Randomized clinical trial of groin hernia repair with titanium-coated lightweight mesh compared with standard polypropylene mesh

Randomized comparison of self-fixating and sutured mesh in open inguinal hernia repair

Background

Chronic groin pain after mesh repair of inguinal hernia has been attributed to the presence of sutures.

Methods

This randomized clinical trial compared inguinal hernia repair using a self-fixating composite mesh or a sutured lightweight mesh, with pain at 1 year as primary outcome. Patients completed a self-evaluation questionnaire at 2 weeks and were examined after 1 year.

Results

Some 198 patients received self-fixating mesh and 196 sutured mesh. There were no differences between the groups in mean pain scores measured on a visual analogue scale during 2 weeks of immediate convalescence or at 1 year. Chronic pain and discomfort was experienced by 36·3 per cent of patients in the self-fixating and 34·1 per cent in the sutured mesh group (P = 0·658), affecting the everyday life of 1·1 and 2·8 per cent respectively (P = 0·448).

Conclusion

Open inguinal hernia repair with a composite self-fixating mesh resulted in similar pain in the early postoperative convalescence period and at 1 year as repair with a sutured lightweight mesh. Registration number: NCT01026935 (http://www.clinicaltrials.gov).

Is Muscular Atrophy a Contraindication in Laparoscopic Abdominal Wall Defect Repair? A Prospective Study

Laparoscopic surgery for abdominal wall hernias improves short-term results as compared with open hernia surgery. However, no evidence exists to recommend this approach for pseudohernias, which are abdominal wall defects postsurgery caused by denervation and muscular atrophy. The purpose of this study is to analyze whether the laparoscopic approach benefits patients with a pseudohernia. A prospective nonrandomized, single-center clinical study was conducted of 24 patients operated on for pseudohernia. This study was designed with the basic principle of one unit, one surgeon, one mesh, and two techniques (laparoscopic or open double prosthetic repair). The primary end point was assessment of the abdominal wall according to: 1) abdominal perimeter; 2) computed tomography scan; and 3) degree of satisfaction. The secondary end points were intraoperative parameters and comorbidity. Laparoscopy offered no benefits in patients with pseudohernias. Open surgery offered no significant differences in intra- and postoperative morbidity, but if the initial weakness improved with a decrease in abdominal perimeter and visceral content, then there was more than 90 per cent satisfaction ( P < 0.05). The laparoscopic approach does not improve the bulge caused by abdominal muscle atrophy. The option of a muscular and prosthetic reconstruction provides better clinical and cosmetic results.

Randomized clinical trial comparing inguinal hernia repair with Lichtenstein technique using non-absorbable or partially absorbable mesh. Preliminary report

INTRODUCTION

The Lichtenstein technique is currently considered the "gold standard" of open, anterior inguinal hernia repair. It is not free, however, of adverse effects, which may be caused by the implemented synthetic material.

AIM

Determination the influence of the mesh employed on treatment results including immediate complications, return to everyday activities, chronic pain occurrence and hernia recurrence.

MATERIAL AND METHODS

Tension-free hernia repair using the Lichtenstein technique was performed in all the 59 patients randomized to trial groups. Group P with heavyweight polypropylene mesh contained 34 patients; group V with lightweight, partially absorbable mesh (polypropylene/polyglactin 910) consisted of 25 people. Controlled, scheduled follow-up appointments took place after the 7(th) day and the 3(rd) and 6(th) month. Patients were clinically assessed and pain intensity was determined on an analogue-visual scale.

RESULTS

No statistically significant influence of the type of mesh on the risk of early complications, severe pain intensity, the length of hospital stay, time of recovery, or patients' satisfaction with treatment was observed. After 6 months also no statistically significant differences were observed between groups with regard to recurrence rate (P 3.4% vs. V 4.0%), chronic pain (P 5.9% vs. V 4.0%) and ailments such as "foreign body presence" (V vs. P, OR = 0.30, 95% CI 0.077-1.219, p = 0.093) incidence, although their probability was 70% lower for V mesh.

