Laparoscopic transabdominal preperitoneal (TAPP) groin hernia repair using n-butyl-2-cyanoacrylate (LiquiBandFIX8) for mesh fixation and peritoneal closure: case report about extraperitoneal hematoma

Introduction: A symptomatic inguinal hernia is a prevalent condition that typically requires surgical intervention. Various surgical approaches have been established for hernia repair, including several techniques for peritoneal closure and mesh fixation in laparoscopic surgery. N-butyl-2-cyanoacrylate, such as LiquiBandFIX8, offers a time-saving alternative to invasive methods for both mesh fixation and peritoneal closure. While n-butyl-2-cyanoacrylate is employed in various closure procedures, LiquiBandFIX8 is specifically designed for mesh fixation in inguinal hernia repair. Case presentation: We present a case of a 68-year old man undergoing transabdominal preperitoneal inguinal hernia repair under full heparinization. LiquiBandFIX8 was employed for mesh fixation and peritoneal closure. Upon conducting a revision laparoscopy due to a significant postoperative hematoma, we found that the mesh and peritoneum remained undamaged and fully sealed, indicating an effective fixing technique. Both the initial repair and the subsequent revision surgery were documented and the videos were subsequently analyzed. Conclusion: LiquiBandFIX8 provides a reliable adhesive strength and appropriate application for peritoneal closure and mesh fixation. When encountering extraperitoneal fluid collection, there is no anticipation of intraabdominal complications.


Introduction
With a lifetime prevalence ranging from 27 to 43% in males and 3 to 6% in females, groin hernias and their surgical repair are among the most common medical conditions, with over 20 million procedures performed globally [1] .Virtually all hernias cause symptoms and surgery is the only definitive remedy [2] .The 2018 guidelines recommend mesh fixation as the primary choice during laparoscopic transperitoneal procedures [3] .Using fibrin sealant for mesh fixation has been associated with a reduction in postoperative complications and a shorter procedure duration compared to staples [4] .Subsequently, the peritoneum is typically closed using running sutures [5] .
The aim of this case report is to demonstrate that the adhesive technique for mesh fixation and peritoneal closure using n-butylcyanoacrylate (LiquiBandFIX8, Advanced Medical Solutions Limited, Western Wood Way, Langage Science Park, Plymouth, Devon PL7 5BG, UK) can also be safely employed as an adequate alternative expanding its application beyond sutures or tacks.To our knowledge there is no other trial reporting results of adhesive strength following hematoma in the surgical field.This case has been reported in line with the SCARE (Surgical CAse REport) criteria [6] .

Case presentation
Our male patient (68 years) with symptomatic inguinal hernia underwent bilateral transabdominal preperitoneal inguinal hernia repair (TAPP), full heparinized due to aortic replacement and heart valve.Mesh fixation and peritoneal closure were done using n-butyl-cyanoacrylate.The bilateral TAPP procedure was

HIGHLIGHTS
• Cyanoacrylate glue is an easy tool for peritoneal closure, which does not require high expertise.• LiquiBandFIX8 can be used for mesh fixation and peritoneal closure.• A closed peritoneum after laparoscopic transabdominal preperitoneal inguinal hernia repair can withstand high pressure.
performed by an experienced laparoscopic surgeon.By using a TiO 2 Bilateral Mesh 30 × 11 cm (Advanced Medical Solutions Limited) fixated with n-butyl-2-cyanoacrylate (LiquiBandFIX8), a bilateral correction of the hernias was accomplished.The mesh was punctually fixated with LiquiBandFIX8.Subsequently, it was also used for closing the peritoneum (Fig. 1).Beside all three trocar sites, they were injected with local anesthetics.
To ensure quality control, all surgeries performed at the Kepler University Surgical Department are meticulously recorded, and critical stages of the procedure are documented through photographs.Two days after the surgery, the patient presented with supra-symphyseal swelling, along with pain and a drop in hemoglobin levels.A computed tomography (CT) scan subsequently confirmed the presence of a sizable hematoma measuring 8 × 12 × 13 cm, extending up to the umbilicus, as depicted in Figure 2.
Therefore, we opted to conduct a laparoscopic revision, focusing on evacuating the hematoma and achieving hemostasis.During this revision laparoscopy, it was remarkably evident that, despite containing an extraperitoneal hematoma measuring 700 ml, the peritoneum maintained its integrity and withstood the substantial pressure, as depicted in Figure 3. Upon reopening the peritoneum and removing the hematoma, the mesh remained unharmed and perfectly positioned.Although a specific bleeding source was not identified, it was attributed to diffuse bleeding stemming from full heparinization.Subsequently, the patient experienced an uneventful recovery and was discharged with bilateral groin hernia repair after 5 days.During a follow-up clinical examination one year later, the patient remained entirely asymptomatic, with no indications of hernia recurrence.

