Use of cyanoacrylate glue for mesh fixation and peritoneal flap closure in laparoscopic transabdominal preperitoneal repair of inguinal hernia

Use of cyanoacrylate glue for mesh fixation and peritoneal flap closure in laparoscopic transabdominal preperitoneal repair of inguinal hernia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Use of cyanoacrylate glue for mesh fixation and peritoneal flap closure in laparoscopic transabdominal preperitoneal repair of inguinal hernia Peter Siaperas, Panayiotis Antoniou, Giorgos Skouroumouni This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8224771/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair has gained popularity due to its association with less postoperative pain and shorter recovery period, compared to the open traditional techniques. This study evaluated the efficacy and safety of cyanoacrylate glue in TAPP repair, mainly focusing on its effect on postoperative pain. Cyanoacrylate glue was applied both for mesh fixation and peritoneal flap closure. A total of sixty patients with unilateral inguinal hernia were enrolled and followed-up for one year. The visual analog scale (VAS) was used to assess the pain during the early and late postoperative period. The mean operative time was 58 minutes and the mean time for peritoneal flap closure was 2.15 minutes. The VAS score at the first and seventh day was 2.77 and 1.5 respectively, while after one month the score was 0. There was no case of recurrence and no major complications were reported. The findings suggest that application of cyanoacrylate glue for mesh fixation and peritoneal flap closure is a safe and effective method with promising results. This technique seems to cause less postoperative pain compared to others described in the literature. However, large-scale randomized controlled trials should be carried out to confirm these findings. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research TAPP cyanoacrylate glue mesh fixation peritoneal flap closure postoperative pain Figures Figure 1 Figure 2 Introduction Inguinal hernia refers to an abnormal protrusion of abdominal content such as omentum, small or large intestine through a defect in the lower abdominal wall. Risk factors associated with the development of inguinal hernia include age, male sex, genetic predisposition, smoking, chronic obstructive pulmonary disease and increased intra-abdominal pressure. Clinical presentations vary from being asymptomatic or feeling a burning sensation to exhibiting signs of obstruction or strangulation. Inguinal hernia is the most common cause for referral to general surgeons, considering that the definitive management requires surgical intervention [ 1 ]. Over the years, several techniques have been described for inguinal hernia repair. The two main approaches are the laparoscopic (Transabdominal Preperitoneal or Totally Extraperitoneal) and open tension-free repair. In the past, the laparoscopic techniques were controversial due to their association with increased recurrence rate. However, latest studies demonstrated that laparoscopic surgery of inguinal hernia is associated with lower chronic pain, recurrence rate, reduced hospitalization period and earlier return to daily activities [ 2 ]. Additionally, the presence of bilateral inguinal hernia or recurrence is considered an indication for laparoscopic repair. Some of the contraindications include the inability of patients to tolerate general anesthesia due to comorbidities, several intra-abdominal adhesions and inguinal hernia recurrence after laparoscopic approach [ 1 ]. In this study, laparoscopic transabdominal preperitoneal (TAPP) technique was performed for inguinal hernia repair. Over the last decade, laparoscopic inguinal hernia repair has gained popularity, therefore several modifications were applied aiming primarily to reduce post-operative pain and promote earlier mobilization. More precisely, in TAPP inguinal hernia repair some of the modifications include the type of mesh applied, the methods of mesh fixation and the closure of the peritoneum. Different ways are currently employed to fix the mesh and close the peritoneal flap including sutures, staples and cyanoacrylate or fibrin glue [ 3 – 4 ]. Some researches supported that application of staples or sutures for mesh fixation and peritoneal flap closure is associated with several complications. More specifically, the use of tacks has been correlated with increased post-operative pain and hematoma formation due to higher risk of damaging the ilio-hypogastric nerve or blood vessels respectively. Additionally, the use of staples may be associated with severe hemorrhage due to accidental injury of inferior epigastric vessels during mesh fixation [ 5 – 6 ]. Peritoneal flap closure with sutures increases also post-operative pain and the risk of peritoneal rupture, which may result in internal hernia and small bowel obstruction [ 7 ]. Several studies have been carried out to demonstrate the benefits of applying surgical glue in TAPP inguinal hernia repair. The results showed that mesh fixation and peritoneal flap closure with surgical glue reduce post-operative pain and decrease the risk of bleeding and hematoma formation. However, further studies are required to clearly demonstrate the efficacy of glue and its safety [ 5 ]. The aim of this study is to evaluate the use of cyanoacrylate glue in TAPP repair, mainly