Glue Versus Suture Fixation of Mesh During Open Repair of Inguinal Hernias: A Systematic Review and Meta-analysis

In vivo comparison of mesh fixation solutions in open and laparoscopic procedures for inguinal hernia repair: A meta-analysis

Background

Abdominal hernia repair surgeries involve the fixation of a surgical mesh to the abdominal wall with different means such as suture, tacks, and glues. Currently, the most effective mesh fixation system is still debated. This review compares outcomes of mesh fixation in different surgical procedures, aiding surgeons in identifying the optimal technique.

Methods

A meta-analysis was conducted according to PRISMA guidelines. Articles published between January 2003 and January 2023 were searched in electronic databases. Randomized controlled trials (RCTs) comparing mesh fixation with cyanoacrylate-based or fibrin glues with classical fixation techniques (sutures, tacks) in open and laparoscopic procedures were included.

Results

17 RCTs were identified; the cumulative study population included 3919 patients and a total of 3976 inguinal hernias. Cyanoacrylate-based and fibrin glues were used in 1639 different defects, suture and tacks in 1912 defects, self-gripping mesh in 404 cases, and no mesh fixation in 21 defects. Glue fixation resulted in lower early postoperative pain, and chronic pain occurred less frequently. The incidence of hematoma was lower with glue fixation than with mechanical fixation. Recurrence rate, seroma formation, operative and hospitalization time showed no significant differences; but significantly, a higher number of people in the glue group returned to work by 15- and 30-days after surgery when compared to the tacker and suture groups in the same time frame.

Conclusion

Cyanoacrylate and fibrin glue may be effective in reducing early and chronic pain and hematoma incidence without increasing the recurrence rate, the seroma formation, or the operative and hospitalization time.

Perioperative Risk Factors for Persistent Postsurgical Pain After Inguinal Hernia Repair: Systematic Review and Meta-Analysis

Persistent postsurgical pain (PPSP) is one of the most bothersome and disabling long-term complications after inguinal hernia repair surgery. Understanding perioperative risk factors that contribute to PPSP can help identify high-risk patients and develop risk-mitigation approaches. The objective of this study was to systematically review and meta-analyze risk factors that contribute to PPSP after inguinal hernia repair. The literature search resulted in 303 papers included in this review, 140 of which were used for meta-analyses. Our results suggest that younger age, female sex, preoperative pain, recurrent hernia, postoperative complications, and postoperative pain are associated with a higher risk of PPSP. Laparoscopic techniques reduce the PPSP occurrence compared to anterior techniques such as Lichtenstein repair, and tissue-suture techniques such as Shouldice repair. The use of fibrin glue for mesh fixation was consistently associated with lower PPSP rates compared to tacks, staples, and sutures. Considerable variability was observed with PPSP assessment and reporting methodology in terms of study design, follow-up timing, clarity of pain definition, as well as pain intensity or interference threshold. High or moderate risk of bias in at least one domain was noted in >75% of studies. These may limit the generalizability of our results. Future studies should assess and report comprehensive preoperative and perioperative risk factors for PPSP adjusted for confounding factors, and develop risk-prediction models to drive stratified PPSP-mitigation trials and personalized clinical decision-making. PERSPECTIVE: This systematic review and meta-analysis summarizes the current evidence on risk factors for persistent pain after inguinal hernia repair. The findings can help identify patients at risk and test personalized risk-mitigation approaches to prevent pain. PROSPERO REGISTRATION: htttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=154663.

Sutureless Repair for Open Treatment of Inguinal Hernia: Three Techniques in Comparison

Currently, groin hernia repair is mostly performed with application of mesh prostheses fixed with or without suture. However, views on safety and efficacy of different surgical approaches are still partly discordant. In this multicentre retrospective study, three sutureless procedures, i.e., mesh fixation with glue, application of self-gripping mesh, and Trabucco's technique, were compared in 1034 patients with primary unilateral non-complicated inguinal hernia subjected to open anterior surgery. Patient-related features, comorbidities, and drugs potentially affecting the intervention outcomes were also examined. The incidence of postoperative complications, acute and chronic pain, and time until discharge were assessed. A multivariate logistic regression was used to compare the odds ratio of the surgical techniques adjusting for other risk factors. The application of standard/heavy mesh, performed in the Trabucco's technique, was found to significantly increase the odds ratio of hematomas (p = 0.014) and, most notably, of acute postoperative pain (p < 0.001). Among the clinical parameters, antithrombotic therapy and large hernia size were independent risk factors for hematomas and longer hospital stay, whilst small hernias were an independent predictor of pain. Overall, our findings suggest that the Trabucco's technique should not be preferred in patients with a large hernia and on antithrombotic therapy.

Cyanoacrylate mesh fixation for laparoscopic inguinal hernia repair: a prospective, multicenter, single-arm study

BACKGROUND

Inguinal hernia repair is among the most frequently performed surgical procedures. Alternatives to penetrating mesh fixation, such as surgical glue, are being investigated for their potential benefit in reducing chronic pain. The aim of this study was to assess the efficacy of the n-hexyl cyanoacrylate glue Ifabond™ for mesh fixation in laparoscopic inguinal hernia repair.

METHODS

This prospective, multicenter, single-arm study collected data from laparoscopic inguinal hernia repairs using Ifabond™ (Peters Surgical, Boulogne-Billancourt Cedex, France) and a standard [Promesh® SURG ST (Peters Surgical)/Biomesh® P1 (Cousin Biotech, Wervicq-Sud, France)] or lightweight [Promesh® SURG LI (Peters Surgical)/Premium® Implant (Cousin Biotech)] polypropylene mesh. The primary endpoint was postoperative pain [100-scale Visual Analog Scale (VAS)]. Secondary endpoints were complications, hernia recurrences, and quality of life (QoL) (EQ-5D-3L health index and EQ-VAS). Patients were followed up at 5 weeks and 12 months after surgery.