Discussion
In summary, the peritoneal closure resisted the pressure of the 8 × 12 × 13 cm postoperative hematoma and was undamaged.No specific bleeding source could be identified.Therefore, it is highly probable that the bleeding was diffuse and attributed to full heparinization.The revisional surgery was filmed and affirmed the integrity of the glue seam despite the pressure of the hematoma.As a 5 mm nonpenetrating laparoscopic fixation tool, it is scheduled as an internal application of cyanoacrylate adhesive (0.0125 g per trigger = 33 triggers) during laparoscopic procedures for attaching hernia meshes [7] .The recommended approach involved exclusively applying the adhesive around the defect and along the mesh's edges.N-butyl-2-cyanoacrylate is the preferred substance for mesh fixation in view of stability and adhesive strength compared to fibrin glue, tolerating a higher abdominal pressure [8] .N-butyl-2-cyanoacrylate is employed in various closure techniques including cutaneous closure, managing bleeding, or addressing corneal perforations [9][10][11] .Peritoneal closure, in particular, can be accomplished easily using LiquiBandFIX8 [7,12] .The treatment procedure of inguinal hernias can be done openly (e.g.Lichtenstein), laparoscopically [TAPP, TEP (laparoscopic totally extraperitoneal inguinal hernia repair)], with penetrating fixation of the mesh (e.g.staples), no penetrating fixation procedure (glue), or with no fixation at all [5,13] .Meshes without fixation do not  sufficiently endure pressure [8] .Regarding the recurrence of groin hernias, a great meta-analysis (n = 3966) showed no differences between open and laparoscopic surgery.Likewise, the recurrence rate is similar in terms of mesh fixation [14] .Despite that, laparoscopic repair was associated with a reduced rate of acute pain compared to open repair and also reduced odds of chronic pain [15] .The current international guidelines for groin hernia treatment recommend a mesh fixation in both surgical methods as the standard of care [3] .Postoperative chronic pain appears within 5-20% of the patients and sexual dysfunction within 9.4% as a negative effect on a patient's life [16][17][18] .The application of fibrin glue for mesh fixation reduces the risk of postoperative chronic pain [14] .The primary complications, both in the early and late stages, include hematoma, wound infections, damage to the ductus deferens or nervus ilioinguinalis, and recurrence of the hernia.The application of a mesh combined with fibrin sealant fixation has been shown to mitigate these risks [3,[19][20][21] .In a study conducted by Kukleta et al. [22] in 2012 involving 1300 TAPP operations, it was observed that the utilization of n-butyl-2cyanoacrylate and other fixation products resulted in perfect mesh integration and the absence of any infections.

Conclusion
This case report highlights LiquiBandFIX8 as an appealing and secure alternative for fixing the prosthetic mesh and closing the peritoneal defect during laparoscopic hernia repair.Additionally, this procedure is straightforward and efficient with a reduced risk of chronic pain.When used by professionals, it can withstand high pressure, demonstrating its impressive suitability for safe peritoneal closure and mesh fixation.Nevertheless, further studies are essential to validate the effectiveness of n-butyl-cyanoacrylate for both mesh fixation and peritoneal closure to establish a standardized approach.

Figure 3 .
Figure 3. Peritoneum at laparoscopic revision with sufficient glue sealant above retroperitoneal hematoma.