focusing on its effect on postoperative pain. Cyanoacrylate glue was applied both for mesh fixation and peritoneal flap closure. Materials and methods Study design and data collection In this study, a total of sixty patients with inguinal hernia who underwent laparoscopic TAPP inguinal repair using cyanoacrylate glue have been enrolled and followed-up for one year starting from January 2023 until the end of 2024. Patients between the ages of 18–65 years, with unilateral inguinal hernia were included in this study. Exclusion criteria are the following: inability of the patient to undertake general anesthesia (American Society of Anesthesiologist grade more than 3, chronic obstructive pulmonary disease and coronary artery disease), patients with bilateral hernia, recurrence, complicated hernias (strangulated, incarcerated or obstructed) and previous prostatectomy. A written informed consent was obtained from every patient before enrollment to the particular study. Ethical approval for this study was provided by the Scientific Council of the General Hospital of Athens “Sismanogleio”, Athens, Greece. All methods were performed in accordance with the relevant guidelines and regulations. Laparoscopic TAPP inguinal hernia repair surgeries were conducted by a single surgeon with considerable experience in laparoscopic TAPP technique, in a single center. This study mainly focuses on postoperative pain which was assessed by a Visual Analogue Scale (VAS) and a particular score was given. The scale is calibrated from 0 (no pain) to 10 (excruciating unbearable pain). However, other variables such as mean operative time, mean time for peritoneal flap closure and median hospital stay were reported. The patients were also assessed for the presence of adverse surgical outcomes. More precisely, early surgical complications, occurring during the first month post-operatively, include seroma or hematoma formation and bladder injury whereas late surgical complications, occurring after the first month, include chronic pain, hernia recurrence or trocar site hernia. The patients were followed-up for 1 year and the VAS score was assessed on the first and seventh day (early postoperative period) and on the first, sixth and twelfth month (late postoperative period). Surgical technique and Perioperative Preparation Chest X-ray, electrocardiogram and preoperative laboratory investigation including full blood count, liver and renal function tests, were all performed the day before surgery. A single dose of second generation cephalosporin was given as antibiotic prophylaxis 1-hour before the operation. The patients received general anesthesia and placed in a supine flat position. Pneumoperitoneum was established with a Veress needle at the supraumbilical area and an 11 mm trocar was placed. A 30-degree laparoscope was introduced and after inspection of the abdominal cavity, two 5 mm working trocars were placed in the following locations. The first 5 mm trocar which was ipsilateral to the hernia site was placed 1 cm above the level of the umbilicus and the contralateral 5 mm trocar was placed 1 cm under the level of the umbilicus. The peritoneal flap was then created 4 cm above the abdominal wall defect starting laterally, approximately 2 cm above the anterior superior iliac spine until the medial umbilical ligament. Careful dissection was performed medial and lateral to the inferior epigastric vessels at the Retzius space and pubic bone. Cooper ligament was also identified. The hernia sac was reduced and separated from the spermatic cord. Once dissection and hemostasis was complete, a polypropylene mesh 10.8 x 16 cm was inserted in the abdominal cavity. The mesh was placed to cover the defect and the entire inguino-femoral space. As it is demonstrated in Fig. 1 a and b, fixation was achieved using the Glutack and appliying a cyanoacrylate glue [Glubran® 2 (N-butyl cyanoacrylate metacryloxysulfolane, NBCA-MS)] at the Cooper Ligament, pubic bone and around the mesh border. Peritoneal flap closure was the performed, after reducing the intra-abdominal pressure to 8 mm Hg and applying cyanoacrylate glue Glubran® 2 (NBCA-MS) between the two peritoneal sites using the Glutack. This is demonstrated in Fig. 1 c and d. The trocars were then removed under direct vision. The patients were transferred to the ward for an overnight stay. In terms of analgesia during hospitalization patients received 1 gr paracetamol IV every 6 hours and after discharge it was further administered systematically per os for 5 days. As it was previously mentioned the VAS score was assessed on the first and seventh day and at the first, sixth and twelfth month. Results Patient demographics and hernia characteristics A total of 60 patients underwent laparoscopic TAPP hernioplasty, all of which were followed for one year and different parameters were assessed. As it is demonstrated in table 1, the study’s sample consisted of 57 males and 3 females with a mean age of 56 years and a mean BMI of 26 kg/m 2 . The majority of patients were assigned an ASA score of I (n = 47), while the rest received a score of II (n = 9) and III (n = 4). From the total amount of patients, 37 presented with right-sided hernia and 23 with left-sided, and according to the European Hernia Society classification there were a mean type of L1 (38%), M1 (29%), L2 (18%), M2 (15%) hernias [ 8 ]. The most common comorbidities of