RESULTS

Six-hundred and thirteen patients underwent laparoscopic inguinal hernia repair. Postoperative pain decreased at 5-week (3.97 ± 10.04; p < 0.0001) and 12-month (3.83 ± 11.26; p < 0.0001) follow-up compared with before surgery (26.96 ± 19.42). One hundred and fifteen patients (13.74%) experienced chronic pain in the groin at 12-month follow-up, of whom 14 (2.67%) required analgesics. There were 6 patients with major morbidities and one patient died of an unrelated cause. Two hernia recurrences occurred within 12-month follow-up. Patients' QoL increased from an EQ-5D-3L index score of 0.82 ± 0.19 preoperatively to 0.90 ± 0.15 at 5 weeks (p < 0.0001) and 0.92 ± 0.15 at 12 months after surgery (p < 0.0001). The EQ-VAS general health scoring increased from 79.03 ± 12.69 preoperatively to 84.31 ± 9.97 at 5-week (p < 0.0001) and 84.16 ± 14.48 at 12-month follow-up (p < 0.0001).

CONCLUSIONS

Ifabond™ (Peters Surgical) is a safe, reliable, and feasible fixation method for laparoscopic inguinal hernia repair with a very high surgeon satisfaction score, improved patients' QoL, and comparable risk of developing chronic pain and postoperative complications as described in the literature.

Cost-effectiveness analysis of mesh fixation techniques for laparoscopic and open inguinal hernia surgeries

Purpose

This study reports economic evaluation of mesh fixation in open and laparoscopic hernia repair from a prospective real-world cohort study, using cost-effectiveness analysis (CEA) and cost-utility analysis (CUA).

Methods

A prospective real-world cohort study was conducted in two university-based hospitals in Thailand from November 2018 to 2019. Patient data on hernia features, operative approaches, clinical outcomes, associated cost data, and quality of life were collected. Models were used to determine each group’s treatment effect, potential outcome means, and average treatment effects. An incremental cost-effectiveness ratio was used to evaluate the incremental risk of hernia recurrences.

Results

The 261 patients in this study were divided into six groups: laparoscopic with tack (LT, n = 47), glue (LG, n = 26), and self-gripping mesh (LSG, n = 30), and open with suture (OS, n = 117), glue (OG, n = 18), and self-gripping mesh (OSG, n = 23). Hernia recurrence was most common in LSG. The mean utility score was highest in OG and OSG (both 0.99). Treatment costs were generally higher for laparoscopic than open procedures. The cost-effectiveness plane for utility and hernia recurrence identified LSG as least cost effective. Cost-effectiveness acceptability curves identified OG as having the highest probability of being cost effective at willingness to pay levels between $0 and $3,300, followed by OSG.

Conclusion

Given the similarity of hernia recurrence among all major procedures, the cost of surgery may impact the decision. According to our findings, open hernia repair with adhesive or self-gripping mesh appears most cost-effective.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08491-4.

Comparison of glue versus suture mesh fixation for primary open inguinal hernia mesh repair by Lichtenstein technique: a systematic review and meta-analysis

BACKGROUND

The use of glue as a mesh fixator in open Lichtenstein inguinal hernia repair (IHR) has gained popularity to reduce recurrence and postoperative complications. This meta-analysis aims to provide an up-to-date review to compare glue versus suture fixation in primary open Lichtenstein IHR.

METHODS

PubMed, Embase, The Cochrane Library, Web of Science, and Springer were systematically searched till June 2021 for randomized controlled trials (RCTs) comparing glue versus suture fixation in open Lichtenstein IHR. Primary outcomes were early (at 1 year) and late recurrence (5 years or more). Secondary outcomes were the length of operation, postoperative haematoma and seroma, and chronic pain at 1 year.

RESULTS

A total of 17 RCTs with 3150 hernias (glue n = 1582, suture n = 1568) were included. Only three studies reported late recurrence. Glue fixation was associated with shorter operative duration (MD - 4.17, 95% CI - 4.82, - 3.52; p < 0.001 and a lower incidence of haematoma formation (OR 0.51, 95% CI 0.32, 0.81; p = 0.004). There was no significant difference in postoperative seroma (OR 0.72, 95% CI 0.35, 1.49; p = 0.38), chronic pain after 1 year (OR 1.10, 95% CI 0.73, 1.65; p = 0.65), early recurrence (OR 1.11, 95% CI 0.45, 2.76; p = 0.81, I² = 0%), and late recurrence (OR 1.23, 95% CI 0.59, 2.59; p = 0.59, I² = 0%).

CONCLUSION

Early and late recurrence were comparable between glue and suture fixation in open Lichtenstein IHR patients. Glue fixation had shorter operating time and lower haematoma formation than suture fixation. Chronic pain and seroma formation were comparable. More RCTs should report long-term outcomes.

Mesh-fixation technique for inguinal hernia repair: umbrella review

Background

Mesh-based repair is the standard of surgical care for symptomatic inguinal hernias. Many systematic reviews and meta-analyses (SRMAs) addressed various aspects of these procedures. This umbrella review aimed to report the evidence from all previous SRMAs for open and laparoscopic inguinal hernia repair.

Methods

SRMAs were identified from MEDLINE, Scopus, Cochrane, Embase, DARE, PROSPERO, CINAHL, JBISRIS, EPPI-Centre, Wiley Online Library and ScienceDirect database according to PRISMA guidelines. Data including mesh-fixation techniques and surgical approach were extracted from selected SRMAs. The corrected covered area was calculated to address study overlap across reviews, and an excess significance test was used to assess potential bias. The outcomes of interest were hernia recurrence, chronic groin pain, operating time, postoperative pain, duration of hospital stay, return to daily life activities, and postoperative complication.

Results

Thirty SRMAs were included between 2010 and 2019: 16 focused on open repair, and 14 focused on laparoscopic repair, with a high degree of overlap (open repairs, 41 per cent; laparoscopic repairs, 30–57 per cent). Sufficient evidence was available on hernia recurrence, chronic groin pain, and operative time. Effects of glue on hernia recurrence were inconclusive in open and laparoscopy approaches, P = 0.816 and 0.946 respectively. Glue was significantly associated with lower persistent groin pain, in open repair (versus suture) and in laparoscopic repair (versus tack). SRMAs suggested that self-gripping mesh was associated with shorter operating time in open surgery, although with only a few minutes of improvement (0.36–7.85 min, P < 0.001).

Conclusion

In this umbrella review, chronic groin pain and operating time were the only outcomes for which there was sufficient evidence supporting the effectiveness respectively of glue and self-gripping mesh.