CONCLUSIONS

The preliminary results confirm the effectiveness of the Lichtenstein technique for hernia repair with both types of meshes. It appears that use of a partially absorbable mesh is connected with lower risk of postoperative complications, but the final results require multicentre trials in a larger series of patients.

Systematic review and meta-analysis of the use of lightweight versus heavyweight mesh in open inguinal hernia repair

BACKGROUND

The objective of this study was systematically to analyse published randomized trials comparing lightweight mesh (LWM) with heavyweight mesh (HWM) in open inguinal hernia repair.

METHODS

Randomized trials on LWM versus HWM were selected from the standard electronic databases. Reported outcomes were analysed systematically using RevMan. Pooled risk ratios were calculated for categorical outcomes, and mean differences for secondary continuous outcomes, using the fixed-effects and random-effects models for meta-analysis.

RESULTS

Nine randomized trials containing 2310 patients were included. There was significant heterogeneity among trials. There was no difference in duration of operation, postoperative pain, recurrence rate, testicular atrophy and time to return to work between LWM and HWM groups. The two mesh types had a similar risk of perioperative complications, but LWM was associated with a reduced risk of developing chronic groin pain (risk ratio (RR) 0·61, 95 per cent confidence interval 0·50 to 0·74) and a reduced risk of developing other groin symptoms, such as stiffness and foreign body sensations (RR 0·64, 0·50 to 0·81).

CONCLUSION

The use of LWM for open inguinal hernia repair was not associated with an increased risk of hernia recurrence. LWM reduced the incidence of chronic groin pain as well as the risk of developing other groin symptoms.

Inguinodynia following Lichtenstein tension-free hernia repair: A review

Chronic Groin Pain (Inguinodynia) following inguinal hernia repair is a significant, though under-reported problem. Mild pain lasting for a few days is common following mesh inguinal hernia repair. However, moderate to severe pain persisting more than 3 mo after inguinal herniorrhaphy should be considered as pathological. The major reasons for chronic groin pain have been identified as neuropathic cause due to inguinal nerve(s) damage or non-neuropathic cause due to mesh or other related factors. The symptom complex of chronic groin pain varies from a dull ache to sharp shooting pain along the distribution of inguinal nerves. Thorough history and meticulous clinical examination should be performed to identify the exact cause of chronic groin pain, as there is no single test to confirm the aetiology behind the pain or to point out the exact nerve involved. Various studies have been performed to look at the difference in chronic groin pain rates with the use of mesh vs non-mesh repair, use of heavyweight vs lightweight mesh and mesh fixation with sutures vs glue. Though there is no convincing evidence favouring one over the other, lightweight meshes are generally preferred because of their lesser foreign body reaction and better tolerance by the patients. Identification of all three nerves has been shown to be an important factor in reducing chronic groin pain, though there are no well conducted randomised studies to recommend the benefits of nerve excision vs preservation. Both non-surgical and surgical options have been tried for chronic groin pain, with their consequent risks of analgesic side-effects, recurrent pain, recurrent hernia and significant sensory loss. By far the best treatment for chronic groin pain is to avoid bestowing this on the patient by careful intra-operative handling of inguinal structures and better patient counselling pre- and post-herniorraphy.

Open inguinal hernia repair with the use of a polyglycolic acid-trimethylene carbonate absorbable mesh: a pilot study

PURPOSE

Tension-free repair with mesh placement has become the gold standard for open inguinal hernia surgery. Traditionally, non absorbable materials have been used for mesh manufacture. The purpose of this pilot study was to evaluate the efficacy of using a totally absorbable prosthetic mesh for open inguinal hernia repair.

METHODS

Ten patients with elective inguinal hernias were set to undergo open tension-free inguinal hernia repair with the use of polyglycolic acid-trimethylene carbonate absorbable mesh. In this pilot study, we looked primarily at recurrence and chronic pain assessed 1 year after the operation, while immediate postoperative complications were also recorded.

RESULTS

All patients were discharged from the hospital the day after surgery. In three patients (30%), a Foley catheter was inserted to relieve symptoms of urinary retention. None of the patients had any immediate postoperative complication. At the 1st year follow up, none of the patients had clinical signs of recurrence. However, one patient experienced intermittent pain in the operated inguinal area.