the patients were hypertension (n = 13), diabetes mellitus (n = 8) and dyslipidemia (n = 9). Surgical Outcomes and Postoperative Pain As it is demonstrated in Table 2 , in terms of the mean operative time, the surgical process lasted 58 minutes without any case of conversion and the mean time for peritoneal flap closure was 2.15 minutes. The median hospital stay of the patients was 1 day. No intraoperative complication reported during the surgical procedure, but there was 1 case of small hematoma at the trocar site (2%) and 1 case of wound seroma (2%), in the early post-operative period. The recurrence and trocar site hernia rate were both 0%, and no case of chronic pain was reported after 1-year of follow-up. As it is demonstrated in Fig. 2 , the VAS score during the early postoperative period was 2.77 on day 1 and 1.5 on day 7, however during the late postoperative period the VAS score was 0. Discussion The benefits of laparoscopic TAPP inguinal hernia repair are well established and this technique has undergone several modifications in order to enhance its efficacy and minimize the postoperative complications [ 9 ]. Some of the aspects of TAPP approach that are under discussion include the method of mesh fixation and peritoneal flap closure. Several studies demonstrated a correlation between these two variables with the amount of postoperative pain. As it was previously stated, several methods were described to fix the mesh and close the peritoneal flap including staples, sutures and glue [ 10 ]. This study mainly focuses on assessing the use of cyanoacrylate glue in TAPP inguinal hernia repair mainly focusing on postoperative pain, after its application for mesh fixation and peritoneal flap closure. The postoperative pain, as measured by the VAS score, demonstrated a progressive reduction after the first postoperative day and no pain has been reported after the first month post-surgery. Application of cyanoacrylate glue was a safe and an effective method as proven by the minor complication rate reported, after 60 cases. There was no case of bleeding or chronic pain both of which are associated with the use of staples or sutures. This is also supported by the international guidelines for inguinal hernia management issued by the European Hernia Society supporting that atraumatic mesh fixation should be considered, as it is associated with reduced postoperative pain and improved patient comfort [ 11 ]. A large meta-analysis study of Kitching et al, concluded that glue is preferable to staples for mesh fixation as it is associated with lower risk of postoperative pain and bleeding. The findings of our study are in concordance, in terms of the complication rate and the VAS score pattern during the early and late postoperative period following the use of cyanoacrylate glue [ 5 ]. However, a limitation of our study is the absence of a second patient group in which staples would have been used for mesh fixation and peritoneal flap closure. This would have allowed a direct comparison between the two patient groups. The particular study will be carried out in our surgical department in the future. As it was previously stated, the two main types of adhesive glues that are currently employed in TAPP inguinal hernia repair include fibrin and cyanoacrylate. In the literature, several studies were performed in order to assess the efficacy and safety of either fibrin or cyanoacrylate glue. For example a research performed by Manish et al, demonstrated that application of fibrin glue during mesh fixation is associated with reduced postoperative pain, earlier return to daily activities as well as reduced risk for hematoma formation [ 4 ]. A similar research to ours supported that fibrin glue is a safe and effective method for mesh fixation and peritoneal flap closure [ 12 ]. Additionally, other studies were carried out in which cyanoacrylate glue was applied for mesh fixation and peritoneal flap closure. These demonstrated that application of cyanoacrylate glue is also an effective method and is associated with less postoperative pain compared to tacks or sutures. As it can be derived from the above, application of cyanoacrylate glue, in TAPP inguinal hernia repair, minimizes postoperative pain as well as intraoperative and postoperative complications. This contributed to its wider application in everyday clinical practice of TAPP inguinal hernia repair and can be reflected by the growing body of evidence in the literature [ 7 ], [ 13 ]. Several studies were previously mentioned and demonstrated the benefits of either fibrin or cyanoacrylate glue in TAPP repair. As it can be derived from the above, both glue types are associated with less experienced postoperative pain and complications. However, in the current literature the number of studies which compare the two glue types in TAPP inguinal hernia repair in terms of their benefits and outcomes is very limited. Conclusion The findings of our surgical department are consistent with the current literature, suggesting that application of cyanoacrylate glue for mesh fixation and peritoneal flap closure is safe and effective method. It is also associated with minor complications and seems to cause less postoperative pain, facilitating earlier return to everyday activities compare to tacks and suture fixation. Despite the growing interest in mesh fixation methods, larger randomized controlled trials