Chronic Pain as a Complication in Open Inguinal Hernia Repair: A Retrospective Study of Consenting Practice in a Single Centre

Introduction

Inguinal hernia repair is one of the most commonly performed procedures in general surgery in the United Kingdom. Chronic pain as a long-term postoperative complication of this procedure has been extensively documented in the literature. However, this complication is often undisclosed during the consenting process. This omission impairs the patients’ informed decision-making process. The Montgomery v Lanarkshire Health Board case, in 2015, changed the way in which patient consent is viewed legally. This has made proper consent practices more important to surgeons undertaking procedures.

Aim

The objective is to assess if there has been an improvement in consenting practices by comparing consent forms from 2015 (the year of the Montgomery ruling) and 2019, specifically in regard to the risk of chronic groin pain following open inguinal hernia repair with mesh.

Methods

This was a retrospective review of patients who underwent open inguinal hernia repair using a prosthetic mesh in 2015 and 2019. The medical records were retrieved on the trust’s electronic medical record system using the patient's hospital number. The following parameters were obtained: patient demographics, preoperative clinic letters, operation notes and consent forms. The clinic letters and consent forms were systematically reviewed for any mention of chronic groin pain.

Results

In 2015 and 2019, 163 and 56 open inguinal hernia repairs with mesh were performed, respectively. The median age of patients was 63 (28-88) and 64.5 (19-88) in the respective years. Throughout both years there was a predominance in male patients, and the majority of cases were performed on an elective basis. Consent for chronic pain was present in 60.7% and 62.5% of cases in 2015 and 2019, respectively (p=0.055).

Conclusion

Despite the importance of adequate consenting practice, we found no significant improvement in consenting practice for chronic pain following open inguinal hernia repair in the four years following the Montgomery ruling.

Mesh fixation with fibrin glue versus tacker in laparoscopic totally extraperitoneal inguinal hernia repair

BACKGROUND

The advent of mesh was a breakthrough in the field of hernia surgery. Mechanical methods of mesh fixation are hypothesized to cause more tissue trauma than nonmechanical methods. The present study was conducted to study the outcomes of mesh fixation using fibrin glue, a nonmechanical method versus tackers in totally extraperitoneal repair (TEP) of unilateral inguinal hernia.

METHODS

A randomized controlled single blinded study was conducted in India from June 2017 to March 2019. Patients diagnosed with unilateral uncomplicated inguinal hernia with a hernial sac of size not more than 5 cm were invited to participate in the study. Sample size was 60 patients randomized into groups just before mesh fixation. In group A mesh was fixed using tackers while in group B mesh was fixed using fibrin glue. Patients were followed-up prospectively for 3 months.

RESULTS

There was no statistical difference between the two groups with respect to operating time. Average hospital stay and pain scores at all follow-ups were better for fibrin glue group. There was no difference in the incidence of postoperative urinary retention, seroma formation and hematoma formation between the two groups. Patients of fibrin glue group had early restart of daily activities at 15 days follow-up when compared to tacker group.

CONCLUSION

Fibrin glue fixation technique should be advocated over tackers for mesh fixation in TEP considering the better outcomes and cost-effectiveness of the technique.

Results of a Prospective Cohort Study on Open Rives Technique of the Midline Incisional Hernia: Midline Closure and Mesh Overlap

Background. Rives repair has been traditionally used for large abdominal wall defects with good results on terms of recurrence. However, it is limited by the lateral border of the posterior rectus sheath. The objective of our study was to evaluate recurrence rate, midline closure and mesh overlap in patients operated on elective midline incisional hernia by open Rives retromuscular repair. Methods. This is a prospective observational study of 83 patients who underwent elective open Rives technique between January 2014 and December 2018. Main inclusion criteria were adults with a midline incisional hernia. Recurrence, midline closure and mesh overlap were determined. Results. At a median postoperative follow-up of 32 (5-59) months, 8 cases of recurrence were reported. Patients with recurrence had wider hernia defects (101 ± 52 mm vs 66 ± 36 mm, P = .014) and were repaired with wider meshes (191 ± 93 mm vs 137 ± 68 mm, P = .042). However, although it was not statistically significant, midline closure was lower (38% vs 59%), as well as the overlapping relationship between mesh area and hernia defect area (2.937:1 vs 3.732:1) on patients that developed a recurrence. Conclusions. Rives technique provides good mid-term results in a midline incisional hernia (10% of recurrence at 36 months), including wider hernias in the recurrent cohort. The authors believe that other techniques which allow midline closure and placement of bigger meshes should be considered, especially in those hernias classified as W3 on EuraHS classification (more than 10 cm on width size).

Ultrasound-guided microwave ablation in the treatment of inguinal neuralgia

Chronic groin pain can be due to a variety of causes and is the most common complication of inguinal hernia repair surgery. The etiology of pain after inguinal hernia repair surgery is often multifactorial though injury to or scarring around the nerves in the operative region, namely the ilioinguinal nerve, genital branch of the genitofemoral nerve, and the iliohypogastric nerve, is thought to be a key factor in causing chronic post-operative hernia pain or inguinal neuralgia. Inguinal neuralgia is difficult to treat and requires a multidisciplinary approach. Radiologists play a key role in the management of these patients by providing accurate image-guided injections to alleviate patient symptoms and identify the pain generator. Recently, ultrasound-guided microwave ablation has emerged as a safe technique, capable of providing durable pain relief in the majority of patients with this difficult to treat condition. The objectives of this paper are to review the complex nerve anatomy of the groin, discuss diagnostic ultrasound-guided nerve injection and patient selection for nerve ablation, and illustrate the microwave ablation technique used at our institution.

Cyanoacrylate Glue Versus Absorbable Tacks in Mesh Fixation for Laparoscopic Extraperitoneal Inguinal Hernia Repair: A Randomized Controlled Trial

BACKGROUND

Cyanoacrylate glue (Glubran 2) is a synthetic adhesive mesh fixation material. Its utility is being evaluated in laparoscopic total extraperitoneal (TEP) inguinal hernia repair (IHR). A multicentre randomized controlled trial was performed comparing Glubran 2 to standard of care absorbable tacks, particularly assessing chronic postoperative inguinal pain and its effects.

MATERIALS AND METHODS

Patients undergoing elective TEP IHR at 2 centers from 2017 to 2019 were randomly assigned to Glubran 2 or absorbable tack mesh fixation, and followed for 6 months. All other aspects of surgery and aftercare remained the same. Surgeons documented operative and fixation time, and the placement of fixation on standardized diagrams. Via a questionnaire, aspects of inguinal pain were evaluated before surgery, and at various time-points postoperatively over 6 months. Postoperative clinical factors were also collected.