CONCLUSIONS

Open inguinal hernia repair with the use of polyglycolic acid-trimethylene absorbable mesh proved efficient in the given patient sample. Further studies with a larger number of patients and longer follow up are needed in order to confirm the possible favourable effects of this mesh type.

[Historic analysis of complex incisional hernia: to an understanding of the double prosthetic repair technique]

The treatment of complex incisional hernias is, on occasions, a real social and professional, and still controversial, challenge. A multitude of techniques have been described over the years in an attempt to solve this problem. The social context and technological development of each period are essential to understand the continuous changes in the way of performing these techniques. This article caries out an historical review of the prosthetic treatment of incisional hernias, trying to understand and apply the basic principles of the treatment of all incisional hernias to the repair with a double mesh.

Which mesh for hernia repair?

INTRODUCTION

The concept of using a mesh to repair hernias was introduced over 50 years ago. Mesh repair is now standard in most countries and widely accepted as superior to primary suture repair. As a result, there has been a rapid growth in the variety of meshes available and choosing the appropriate one can be difficult. This article outlines the general properties of meshes and factors to be considered when selecting one.

MATERIALS AND METHODS

We performed a search of the medical literature from 1950 to 1 May 2009, as indexed by Medline, using the PubMed search engine (www.pubmed.gov). To capture all potentially relevant articles with the highest degree of sensitivity, the search terms were intentionally broad. We used the following terms: 'mesh, pore size, strength, recurrence, complications, lightweight, properties'. We also hand-searched the bibliographies of relevant articles and product literature to identify additional pertinent reports.

RESULTS AND CONCLUSIONS

The most important properties of meshes were found to be the type of filament, tensile strength and porosity. These determine the weight of the mesh and its biocompatibility. The tensile strength required is much less than originally presumed and light-weight meshes are thought to be superior due to their increased flexibility and reduction in discomfort. Large pores are also associated with a reduced risk of infection and shrinkage. For meshes placed in the peritoneal cavity, consideration should also be given to the risk of adhesion formation. A variety of composite meshes have been promoted to address this, but none appears superior to the others. Finally, biomaterials such as acellular dermis have a place for use in infected fields but have yet to prove their worth in routine hernia repair.

Eklund A, Montgomery A, Bergkvist L, Rudberg C. Chronic pain 5 years after randomized comparison of laparoscopic and Lichtenstein inguinal hernia repair

Background

Chronic postoperative pain is a major drawback of inguinal hernia repair. This study compared the frequency of chronic pain after laparoscopic (totally extraperitoneal patch, TEP) and open (Lichtenstein) repairs.

Methods

A randomized multicentre study with 5 years' follow-up was conducted on men with a primary inguinal hernia. Chronic pain was categorized as mild, moderate or severe by blinded observers. A subgroup analysis was performed on 121 patients who experienced moderate or severe pain at any time during follow-up.

Results

Overall, 1370 of 1512 randomized patients underwent surgery, 665 in the TEP and 705 in the Lichtenstein group. The total incidence of chronic pain was 11·0 versus 21·7 per cent at 1 year, 11·0 versus 24·8 per cent at 2 years, 9·9 versus 20·2 per cent at 3 years and 9·4 versus 18·8 per cent at 5 years in the TEP and Lichtenstein groups respectively (P &lt; 0·001). After 5 years, 1·9 per cent of patients in the TEP and 3·5 per cent in the Lichtenstein group reported moderate or severe pain (P = 0·092). Of the 121 patients, 72 (59·5 per cent) no longer reported pain a median of 9·4 (range 6·7–10·8) years after operation.

Conclusion

Five years after surgery only a small proportion of patients still report moderate to severe chronic pain. Laparoscopic inguinal hernia repair leads to less chronic pain than open repair. Registration number: NCT00568269 (http://www.clinicaltrials.gov).