should be carried out to confirm the above findings and also assess whether there is a difference between fibrin and cyanoacrylate glue in terms of efficacy and outcomes. Declarations Competing interests The authors declare no competing interests. Funding statement This study was supported by Spine Action ltd which provided the publication fee. Author Contribution P.S conceived the original idea and performed the surgical operations. P.A and G.S designed the study, collected the data, did the literature review, and wrote the main manuscript. P.A edited the manuscript. All authors critically reviewed the manuscript and gave their consent. Data Availability All the provided data of the study are included in this published article. Further inquiries can be directed to the corresponding author. References McBee, P. J., Walters, R. W. & Fitzgibbons, R. J. Current status of inguinal hernia management. Int. J. Abdom. Wall Hernia Surg. 5 (4), 159–164. 10.4103/ijawhs.ijawhs_36_22 (2022). Ferrarese, A. et al. Fibrin glue versus stapler fixation in laparoscopic transabdominal inguinal hernia repair: A single center 5-Year experience and analysis of the results in the elderly. Int. J. Surg. 12 10.1016/j.ijsu.2014.08.371 (2014). Wilson, P. & Hickey, L. Laparoscopic transabdominal preperitoneal (TAPP) groin hernia repair using n-butyl-2-cyanoacrylate (Liquiband®FIX8TM) for mesh fixation and peritoneal closure: Learning experience during introduction into clinical practice. Hernia 23 (3), 601–613. 10.1007/s10029-018-1861-6 (2018). Manish, R. et al. ‘Short-term outcomes of fibrin glue versus absorbable tackers for mesh fixation in laparoscopic TAPP inguinal hernia repair: A randomised clinical trial’, 41(1). JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH . (2023). 10.7860/jcdr/2023/61047.17904 Kitching, S. et al. Glue versus tackers for mesh fixation in laparoscopic inguinal hernia repair: A meta-analysis and trial sequential analysis. Hernia 29 (1). 10.1007/s10029-025-03315-w (2025). Suárez-Grau, J. M. et al. Closure of the peritoneum in laparoscopic transabdominal Preperitoneal inguinal hernia repair (TAPP) with cyanoacrylate glue in a microdroplet device: A single surgeon prospective comparison vs. barbed suture. J. Abdom. Wall Surg. 3 10.3389/jaws.2024.12562 (2024). Huguenin-Dezot, M. et al. Glued suture-less peritoneum closure in laparoscopic inguinal hernia repair reduces acute postoperative pain. Sci. Rep. 14 (1). 10.1038/s41598-024-62364-w (2024). Miserez, M. et al. The European hernia society groin hernia classication: Simple and easy to remember. Hernia 11 (2), 113–116. 10.1007/s10029-007-0198-3 (2007). The HerniaSurge Group. ‘International guidelines for Groin Hernia Management’ Hernia , 22(1), pp. 1–165. (2018). 10.1007/s10029-017-1668-x Rey Chaves, C. E. et al. Postoperative pain in transabdominal preperitoneal laparoscopic hernia repair with staple fixation versus self-fixation mesh. Heliyon 10 (9). 10.1016/j.heliyon.2024.e30033 (2024). Miserez, M. et al. Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 18 (2), 151–163. 10.1007/s10029-014-1236-6 (2014). Ielpo, B. et al. Laparoscopic transabdominal Preperitoneal (TAPP) inguinal hernia repair using fibrin glue for fixation of the mesh and peritoneum closure. Surg. Laparosc. Endosc. Percutan. Tech. 30 (4). 10.1097/sle.0000000000000797 (2020). Koprivica, R. Use of cyanoacrylate adhesive for fixation of mesh and peritoneum in transabdominal laparoscopic hernia inguinal repair. Med. Res. Archives . 13 (4). 10.18103/mra.v13i4.6340 (2025). Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8224771","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":557699947,"identity":"7b067505-fa0b-4e6a-ad62-2694013e2dfa","order_by":0,"name":"Peter Siaperas","email":"","orcid":"","institution":"Sismanoglion General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Siaperas","suffix":""},{"id":557699948,"identity":"464fce0d-2388-4325-ba98-98c865e3878d","order_by":1,"name":"Panayiotis 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closure\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8224771/v1/642b0f0b008e262311aadb60.png"},{"id":98427402,"identity":"c04033ed-96a5-4d56-b15e-20227894663f","added_by":"auto","created_at":"2025-12-17 16:40:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":27767,"visible":true,"origin":"","legend":"\u003cp\u003eVAS score during postoperative period\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8224771/v1/afb76d4e230d52807e6f02f2.png"},{"id":98624407,"identity":"33ea57e4-9c4a-41ac-b6fc-32d797a6420c","added_by":"auto","created_at":"2025-12-19 17:08:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2708785,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8224771/v1/42b800e4-8032-499e-bf33-678c69a5f85d.pdf"},{"id":98427522,"identity":"f3c2761c-4f59-41df-b621-166a9d803777","added_by":"auto","created_at":"2025-12-17 16:40:37","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18683,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8224771/v1/e5c28b5449d7c9a8b4373ac4.