Fibrin Glue in Gynecologic Surgery

Abstract

Fibrin glue has been shown to be effective in establishing hemostasis, enhancing adhesion among tissues, and stimulating tissue repair. At our institution, experience with Tissucol has been acquired mainly in three fields: conservative surgery of the uterus and/or ovaries, surgery for relief of stress incontinence, and gynecologic oncology surgery. In order to evaluate the effect of fibrin glue application on myometrial and perimetrial hematoma formation and on postoperative adhesions in 24 patients undergoing multiple myomectomy, the injection of Tissucol by Duploject on each suture line was part of the reconstruction, by layers, of the uterus. Echography was performed in all patients 10 and 30 days after surgery. Evaluation of adhesions has so far been possible in nine patients during cesarean section or laparoscopy. Comparison with historical controls collected since 1987 indicates significant reduction of febrile morbidity and formation of hematomas and adhesions. Fifty-two patients affected by first to second degree cystocele and genuine stress incontinence, proved by clinical, radiological, and urodynamic investigation, were scheduled for a Burch’s colposuspension. In order to evaluate the effect of enhancing adhesiveness and fibrosis on the cure rate of stress incontinence, 18 randomly assigned patients received fibrin glue associated with the surgical procedure. Just before tying sutures suspending the vagina to Cooper’s ligament, Tissucol with a low thrombin concentration (4 IU/ml) was applied, with the spray set over the paravaginal fascia. The vagina was elevated towards the corresponding ligament by the surgeon’s fingers and pressure was maintained for 5 min; tamponade of the vagina was performed until the next morning. Despite more favorable clinical, radiological, and urodynamic findings in the fibrin glue treated group, no differences were found in the cure rate of genuine stress incontinence at a 2 year follow-up. In order to prevent hematomas, prolonged lymphorrhea, and lymphoceles in ten patients treated by enlarged hysterectomy (Piver type II–III) and pelvic para-aortic lymphadenectomy for endometrial or cervical cancer, the retroperitoneal field was sprayed with Tissucol (thrombin 500 IU/ml), usually 5 ml for each side of the pelvis. Comparison with historical controls demonstrated significant advantages in terms of hematoma formation, quantity and duration of pelvic drains, need for postoperative blood transfusion, plasma administration and febrile morbidity. No lymphocele had become apparent by the 1 year follow-up CT scan. Based on these data, a randomized controlled trial is currently going on.