RESULTS

A total of 106 operative sides were randomized to either glue (51) or tack (55) mesh fixation over a 14-month period. Similar median operative times between tack (83.0 min) and glue fixation (75.0 min) were observed. There were no significant surgical complications or observed hernia recurrences in either group. There was no significant difference in pain scores between the 2 groups at all time-points after analysis through mixed effects modeling. Temporal pain profiles over time were also similar. Totally, 55% of patients in the glue group had returned to work within 2 weeks of surgery. There was no increase in complications or pain scores despite regular lateral fixation of glue in these patients.

CONCLUSION

Adding to known data, we observed no significant difference in postoperative pain, demonstrating that cyanoacrylate glue is a viable and safe alternative fixation method to absorbable tacks in laparoscopic TEP IHR. As secondary outcomes, cyanoacrylate glue permits some patients to return to work early, and we observed regular lateral mesh glue fixation without increased pain or complications.

Laparoscopic repair of inguinal hernia: retrospective comparison of TEP and TAPP procedures in a tertiary referral center

BACKGROUND

The technical evolution of hernia repair has brought to the introduction of laparoscopy in this field. The most common laparoscopic techniques are transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair. Indirect comparisons between TAPP and TEP have raised questions as to which is the superior approach in improving patient outcomes; however, there is still a scarcity of data directly comparing these laparoscopic approaches. The aim of this report is to offer a retrospective comparison between the two techniques with a long-term follow-up.

METHODS

This study is a retrospective comparative study, comparing TEP and TAPP in the treatment of groin hernias. All patients undergoing laparoscopic hernia repair from 2015 and 2020 at a large UK Hospital Trust with tertiary referral center, were considered as eligible for inclusion. The primary endpoint was rate of successful surgery defined as absence of recurrence and chronic pain at the end of the follow-up. Secondary endpoints were conversion rate (the switch from TEP to TAPP was considered as a conversion for the index procedure), need for admission, readmission rate, serious adverse events (including visceral injuries and vascular injuries), rate of persisting pain at the end of follow-up, operative time and overall complications rate (hematoma, seroma, wound/superficial infection, mesh/deep infection, port site hernia).

RESULTS

Of the patients included in the study who underwent laparoscopic repair of inguinal hernia between 2015 and 2020, 140 (55.1%) underwent TEP and 114 (44.9%) had TAPP repair. The mean operative time did not differ between the two groups (P=0.202). The conversion rate was nil. The two procedures did not differ for intraoperative and postoperative complications. The length of hospital stay was significantly longer in the TAPP group (P<0.0001). The overall recurrence rate was 2.4%. and did not differ between the two groups. Costs were acquired from the clinical coding department. Mean costs were measured in pounds sterling and a significant difference was noted between the two groups (P=0.083). In the short term, the most common complication was seroma formation and was significantly more frequent in the TAPP group (P<0.001). In the long term, chronic pain was the most frequent complication in both groups and significant correlated when the operation performed for recurrent hernia, whereas the hernia Type 3 was a factor that which influenced recurrence.

CONCLUSIONS

In conclusion, TAPP and TEP have similar, overall complication risks, postoperative acute and chronic pain incidence and recurrence rates. Since TAPP and TEP have comparable outcomes it is recommended that the choice of the technique should be based on the surgeon's skills, education, and experience.

Comparing suture with N-Hexyl Cyanoacrylate glue for mesh fixation in inguinal hernia repair, a randomised clinical trial

PURPOSE

Inguinal hernia is a common surgical problem and different methods are currently used to repair it. In The Lichtenstein technique, the inguinal floor defect is buttressed with a prosthetic mesh and commonly, sutures are used for mesh fixation. N-Hexyl Cyanoacrylate is a gluelike product that can be used for mesh fixation as a substitute with fewer complications. This study was done for comparing therapeutic outcomes of mesh fixation with suture and N-Hexyl cyanoacrylate glue in inguinal hernia repair with the Lichtenstein method.

METHODS

In a two-arm parallel-group randomised controlled trial with blinded patients, 58 hernia cases who were candidates for hernia repair with the Lichtenstein method entered the study and randomly divided into two groups. In the control group, the mesh that was used for inguinal floor reinforcement was fixed with sutures and in the intervention group with N-Hexyl Cyanoacrylate glue. The results including acute and chronic pain, hospital stay, complications, and recurrence rate after one year were compared.

RESULTS

There was no recurrence. According to the numeric rating scale (NRS), mean postoperative pain (acute pain) was 6.5 and 5.7 points in the suture and N-Hexyl Cyanoacrylate glue groups respectively, with significant difference (P = 0.006). Mean duration of surgery was 73.3 and 64.5 min in the suture and N-Hexyl cyanoacrylate glue groups respectively, with significant difference (P = 0.014). Complications, hospital stay days, and chronic pain did not differ across the groups (P > 0.05).

CONCLUSION

Mesh fixation with N-Hexyl cyanoacrylate glue in hernia repair with the Lichtenstein method can lower postoperative pain and duration of surgery and this product might be used as a substitute for suture.

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

INTRODUCTION

Inguinal hernioplasty is the standard treatment for inguinal hernia in adults. Mesh fixation was used to keep mesh in place for which various mesh fixation techniques have been used in laparoscopic inguinal hernia repair in adults, but their effectiveness has remained inconclusive.

AIM OF THE WORK

to evaluate non fixation method of mesh laparoscopic inguinal hernioplasty as safe and effective as regard short and long term outcomes.

PATIENTS AND METHODS

Over the period from July 2013 to July 2018, 798 patients with oblique inguinal hernias undergoing Trans abdominal preperitoneal technique (TAPP) were randomized into 3 groups: Group A; mesh non fixation 266 patients. Group B; tacker mesh fixation 266 patients Group C: Cyanoacrylic tissue glues (Histoacryl) mesh fixation 266 patients. Clinical effects were assessed by the following variables: intraoperative data, postoperative outcome as regard recurrence rate, postoperative pain [on visual analogue score (VAS)], analgesic consumption, operation time, hospital stay, and patient costs. Follow up was 18 months.

RESULTS

There was no statistical difference between groups (A) and Group (C) regarding operative time, postoperative complications, and length of hospital stay and risk of chronic groin pain, postoperative pain score. In Group (B): the postoperative pain and complications were higher. There were 5 cases of hernia recurrence in all groups, but no significant differences among the three groups.