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Use of cyanoacrylate glue for mesh fixation and peritoneal flap closure in laparoscopic transabdominal preperitoneal repair of inguinal hernia","fulltext":[{"header":"Introduction","content":"\u003cp\u003eInguinal hernia refers to an abnormal protrusion of abdominal content such as omentum, small or large intestine through a defect in the lower abdominal wall. Risk factors associated with the development of inguinal hernia include age, male sex, genetic predisposition, smoking, chronic obstructive pulmonary disease and increased intra-abdominal pressure. Clinical presentations vary from being asymptomatic or feeling a burning sensation to exhibiting signs of obstruction or strangulation. Inguinal hernia is the most common cause for referral to general surgeons, considering that the definitive management requires surgical intervention [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOver the years, several techniques have been described for inguinal hernia repair. The two main approaches are the laparoscopic (Transabdominal Preperitoneal or Totally Extraperitoneal) and open tension-free repair. In the past, the laparoscopic techniques were controversial due to their association with increased recurrence rate. However, latest studies demonstrated that laparoscopic surgery of inguinal hernia is associated with lower chronic pain, recurrence rate, reduced hospitalization period and earlier return to daily activities [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Additionally, the presence of bilateral inguinal hernia or recurrence is considered an indication for laparoscopic repair. Some of the contraindications include the inability of patients to tolerate general anesthesia due to comorbidities, several intra-abdominal adhesions and inguinal hernia recurrence after laparoscopic approach [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this study, laparoscopic transabdominal preperitoneal (TAPP) technique was performed for inguinal hernia repair. Over the last decade, laparoscopic inguinal hernia repair has gained popularity, therefore several modifications were applied aiming primarily to reduce post-operative pain and promote earlier mobilization. More precisely, in TAPP inguinal hernia repair some of the modifications include the type of mesh applied, the methods of mesh fixation and the closure of the peritoneum. Different ways are currently employed to fix the mesh and close the peritoneal flap including sutures, staples and cyanoacrylate or fibrin glue [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSome researches supported that application of staples or sutures for mesh fixation and peritoneal flap closure is associated with several complications. More specifically, the use of tacks has been correlated with increased post-operative pain and hematoma formation due to higher risk of damaging the ilio-hypogastric nerve or blood vessels respectively. Additionally, the use of staples may be associated with severe hemorrhage due to accidental injury of inferior epigastric vessels during mesh fixation [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Peritoneal flap closure with sutures increases also post-operative pain and the risk of peritoneal rupture, which may result in internal hernia and small bowel obstruction [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSeveral studies have been carried out to demonstrate the benefits of applying surgical glue in TAPP inguinal hernia repair. The results showed that mesh fixation and peritoneal flap closure with surgical glue reduce post-operative pain and decrease the risk of bleeding and hematoma formation. However, further studies are required to clearly demonstrate the efficacy of glue and its safety [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The aim of this study is to evaluate the use of cyanoacrylate glue in TAPP repair, mainly focusing on its effect on postoperative pain. Cyanoacrylate glue was applied both for mesh fixation and peritoneal flap closure.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and data collection\u003c/h2\u003e\u003cp\u003eIn this study, a total of sixty patients with inguinal hernia who underwent laparoscopic TAPP inguinal repair using cyanoacrylate glue have been enrolled and followed-up for one year starting from January 2023 until the end of 2024. Patients between the ages of 18\u0026ndash;65 years, with unilateral inguinal hernia were included in this study. Exclusion criteria are the following: inability of the patient to undertake general anesthesia (American Society of Anesthesiologist grade more than 3, chronic obstructive pulmonary disease and coronary artery disease), patients with bilateral hernia, recurrence, complicated hernias (strangulated, incarcerated or obstructed) and previous prostatectomy. A written informed consent was obtained from every patient before enrollment to the particular study. Ethical approval for this study was provided by the Scientific Council of the General Hospital of Athens \u0026ldquo;Sismanogleio\u0026rdquo;, Athens, Greece. All methods were performed in accordance with the relevant guidelines and regulations.\u003c/p\u003e\u003cp\u003eLaparoscopic TAPP inguinal hernia repair surgeries were conducted by a single surgeon with considerable experience in laparoscopic TAPP technique, in a single center. This study mainly focuses on postoperative pain which was assessed by a Visual Analogue Scale (VAS) and a particular score was given. The scale is calibrated from 0 (no pain) to 10 (excruciating unbearable pain). However, other variables such as mean operative time, mean time for peritoneal flap closure and median hospital stay were reported. The patients were also assessed for the presence of adverse surgical outcomes. More precisely, early surgical complications, occurring during the first month post-operatively, include seroma or hematoma formation and bladder injury whereas late surgical complications, occurring after the first month, include chronic pain, hernia recurrence or trocar site hernia. The patients were followed-up for 1 year and the VAS score was assessed on the first and seventh day (early postoperative period) and on the first, sixth and twelfth month (late postoperative period).