Repair of complex incisional hernias using double prosthetic repair: single-surgeon experience with 50 cases

BACKGROUND

The treatment of complex incisional hernias is still difficult and controversial. With technologic developments we can modify and update the operative techniques described for treating complex abdominal wall hernias.

METHODS

This is a prospective study of 50 patients with complex incisional hernias undergoing complex abdominal wall herniorrhaphy at a university hospital. All patients were evaluated in a multidisciplinary clinic dedicated to abdominal wall reconstruction. All patients underwent pre-operative computed tomography. Complex incisional hernias were regarded as those with multiple recurrences (>3 times), a previous mesh complicated by fistula and chronic infection, giant diffuse lumbar hernias, an associated parastomal hernia, or hernias developing after bariatric surgery. The operative technique was a double reconstruction prosthetic mesh. The type of repair as well as clinical, operative, and follow-up data were analyzed.

RESULTS

Eight patients had considerable loss of tissue, 5 had trophic skin lesions, and 2 had chronic suppurative infection. The mean size of the defects was 18.2 cm. Morbidity included 5 cases of seroma, 2 neuralgias, and 2 cutaneous necroses. The mean duration of hospital stay was 5 days (range, 2-9). Complete follow-up (mean, 48 months; range, 12-108) showed no recurrent hernias.

CONCLUSION

While awaiting a longer follow-up to confirm the results, we conclude that complex incisional hernias can be repaired safely and with a low morbidity and recurrence rate by means of a double prosthetic repair technique.

Randomised clinical trial comparing lightweight mesh with heavyweight mesh for inguinal hernioplasty

PURPOSE

The aim of the present randomised clinical study was to compare the incidence of post-operative chronic groin pain and the feeling of a foreign body after inguinal hernioplasty with lightweight (LW) and heavyweight (HW) mesh, as well as to evaluate the patient's quality of life after inguinal hernia repair.

METHODS

A total of 135 patients were randomised into the HW mesh group (66 patients) and the LW mesh group (69 patients). A tension-free repair using the Lichtenstein technique was performed on all patients. Pain scores were measured on a visual analogue scale. To evaluate the patient's quality of life, the Medical Outcomes Study Short-Form (SF) 36 questionnaire was completed by the patient.

RESULTS

There were significantly more patients with pain at rest in the HW mesh group than in the LW mesh group at 6 months follow-up (6.3 vs. 0%, P = 0.038). The feeling of a foreign body at the operation site was experienced by 32.8% of the patients in the HW group and by 20.9% of the patients in the LW group after 6 post-operative months (P = 0.123). There were no significant differences in any dimension of quality of life on the SF36 between the two study groups 6 months after surgery.

CONCLUSIONS

Our study shows that, compared with HW mesh, LW mesh has some advantages in reducing chronic groin pain at the operation site after inguinal hernioplasty. According to our study, there was no difference in the feeling of a foreign body and in the quality of life between the two study groups.

Tension-free by mesh-plug technique for inguinal hernia repair in elderly patients

BACKGROUND

elderly patients are steadily becoming a growing part of the population. The aim of this study is to evaluate the outcome of open inguinal hernia repair in patients aged over 65 years.

METHODS

from January 1999 to December 2008, a total of 719 patients underwent open tension-free inguinal hernia repair with mesh-plug; 301 among them were ≥ 65 years old.

RESULTS

elderly patients had a mean age of 72.4 years (women 3.3%), while the mean age of younger patients was 48.7 years (women 5.7%). According to the ASA score, patients aged ≥ 65 years were at significantly higher risk than the younger patients. Spinal anesthesia was used most frequently in both groups. No significant differences were found in postoperative pain, mortality and recurrence. Morbidity and hospital stay were significantly higher in patients aged ≥ 65 years.

CONCLUSIONS

open hernia repair in the elderly is safe and well tolerated, but it is associated with higher morbidity and longer hospitalization.

Do we follow evidence-based medicine recommendations during inguinal hernia surgery? Results of a survey covering 2441 hernia repairs in 2007

BACKGROUND

We conducted a survey to determine whether hernia surgeons follow evidence-based medicine (EBM) criteria in their daily routine.