CONCLUSION

Tacker Mesh fixation increased the risk of chronic groin pain. Pain score was higher with tacker mesh fixation. Laparoscopic TAPP inguinal hernia repair without tacker mesh fixation was safe and feasible with no significant increase in recurrence rates. Furthermore, mesh fixation with tacker procedure increased the risk of postoperative complications and patient costs. All ethical approval was given by our Faculty of Medicine medical ethical committee.

Mesh fixation technique for inguinal hernia repair: protocol for an umbrella review with integrated and updated network meta-analysis

INTRODUCTION

Inguinal hernia mesh repair is the standard care for symptomatic inguinal hernia. Mesh fixation is used to keep mesh in place for which various mesh fixation techniques have been used in open and laparoscopic inguinal hernia repair, but their effectiveness has remained inconclusive. Therefore, we developed a protocol for an umbrella review in order to summarise the evidences with integrate and update data of different mesh fixation techniques in both open and laparoscopic inguinal hernia repair.

METHODS AND ANALYSIS

Previous systematic reviews and meta-analyses will be identified from Medline, Scopus, Cochrane Databases, EMBASE, Database of Abstracts of Reviews of Effects, PROSPERO Register, CINAHL, JBISRIS, EPPI-Centre, Wiley Online Library and Science Direct database. Two reviewers will independently determine studies for eligibility. Disagreement will be solved by consensus and arbitrated by the third reviewer. Data extraction will also be performed by two independent reviewers. For umbrella review, a descriptive analysis will be applied to describe evidence of mesh fixation effectiveness. Overlapping studies and excess significance test will be performed to assess whether previous evidences are bias. In addition, individual studies from meta-analysis and additional published studies will be pooled using network meta-analyses. We will use I² statistic and Cochran's Q test to assess heterogeneity. Risk of bias and publication bias, if appropriate, will be evaluated, as well as overall strength of the evidence.

ETHICS AND DISSEMINATION

This protocol has been registered with PROSPERO and approved with Institutional Review Board, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand (COA 167/2018). The results will be published in peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42018111773.

Meta-analysis of postoperative pain using non-sutured or sutured single-layer open mesh repair for inguinal hernia

Background

Chronic postoperative pain occurs in up to 21·7 per cent of patients undergoing open inguinal hernia repair. Several mesh fixation techniques using glue or self‐gripping meshes have been developed to reduce postoperative pain. The aim of this meta‐analysis was to evaluate RCTs comparing adhesional/self‐gripping and sutured single‐layer open mesh fixations in the repair of inguinal herniation, with postoperative pain as endpoint.

Methods

PubMed, Embase and Cochrane CENTRAL databases were searched systematically for RCTs according to the PRISMA guidelines; the study was registered at PROSPERO (CRD42017056373). Different fixation methods were analysed. The primary outcome, chronic pain, was defined as a postoperative visual analogue scale (VAS) score of at least 3 at 12 months. Secondary outcomes were mean VAS score at 1 week and at 1 month after surgery.

Results

Twenty‐three studies including 5190 patients were included in the meta‐analysis. Adhesional (self‐adhering or glued) or self‐gripping fixation methods were associated with a significantly lower VAS score at 1 week (mean difference –0·49, 95 per cent c.i. ‐0·81 to –0·17; P = 0·003) and at 1 month (mean difference –0·31, –0·58 to –0·04; P = 0·02) after surgery than suture fixation, but the incidence of chronic pain after 12 months was similar in the two groups (odds ratio 0·70, 95 per cent c.i. 0·30 to 1·66). Differences in recurrences and complications between groups did not reach statistical significance.

Conclusion

There was no difference in the incidence of chronic pain 12 months after different mesh repair fixation techniques despite significant reductions in short‐term postoperative pain favouring a non‐sutured technique. There were no differences in recurrence rates or in rates of other complications at 1 year.

Primary unilateral not complicated inguinal hernia with an effective, cheap, less invasive, and easy operation: the Trabucco repair

BACKGROUND

In modern abdominal wall hernia surgery, the achievement of the most effective tailored repair for each specific defect with the less possible invasiveness, the quicker recovery, the lower costs and the fewer risk of local occurrences, recurrences and chronic pain is the most desirable and cutting-edge goal.

METHODS

Since 1989 about 4219 primary unilateral not complicated inguinal hernias have been treated with specific indications with a sutureless and minimally invasive anterior open approach. The great majority of these procedures were performed under local anaesthesia in a day surgery regimen, with a systematic and careful nerve sparing, preservation of cremasteric muscle, and with a 3-5 cm skin incision.

RESULTS

The minimally invasive sutureless nerve sparing open approach has shown a very low rate of seromas (0.45%), haematomas (0.24%) and infections (0.07%) while the width of skin incision challenges even laparoscopy. A significant reduction of both postoperative pain (2.7%) and chronic neuralgia (0.047%) has led to excellent outcomes in patients, also in terms of quality of life. Compared to the Lichtenstein's tension-free technique, which is at now the gold standard open treatment for primary inguinal hernia worldwide, there are no significant differences in the observed recurrence rate (well below 1%).

CONCLUSION

In our experience of almost 30 years we have been able to experiment and refine more and more the sutureless technique proposed by Trabucco for the treatment of primitive inguinal hernia, peer to peer, improving the local anaesthesia and the ability to detect hidden defects during the repair (Spigelian included), reducing the width of the incisions and tractions on the tissues, introducing the concept of a gentle and bloodless "finger surgery" according to a minimally invasive, extremely anatomic, safe, inexpensive, very effective anterior open approach.

Primary inguinal hernia: systematic review and Bayesian network meta-analysis comparing open, laparoscopic transabdominal preperitoneal, totally extraperitoneal, and robotic preperitoneal repair

PURPOSE

The Open Lichtenstein technique, the Laparoscopic Trans-Abdominal PrePeritoneal (TAPP), the Totally Extra Peritoneal (TEP), and the robotic TAPP (rTAPP) are commonly performed. The aim of the present network meta-analysis was to globally compare short-term outcomes within these major surgical techniques for primary unilateral inguinal hernia repair.

METHODS

PubMed, EMBASE, and Web of Science were consulted. A fully Bayesian network meta-analysis was performed.