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurgical technique and Perioperative Preparation\u003c/h3\u003e\n\u003cp\u003eChest X-ray, electrocardiogram and preoperative laboratory investigation including full blood count, liver and renal function tests, were all performed the day before surgery. A single dose of second generation cephalosporin was given as antibiotic prophylaxis 1-hour before the operation. The patients received general anesthesia and placed in a supine flat position. Pneumoperitoneum was established with a Veress needle at the supraumbilical area and an 11 mm trocar was placed. A 30-degree laparoscope was introduced and after inspection of the abdominal cavity, two 5 mm working trocars were placed in the following locations. The first 5 mm trocar which was ipsilateral to the hernia site was placed 1 cm above the level of the umbilicus and the contralateral 5 mm trocar was placed 1 cm under the level of the umbilicus. The peritoneal flap was then created 4 cm above the abdominal wall defect starting laterally, approximately 2 cm above the anterior superior iliac spine until the medial umbilical ligament. Careful dissection was performed medial and lateral to the inferior epigastric vessels at the Retzius space and pubic bone. Cooper ligament was also identified. The hernia sac was reduced and separated from the spermatic cord.\u003c/p\u003e\u003cp\u003eOnce dissection and hemostasis was complete, a polypropylene mesh 10.8 x 16 cm was inserted in the abdominal cavity. The mesh was placed to cover the defect and the entire inguino-femoral space. As it is demonstrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea and b, fixation was achieved using the Glutack and appliying a cyanoacrylate glue [Glubran\u0026reg; 2 (N-butyl cyanoacrylate metacryloxysulfolane, NBCA-MS)] at the Cooper Ligament, pubic bone and around the mesh border. Peritoneal flap closure was the performed, after reducing the intra-abdominal pressure to 8 mm Hg and applying cyanoacrylate glue Glubran\u0026reg; 2 (NBCA-MS) between the two peritoneal sites using the Glutack. This is demonstrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec and d.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe trocars were then removed under direct vision. The patients were transferred to the ward for an overnight stay. In terms of analgesia during hospitalization patients received 1 gr paracetamol IV every 6 hours and after discharge it was further administered systematically per os for 5 days. As it was previously mentioned the VAS score was assessed on the first and seventh day and at the first, sixth and twelfth month.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003ePatient demographics and hernia characteristics\u003c/h2\u003e\u003cp\u003eA total of 60 patients underwent laparoscopic TAPP hernioplasty, all of which were followed for one year and different parameters were assessed. As it is demonstrated in table 1, the study\u0026rsquo;s sample consisted of 57 males and 3 females with a mean age of 56 years and a mean BMI of 26 kg/m\u003csup\u003e2\u003c/sup\u003e. The majority of patients were assigned an ASA score of I (n\u0026thinsp;=\u0026thinsp;47), while the rest received a score of II (n\u0026thinsp;=\u0026thinsp;9) and III (n\u0026thinsp;=\u0026thinsp;4). From the total amount of patients, 37 presented with right-sided hernia and 23 with left-sided, and according to the European Hernia Society classification there were a mean type of L1 (38%), M1 (29%), L2 (18%), M2 (15%) hernias [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The most common comorbidities of the patients were hypertension (n\u0026thinsp;=\u0026thinsp;13), diabetes mellitus (n\u0026thinsp;=\u0026thinsp;8) and dyslipidemia (n\u0026thinsp;=\u0026thinsp;9).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurgical Outcomes and Postoperative Pain\u003c/h3\u003e\n\u003cp\u003eAs it is demonstrated in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e, in terms of the mean operative time, the surgical process lasted 58 minutes without any case of conversion and the mean time for peritoneal flap closure was 2.15 minutes. The median hospital stay of the patients was 1 day. No intraoperative complication reported during the surgical procedure, but there was 1 case of small hematoma at the trocar site (2%) and 1 case of wound seroma (2%), in the early post-operative period. The recurrence and trocar site hernia rate were both 0%, and no case of chronic pain was reported after 1-year of follow-up. As it is demonstrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the VAS score during the early postoperative period was 2.77 on day 1 and 1.5 on day 7, however during the late postoperative period the VAS score was 0.