METHODS

All chiefs of general surgery in Styria (Austria) received a short, simple, two-page, 10-item questionnaire.

RESULTS

We analyzed completed surveys from 15 departments reporting 2441 hernia repairs with a mean patient age of 57.5 +/- 11.6 years. Although five techniques accounted for 96.6% of procedures, the frequency of use of each technique varied considerably among the hospitals. There were high numbers of laparoscopic (36.8%) and sutured (19.9%) repairs.

CONCLUSIONS

Because of the great variance among the evaluated hospitals as to surgical methods and indications, this survey showed that inguinal hernia surgery does not currently comply with EBM.

The Tilburg double blind randomised controlled trial comparing inguinal hernia repair according to Lichtenstein and the transinguinal preperitoneal technique

Background

Anterior open treatment of the inguinal hernia with a tension free mesh has reduced the incidence of recurrence and direct postoperative pain. The Lichtenstein procedure rules nowadays as reference technique for hernia treatment. Not recurrences but chronic pain is the main postoperative complication in inguinal hernia repair after Lichtenstein's technique. Preliminary experiences with a soft mesh placed in the preperitoneal space showed good results and less chronic pain.

Methods

The TULIP is a double-blind randomised controlled trial in which 300 patients will be randomly allocated to anterior inguinal hernia repair according to Lichtenstein or the transinguinal preperitoneal technique with soft mesh. All unilateral primary inguinal hernia patients eligible for operation who meet inclusion criteria will be invited to participate in this trial. The primary endpoint will be direct postoperative- and chronic pain. Secondary endpoints are operation time, postoperative complications, hospital stay, costs, return to daily activities (e.g. work) and recurrence. Both groups will be evaluated.

Success rate of hernia repair and complications will be measured as safeguard for quality.

To demonstrate that inguinal hernia repair according to the transinguinal preperitoneal (TIPP) technique reduces postoperative pain to <10%, with α = 0,05 and power 80%, a total sample size of 300 patients was calculated.

Discussion

The TULIP trial is aimed to show a reduction in postoperative chronic pain after anterior hernia repair according to the transinguinal preperitoneal (TIPP) technique, compared to Lichtenstein.

In our hypothesis the TIPP technique reduces chronic pain compared to Lichtenstein.

Trial registration

ISRCTN 93798494

Lightweight mesh improves functional outcome in laparoscopic totally extra-peritoneal inguinal hernia repair

BACKGROUND

Prosthetic mesh reinforcement is standard practice for inguinal hernia repair but can cause considerable pain and stiffness around the groin and affect physical functioning. This has led to various types of mesh being engineered, with a growing interest in a lighter weight mesh. The aim of this prospective study was to compare the outcome after laparoscopic totally extra-peritoneal (TEP) inguinal repair using new lightweight or traditional heavyweight mesh performed in a single specialist centre.

METHODS

Between November 2004 and July 2005, 250 patients underwent laparoscopic TEP inguinal repair using either lightweight (Ultrapro, 30 g/m(2)) or heavyweight (Prolene, 100 g/m(2)) mesh. Follow-up data was obtained using case note review and telephone-based questionnaire. Patients were followed up within the early and late post-operative periods to assess any changes in outcome.

RESULTS

Follow-up information was obtained for 188 (75%) out of 250 patients. There was no difference between lightweight and heavyweight groups in the incidence or severity of pain/discomfort at mean 4 and 15 months follow-up. There was significantly less interference with physical activity at short and long term follow-up in the lightweight group, in particular lifting (9% vs 21% at mean 4 months, Mann-Whitney U, P = 0.024), walking (1% vs 11% at mean 15 months, Mann-Whitney U, P = 0.006) and vigorous activities (7% vs 19% at mean 15 months, Mann-Whitney-U, P = 0.012). There was no significant difference in awareness of mesh or stiffness in the groin.

CONCLUSIONS

Laparoscopic TEP inguinal hernia repair with a lightweight mesh improves functional outcome in the short and long term. There was significantly less interference with all aspects of physical activity with the lightweight mesh. Pain in both groups was very mild, highlighting the benefits of laparoscopic surgery.