RESULTS

Sixteen studies (51.037 patients) were included. Overall, 35.5% underwent Open, 33.5% TAPP, 30.7% TEP, and 0.3% rTAPP. The postoperative seroma risk ratio (RR) was comparable considering TAPP vs. Open (RR 0.91; 95% CrI 0.50-1.62), TEP vs. Open (RR 0.64; 95% CrI 0.32-1.33), TEP vs. TAPP (RR 0.70; 95% CrI 0.39-1.31), and rTAPP vs. Open (RR 0.98; 95% CrI 0.37-2.51). The postoperative chronic pain RR was similar for TAPP vs. Open (RR 0.53; 95% CrI 0.27-1.20), TEP vs. Open (RR 0.86; 95% CrI 0.48-1.16), and TEP vs. TAPP (RR 1.70; 95% CrI 0.63-3.20). The recurrence RR was comparable when comparing TAPP vs. Open (RR 0.96; 95% CrI 0.57-1.51), TEP vs. Open (RR 1.0; 95% CrI 0.65-1.61), TEP vs. TAPP (RR 1.10; 95% CrI 0.63-2.10), and rTAPP vs. Open (RR 0.98; 95% CrI 0.45-2.10). No differences were found in term of postoperative hematoma, surgical site infection, urinary retention, and hospital length of stay.

CONCLUSIONS

This study suggests that Open, TAPP, TEP, and rTAPP seem comparable in the short term. The surgical management of inguinal hernia is evolving and the effect of the adoption of innovative minimally invasive techniques should be further investigated in the long term. Ultimately, the choice of the most suitable treatment should be based on individual surgeon expertise and tailored on each patient.

Pre-clinical assay of the tissue integration and mechanical adhesion of several types of cyanoacrylate adhesives in the fixation of lightweight polypropylene meshes for abdominal hernia repair

INTRODUCTION

Lightweight (LW) polypropylene (PP) meshes better adapt to host tissue, causing less fibrosis and inflammatory responses than high-density meshes. Mesh fixation using tissue adhesives (TA) that replace conventional sutures may improve the process of hernia repair and tissue trauma. This preclinical study compares the behavior of different cyanoacrylate-based adhesives in the fixation of LW-PP meshes for hernia repair.

METHODS

Partial abdominal wall defects were repaired using LW-PP Optilene meshes in New Zealand rabbits. The following groups were established according to the mesh fixation method: Suture (control), Glubran 2 (n-butyl), Ifabond (n-hexyl), SafetySeal (n-butyl) and Evobond (n-octyl). At 14, 90 and 180 days after surgery, the recovered implants were examined to assess the host tissue integration, the macrophage response and the biomechanical strength.

RESULTS

All the groups showed optimal host tissue incorporation regardless of the fixation procedure. Significantly increased levels of collagen 1 and collagen 3 gene expression (p<0.001) were observed at 14 days compared to the medium- and long-term durations, where the Suture and Glubran groups showed the highest expression of collagen 1. All the adhesives increased the macrophage reaction (p<0.001) compared to sutures at all implant times. Maximal macrophage response was observed in the short-term Glubran group (p<0.01) compared to the rest of the groups. Although SafetySeal and Evobond did not reach the biomechanical resistance of sutures at 14 days, all the adhesives did reach this level in the medium- to long-term periods, providing significantly higher resistance (p<0.05).

CONCLUSIONS

All the cyanoacrylates, despite inducing a significantly increased macrophage response versus sutures, showed optimal host tissue integration and long-term mechanical behavior; thus, they might be good choices for LW-PP mesh hernia repairs.

Management of chronic pain after hernia repair

Chronic pain following inguinal hernia repair is a common problem and feared complication. Up to 16% of people experience chronic pain following the repair of a groin hernia. The aim of this review was to provide an overview of treatment strategies for patients with chronic pain following inguinal hernia repair based on best practice guidelines and current clinical routines. The optimal management of chronic pain following inguinal hernia surgery should begin with a thorough clinical examination to rule out other causes of chronic pain and to rule out a recurrence. A scaled approach to treatment is recommended. Initially, watchful waiting can be tried if it can be tolerated by the patient and then systemic painkillers, escalating to blocks, and surgery as the final option. Surgery should include mesh removal and triple neurectomy following anterior approaches or mesh and tack removal following a posterior approach. The diagnosis and treatment strategies should be performed by or discussed with experts in the field.

A meta-analysis of randomized control trials assessing mesh fixation with glue versus suture in Lichtenstein inguinal hernia repair

BACKGROUND

The use of glue to fix mesh instead of sutures in Lichtenstein inguinal hernia repair has been accepted worldwide, with the increasing worries about postoperative chronic groin pain and recurrence. The aim of this meta-analysis was to clarify which mesh fixation method was more suitable in Lichtenstein inguinal hernia repair.

METHODS

Articles published up to July 2017 were searched using MEDLINE, the Cochrane Library, Embase, and the Web of Science. Randomized controlled trials (RCTs) comparing glue versus suture mesh fixation in Lichtenstein inguinal hernia repair were included in the review. The quality assessment and data extraction of included studies were applied by 2 independent authors. Statistical analysis was performed using RevMan 5.2 software.

RESULTS

Thirteen RCTs with 2375 patients were eligible for inclusion. Eight trials compared synthetic glue with suture fixation and 5 compared biological glue with suture fixation. The results showed that there was a lower incidence of early chronic pain (subgroup analysis, biological glue versus sutures, odds ratio (OR) = 0.41; 95% confidence interval (CI), 0.19-0.90; P = .03), and hematoma (subgroup analysis, synthetic glue versus sutures, OR = 0.56; 95% CI, 0.34-0.95; P = .03) in the glue fixation group. Suture mesh fixation method cost more time in operation than glue (mean difference = -4.60, 95% CI -7.60 to -1.60; P = .003). There was no evidence of an increase in chronic pain or recurrence rates with glue fixation method in the long-term follow-up.

CONCLUSIONS

Mesh fixation with glue compared with sutures in Lichtenstein repair inguinal hernia is faster and less painful, without an increasing in terms of recurrence rates in the long term.

WITHDRAWN: Glue versus suture for mesh fixation in inguinal hernia repair

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International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

The HIPPO Trial, a Randomized Double-blind Trial Comparing Self-gripping Parietex Progrip Mesh and Sutured Parietex Mesh in Lichtenstein Hernioplasty: A Long-term Follow-up Study

OBJECTIVE

To evaluate the effect of a self-gripping mesh (Progrip) on the incidence of chronic postoperative inguinal pain (CPIP) and recurrence rate after Lichtenstein hernioplasty.

