10.1093/bjs/znaa002CrossRefPubMed

21.

Liberati A, Altman DG, Tetzlaff J et al (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. https://doi.org/10.1136/bmj.b2700CrossRefPubMedPubMedCentral

22.

Wan X, Wang W, Liu J, Tong T (2014) Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 14:135. https://doi.org/10.1186/1471-2288-14-135CrossRefPubMedPubMedCentral

23.

Chan MS, Teoh AY, Chan KW et al (2014) Randomized double-blinded prospective trial of fibrin sealant spray versus mechanical stapling in laparoscopic total extraperitoneal hernioplasty. Ann Surg 259:432–437. https://doi.org/10.1097/SLA.0b013e3182a6c513CrossRefPubMed

24.

Jeroukhimov I, Dykman D, Hershkovitz Y et al (2023) Chronic pain following totally extra-peritoneal inguinal hernia repair: a randomized clinical trial comparing glue and absorbable tackers. Langenb Arch Surg 408:190. https://doi.org/10.1007/s00423-023-02932-2CrossRef

25.

Liew W, Wai YY, Kosai NR, Gendeh HS (2017) Tackers versus glue mesh fixation: an objective assessment of postoperative acute and chronic pain using inflammatory markers. Hernia 21:549–554. https://doi.org/10.1007/s10029-017-1611-1CrossRefPubMed

26.

Azevedo MA, Oliveira GBT, Malheiros CA, Roll S (2022) Are there differences in chronic pain after laparoscopic inguinal hernia repair using the transabdominal technique comparing with fixation of the mesh with staples, with glue or without fixation? A clinical randomized, double-blind trial. Arquivos brasileiros de cirurgia digestiva [Braz Arch Dig Surg] 35:e1670. https://doi.org/10.1590/0102-672020220002e1670CrossRefPubMed

27.

Manish R, Chitrambalam TG, Yogish V, George N, Gowsick SAA (2023) Short-term outcomes of fibrin glue versus absorbable tackers for mesh fixation in laparoscopic TAPP inguinal hernia repair: a randomised clinical trial. J Clin Diagn Res 17: P41–P44. https://doi.org/10.7860/JCDR/2023/61047.17904

28.

Habeeb TAAM, Mokhtar MM, Sieda B et al (2020) Changing the innate consensus about mesh fixation in trans-abdominal preperitoneal laparoscopic inguinal hernioplasty in adults: short and long term outcome. Randomized controlled clinical trial. Int J Surg 83:117–124. https://doi.org/10.1016/j.ijsu.2020.09.013CrossRefPubMed

29.

Tolver MA (2013) Early clinical outcomes following laparoscopic inguinal hernia repair. Dan Med J 60:B4672 No available. https://content.ugeskriftet.dk/sites/default/files/scientific_article_files/2018-11/b4672.pdf

30.

Dai X, Zheng J, Yu X et al (2024) Mechanical properties and tissue damage caused by staples in gastrointestinal anastomosis. Proc Inst Mech Eng H 238:33–44. https://doi.org/10.1177/09544119231216283CrossRefPubMed

31.

Son GM, Kwon MS, Ahn H-M et al (2020) Compression injury of the circular stapler for gastrointestinal end-to-end anastomosis: preliminary in-vitro study. Ann Surg Treat Res 99:72–81. https://doi.org/10.4174/astr.2020.99.2.72CrossRefPubMedPubMedCentral

32.

Shah A, Smith AF (2020) Trial sequential analysis: adding a new dimension to meta-analysis. Anaesthesia 75:15–20. https://doi.org/10.1111/anae.14705CrossRefPubMed

33.

Wetterslev J, Jakobsen JC, Gluud C (2017) Trial sequential analysis in systematic reviews with meta-analysis. BMC Med Res Methodol 17:39. https://doi.org/10.1186/s12874-017-0315-7CrossRefPubMedPubMedCentral

34.

Shi Z, Fan X, Zhai S et al (2017) Fibrin glue versus staple for mesh fixation in laparoscopic transabdominal preperitoneal repair of inguinal hernia: a meta-analysis and systematic review. Surg Endosc 31:527–537. https://doi.org/10.1007/s00464-016-5039-yCrossRefPubMed

35.

Kaul A, Hutfless S, Le H et al (2012) Staple versus fibrin glue fixation in laparoscopic total extraperitoneal repair of inguinal hernia: a systematic review and meta-analysis. Surg Endosc 26:1269–1278. https://doi.org/10.1007/s00464-011-2025-2CrossRefPubMed

36.

Howard R, Thumma J, Ehlers A et al (2022) Reoperation for recurrence up to 10 years after hernia repair. JAMA 327:872–874. https://doi.org/10.1001/jama.2022.0744CrossRefPubMedPubMedCentral

37.

Liem MSL, van Duyn EB, van der Graaf Y, van Vroonhoven TJMV (2003) Recurrences after conventional anterior and laparoscopic inguinal hernia repair: a randomized comparison. Ann Surg 237:136–141. https://doi.org/10.1097/00000658-200301000-00019CrossRefPubMedPubMedCentral

38.

Assakran BS, Widyan AM, Al-Lihimy AS et al (2021) Recurrent inguinal hernia post laparoscopic repair: a retrospective single-center study in Qassim Region, Saudi Arabia. Cureus 13:e13682. https://doi.org/10.7759/cureus.13682CrossRefPubMedPubMedCentral

39.

Sajid MS, Ladwa N, Kalra L et al (2013) A meta-analysis examining the use of tacker mesh fixation versus glue mesh fixation in laparoscopic inguinal hernia repair. Am J Surg 206:103–111. https://doi.org/10.1016/j.amjsurg.2012.09.003CrossRefPubMed

Springer Medizin

Abstract

Purpose

Method

Results

Conclusion

Publisher's Note

Introduction

Methods

Eligibility criteria

Search strategy and selection process

Risk of bias assessment

Statistical analysis

Results

Intraoperative outcomes

Postoperative outcomes

Early pain VAS (< 3 months)

Length of hospital stay

Return to work/activity

Chronic pain VAS (> 3 months post operation)

Chronic pain incidence

Haematoma

Seroma

Surgical site infection

Hernia recurrence

Discussion

Declarations

Conflict of interest

Ethical approval

Human and animal rights

Informed consent

Publisher's Note

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