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe benefits of laparoscopic TAPP inguinal hernia repair are well established and this technique has undergone several modifications in order to enhance its efficacy and minimize the postoperative complications [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Some of the aspects of TAPP approach that are under discussion include the method of mesh fixation and peritoneal flap closure. Several studies demonstrated a correlation between these two variables with the amount of postoperative pain. As it was previously stated, several methods were described to fix the mesh and close the peritoneal flap including staples, sutures and glue [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study mainly focuses on assessing the use of cyanoacrylate glue in TAPP inguinal hernia repair mainly focusing on postoperative pain, after its application for mesh fixation and peritoneal flap closure. The postoperative pain, as measured by the VAS score, demonstrated a progressive reduction after the first postoperative day and no pain has been reported after the first month post-surgery. Application of cyanoacrylate glue was a safe and an effective method as proven by the minor complication rate reported, after 60 cases. There was no case of bleeding or chronic pain both of which are associated with the use of staples or sutures. This is also supported by the international guidelines for inguinal hernia management issued by the European Hernia Society supporting that atraumatic mesh fixation should be considered, as it is associated with reduced postoperative pain and improved patient comfort [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA large meta-analysis study of Kitching et al, concluded that glue is preferable to staples for mesh fixation as it is associated with lower risk of postoperative pain and bleeding. The findings of our study are in concordance, in terms of the complication rate and the VAS score pattern during the early and late postoperative period following the use of cyanoacrylate glue [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, a limitation of our study is the absence of a second patient group in which staples would have been used for mesh fixation and peritoneal flap closure. This would have allowed a direct comparison between the two patient groups. The particular study will be carried out in our surgical department in the future.\u003c/p\u003e\u003cp\u003eAs it was previously stated, the two main types of adhesive glues that are currently employed in TAPP inguinal hernia repair include fibrin and cyanoacrylate. In the literature, several studies were performed in order to assess the efficacy and safety of either fibrin or cyanoacrylate glue. For example a research performed by Manish et al, demonstrated that application of fibrin glue during mesh fixation is associated with reduced postoperative pain, earlier return to daily activities as well as reduced risk for hematoma formation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. A similar research to ours supported that fibrin glue is a safe and effective method for mesh fixation and peritoneal flap closure [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAdditionally, other studies were carried out in which cyanoacrylate glue was applied for mesh fixation and peritoneal flap closure. These demonstrated that application of cyanoacrylate glue is also an effective method and is associated with less postoperative pain compared to tacks or sutures. As it can be derived from the above, application of cyanoacrylate glue, in TAPP inguinal hernia repair, minimizes postoperative pain as well as intraoperative and postoperative complications. This contributed to its wider application in everyday clinical practice of TAPP inguinal hernia repair and can be reflected by the growing body of evidence in the literature [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSeveral studies were previously mentioned and demonstrated the benefits of either fibrin or cyanoacrylate glue in TAPP repair. As it can be derived from the above, both glue types are associated with less experienced postoperative pain and complications. However, in the current literature the number of studies which compare the two glue types in TAPP inguinal hernia repair in terms of their benefits and outcomes is very limited.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of our surgical department are consistent with the current literature, suggesting that application of cyanoacrylate glue for mesh fixation and peritoneal flap closure is safe and effective method. It is also associated with minor complications and seems to cause less postoperative pain, facilitating earlier return to everyday activities compare to tacks and suture fixation. Despite the growing interest in mesh fixation methods, larger randomized controlled trials should be carried out to confirm the above findings and also assess whether there is a difference between fibrin and cyanoacrylate glue in terms of efficacy and outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding statement\u003c/h2\u003e\u003cp\u003eThis study was supported by Spine Action ltd which provided the publication fee.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eP.S conceived the original idea and performed the surgical operations. P.A and G.S designed the study, collected the data, did the literature review, and wrote the main manuscript. P.A edited the manuscript. All authors critically reviewed the manuscript and gave their consent.