BACKGROUND

Chronic pain is the most common complication of inguinal hernioplasty. One of the causes may be the use of sutures to secure the mesh.

METHODS

Adult male patients undergoing Lichtenstein hernioplasty for a primary unilateral inguinal hernia were randomized to a self-gripping polyester mesh or a sutured polyester mesh. Follow-up took place after 2 weeks, 3, 12, and 24 months. Pain and quality of life were assessed using the Verbal Rating Scale, Visual Analog Scale, and Short Form 36. CPIP was defined as moderate pain lasting at least 3 months postoperatively.

RESULTS

There were 165 patients in the Progrip mesh group and 166 patients in the sutured mesh group. The incidence of CPIP was 7.3% at 3 months declining to 4.6% at 24 months and did not differ between both groups. Pain and quality of life scores were significantly improved after 2 years. Hernia recurrence rate after 24 months was 2.4% for the Progrip mesh and 1.8% for the sutured mesh (P = 0.213). The mean duration of surgery was significant shorter with the Progrip mesh (44 vs 53 minutes, P < 0.001).

CONCLUSIONS

The self-gripping Progrip mesh does not reduce CPIP rates. Outcomes of the Progrip mesh are comparable to the Lichtenstein technique with the additional advantage of a reduced operation time. NCT01830452.

Comparative Study of Sutureless Fixation of Lightweight Surgical Meshes for Hernia Repair in a Rat Model

The aim of this study was to compare the efficacy of different methods of sutureless fixation of lightweight meshes made of different polymers for repair of experimental hernias. Two lateral hernia defects were modeled in male rats and covered with polyester and polypropylene prostheses. The meshes were fixed with Histacryl glue (group 1), or self-gripping meshes were used (group 2), or the meshes were implanted without fixation (group 3). On day 5 after surgery, mesh position and efficiency of fixation were evaluated. It was found that fixation is necessary for all light surgical meshes. Polyester meshes demonstrated better adhesive properties than polypropylene meshes. The most pronounced differences in the adhesive properties were found for self-gripping prosthesis, while in the groups with glue fixation, the differences were less pronounced.

Comparison of self-gripping mesh and sutured mesh in open inguinal hernia repair: A meta-analysis of long-term results

BACKGROUND

Complications after inguinal hernioplasty pose a significant burden on individual patients and society because of high numbers of repair procedures. Recently, the long-term results of a self-gripping ProGrip mesh for open inguinal hernia repair have become available. The aim of this meta-analyses was to compare these long-term results with the results of a Lichtenstein hernioplasty with a sutured mesh focusing on chronic pain, recurrence rate, foreign body sensation, and operation duration.

METHODS

A systematic review of the literature was undertaken to identify randomized controlled trials comparing open inguinal hernia repair with a self-gripping ProGrip mesh and a conventional Lichtenstein hernioplasty.

RESULTS

In the present meta-analysis, the outcomes of 10 randomized controlled trials enrolling 2,541 patients were pooled. The mean follow-up was 24 months (range 6-72 months). There was no significant difference in the incidence of chronic pain (odds ratio = 0.93; 95% confidence interval, 0.74-1.18), recurrence (odds ratio = 1.34; 95% confidence interval, 0.82-2.19), or foreign body sensation (odds ratio = 0.82; 95% confidence interval, 0.65-1.03), between the self-gripping mesh and sutured mesh group at all follow-up time points. The mean operating time was significantly shorter (odds ratio = -7.58; 95% confidence interval, -9.58 to -5.58) in the self-gripping mesh group.

CONCLUSION

The self-gripping mesh has comparable results with a sutured mesh regarding the incidence of chronic postoperative inguinal pain, recurrence and foreign body sensation. However, long-term results still are based on relatively small patient numbers and outcomes measures are heterogenic. The main advantage of the self-gripping mesh is the consistently significantly reduced operation time.

Host tissue response by the expression of collagen to cyanoacrylate adhesives used in implant fixation for abdominal hernia repair

The less traumatic use of surgical adhesives rather than sutures for mesh fixation in hernia repair has started to gain popularity because they induce less host tissue damage and provoke less postoperative pain. This study examines the host tissue response to a new cyanoacrylate (CA) adhesive (n-octyl, OCA). Partial defects (3 × 5 cm) created in the rabbit anterior abdominal wall were repaired by mesh fixation using OCA, Glubran2^®(n-butyl-CA), Ifabond^®(n-hexyl-CA) or sutures. Samples were obtained at 14/90 days for morphology, collagens qRT-PCR/immunofluorescence and biomechanical studies. All meshes were successfully fixed. Seroma was detected mainly in the Glubran group at 14 days. Meshes fixed using all methods showed good host tissue incorporation. No signs of degradation of any of the adhesives were observed. At 14 days, collagen 1 and 3 mRNA expression levels were greater in the suture and OCA groups, and lower in Ifabond, with levels varying significantly in the latter group with respect to the others. By 90 days, expression levels had fallen in all groups, except for collagen 3 mRNA in Ifabond. Collagen I and III protein expression was marked in the suture and OCA groups at 90 days, but lower in Ifabond at both time points. Tensile strengths were similar across groups. Our findings indicate the similar behavior of the adhesives to sutures in terms of good tissue incorporation of the meshes and optimal repair zone strength. The lower seroma rate and similar collagenization to controls induced by OCA suggests its improved behavior over the other two glues. This article deals with a preclinical study to examine different aspects of the repair process in the host of three alkyl cyanoacrylates (n-butyl (GLUBRAN 2), n-hexyl (IFABOND), and n-octyl cyanoacrylate (EVOBOND)) compared to sutures (control), in the fixation of surgical meshes for hernia repair. It goes into detail about collagen deposition in the repair zone at short and medium term. The results obtained demonstrate lower seroma rate and similar collagenization to sutures induced by the n-octyl suggesting better behavior than the other two cyanoacrylates.

Totally extraperitoneal laparoscopic inguinal hernia repair using a self-expanding nitinol framed hernia repair device: A prospective case series

BACKGROUND

The use of a self-expanding nitinol framed prosthesis (ReboundHRD^®) for totally extraperitoneal laparoscopic inguinal hernia repair (TEP-IHR) could solve issues of mesh shrinkage and associated pain. We prospectively evaluated the use of the ReboundHRD^® mesh for TEP-IHR.