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll the provided data of the study are included in this published article. Further inquiries can be directed to the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMcBee, P. J., Walters, R. W. \u0026amp; Fitzgibbons, R. J. Current status of inguinal hernia management. \u003cem\u003eInt. J. Abdom. Wall Hernia Surg.\u003c/em\u003e \u003cb\u003e5\u003c/b\u003e (4), 159\u0026ndash;164. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/ijawhs.ijawhs_36_22\u003c/span\u003e\u003cspan address=\"10.4103/ijawhs.ijawhs_36_22\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2022).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFerrarese, A. et al. 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Laparoscopic transabdominal preperitoneal (TAPP) groin hernia repair using n-butyl-2-cyanoacrylate (Liquiband\u0026reg;FIX8TM) for mesh fixation and peritoneal closure: Learning experience during introduction into clinical practice. \u003cem\u003eHernia\u003c/em\u003e \u003cb\u003e23\u003c/b\u003e (3), 601\u0026ndash;613. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10029-018-1861-6\u003c/span\u003e\u003cspan address=\"10.1007/s10029-018-1861-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2018).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eManish, R. et al. \u0026lsquo;Short-term outcomes of fibrin glue versus absorbable tackers for mesh fixation in laparoscopic TAPP inguinal hernia repair: A randomised clinical trial\u0026rsquo;, 41(1). \u003cem\u003eJOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH\u003c/em\u003e. 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Postoperative pain in transabdominal preperitoneal laparoscopic hernia repair with staple fixation versus self-fixation mesh. \u003cem\u003eHeliyon\u003c/em\u003e \u003cb\u003e10\u003c/b\u003e (9). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.heliyon.2024.e30033\u003c/span\u003e\u003cspan address=\"10.1016/j.heliyon.2024.e30033\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2024).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMiserez, M. et al. 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Tech.\u003c/em\u003e \u003cb\u003e30\u003c/b\u003e (4). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/sle.0000000000000797\u003c/span\u003e\u003cspan address=\"10.1097/sle.0000000000000797\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2020).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKoprivica, R. Use of cyanoacrylate adhesive for fixation of mesh and peritoneum in transabdominal laparoscopic hernia inguinal repair. \u003cem\u003eMed. Res. Archives\u003c/em\u003e. \u003cb\u003e13\u003c/b\u003e (4). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.18103/mra.v13i4.6340\u003c/span\u003e\u003cspan address=\"10.18103/mra.v13i4.6340\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2025).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"TAPP, cyanoacrylate glue, mesh fixation, peritoneal flap closure, postoperative pain","lastPublishedDoi":"10.21203/rs.3.rs-8224771/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8224771/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eLaparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair has gained popularity due to its association with less postoperative pain and shorter recovery period, compared to the open traditional techniques. This study evaluated the efficacy and safety of cyanoacrylate glue in TAPP repair, mainly focusing on its effect on postoperative pain. Cyanoacrylate glue was applied both for mesh fixation and peritoneal flap closure. A total of sixty patients with unilateral inguinal hernia were enrolled and followed-up for one year. The visual analog scale (VAS) was used to assess the pain during the early and late postoperative period. The mean operative time was 58 minutes and the mean time for peritoneal flap closure was 2.15 minutes. The VAS score at the first and seventh day was 2.77 and 1.5 respectively, while after one month the score was 0. There was no case of recurrence and no major complications were reported. The findings suggest that application of cyanoacrylate glue for mesh fixation and peritoneal flap closure is a safe and effective method with promising results. This technique seems to cause less postoperative pain compared to others described in the literature. However, large-scale randomized controlled trials should be carried out to confirm these findings.\u003c/p\u003e","manuscriptTitle":"Use of cyanoacrylate glue for mesh fixation and peritoneal flap closure in laparoscopic transabdominal preperitoneal repair of inguinal hernia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-12 08:37:37","doi":"10.21203/rs.3.rs-8224771/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a97e1321-6e12-4908-9dcc-d44d68709aec","owner":[],"postedDate":"December 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":59358197,"name":"Health sciences/Diseases"},{"id":59358198,"name":"Health sciences/Health care"},{"id":59358199,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2025-12-18T06:24:43+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-12 08:37:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8224771","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8224771","identity":"rs-8224771","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}