MATERIALS AND METHODS

All patients who underwent a TEP-IHR using the ReboundHRD^® Large mesh from April 2014 till May 2015, were included. No mesh fixation was performed. Follow-up assessments were performed at the day of surgery, 1, 2, and 7 days, 1, 3, 6, and 12 months. Outcome measures include post-operative pain (visual analogue scale, VAS), operative details, complications, and recurrence rate.

RESULTS

In total, 69 TEP-IHR procedures were performed in 54 patients (15 bilateral hernias). No perioperative and 5 (9%) postoperative complications occurred, all graded Clavien-Dindo I-II. The median length of stay was 1 day (range 0-3), with 78% of the operations performed in an ambulatory setting. Median VAS score decreased from 3 (range 0-4) on the day of surgery to 1 (range 0-2) on day 7. Patients were completely pain-free at a median time of 5 (range 1-60) days. The majority (80.4%, 37/46) of the active patients went back to work within 2 weeks (maximum 6 weeks). At a median follow-up of 19 months (range 16-26 months), no recurrences occurred.

CONCLUSION

TEP-IHR using a self-expanding nitinol framed hernia repair device is a safe technique in longterm follow-up. The technique is associated with a low incidence of postoperative pain, a short hospital stay and quick return to normal activities.

Randomized clinical trial of mesh fixation with glue or sutures for Lichtenstein hernia repair

BACKGROUND

Pain is the most likely reason for delay in resuming normal activities after groin hernia repair. The primary aim of this study was to determine whether the use of glue to fix the mesh instead of sutures reduced acute postoperative pain after inguinal hernia repair. Secondary objectives were to compare postoperative complications, chronic pain and early recurrence rates during 1-year follow-up.

METHODS

Some 370 patients who underwent Lichtenstein hernia repair were randomized to receive either glue (Histoacryl®) or non-absorbable polypropylene sutures for fixation of lightweight polypropylene mesh. Postoperative complications, pain and recurrence were evaluated by an independent blinded observer.

RESULTS

Postoperative pain at 8 h, 24 h, 7 days and 30 days was less when glue was used instead of sutures for all measures (P < 0·001). The operation was significantly quicker using glue (mean(s.d.) 35·3(8·7) min versus 39·9(11·1) min for sutures; P < 0·001). There were no significant differences between the groups in terms of postoperative complications, chronic pain and early recurrence at 1-year follow-up.

CONCLUSION

Atraumatic mesh fixation with glue was quicker and resulted in less acute postoperative pain than sutures for Lichtenstein hernia repair. Registration number: NCT02632097 (http://www.clinicaltrials.gov).

Mesh fixation with glue versus suture for chronic pain and recurrence in Lichtenstein inguinal hernioplasty

BACKGROUND

Chronic pain following mesh-based inguinal hernia repair is frequently reported, and has a significant impact on quality of life. Whether mesh fixation with glue can reduce chronic pain without increasing the recurrence rate is still controversial.

OBJECTIVES

To determine whether tissue adhesives can reduce postoperative complications, especially chronic pain, with no increase in recurrence rate, compared with sutures for mesh fixation in Lichtenstein hernia repair.

SEARCH METHODS

We searched the following electronic databases with no language restrictions: the Cochrane Central Register of Controlled Trials (CENTRAL; issue 4, 2016) in the Cochrane Library (searched 11 May 2016), MEDLINE Ovid (1986 to 11 May 2016), Embase Ovid (1986 to 11 May 2016), Science Citation Index (Web of Science) (1986 to 11 May 2016), CBM (Chinese Biomedical Database), CNKI (China National Knowledge Infrastructure), VIP (a full-text database in China), Wanfang databases. We also checked reference lists of identified papers (included studies and relevant reviews).

SELECTION CRITERIA

We included all randomised and quasi-randomised controlled trials comparing glue versus sutures for mesh fixation in Lichtenstein hernia repair. Cluster-RCTs were also eligible.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and assessed the risk of bias independently. Dichotomous outcomes were expressed as odds ratio (OR) with 95% confidence intervals (CI). Continuous outcomes were expressed as mean differences (MD) with 95% CIs.

MAIN RESULTS

Twelve trials with a total of 1932 participants were included in this review. The overall postoperative chronic pain in the glue group was reduced by 37% (OR 0.63, 95% CI 0.44 to 0.91; 10 studies, 1418 participants, low-quality evidence) compared with the suture group. However, the results changed when we conducted subgroup analysis with regard to the type of mesh. Subgroup analysis of included studies using lightweight mesh showed the reduction of chronic pain was less profound and insignificant (OR 0.77, 95% CI 0.50 to 1.17). Subgroup analysis of included studies using heavyweight mesh resulted in a significant benefit from the fixation with glue (OR 0.38, 95% CI 0.17 to 0.82).Hernia recurrence was similar between the two groups (OR 1.44, 95% CI 0.63 to 3.28; 12 studies, 1932 participants, low-quality evidence). Fixation with glue was superior to suture regarding duration of the operation (MD -3.13, 95% CI -4.48 to -1.78; 9 studies, 1790 participants, low-quality evidence); haematoma (OR 0.52, 95% CI 0.31 to 0.86; 10 studies, 1384 participants, moderate-quality evidence); and recovery time to daily activities (MD -1.26, 95% CI -1.89 to -0.63; 3 studies, 403 participants, low-quality evidence).We also investigated adverse events. There were no significant differences between the two groups. For superficial wound infection pooled analyses showed OR 1.23, 95% CI 0.37 to 4.11; 7 studies, 763 participants (low-quality evidence); for mesh/deep infection OR 0.67, 95% CI 0.16 to 2.83; 8 studies, 1393 participants (low-quality evidence). Furthermore, we investigated seroma (a postoperative swelling caused by fluid) (OR 0.83, 95% CI 0.51 to 1.33); and persisting numbness (OR 0.81, 95% CI 0.57 to 1.14).Finally, six trials involving 1009 participants reported postoperative length of stay, resulting in non-significant difference between the two groups (MD -0.12, 95% CI: -0.35 to 0.10)Due to the lack of data, it was impossible to draw any distinction between synthetic glue and biological glue.Eight out of 12 trials showed high risk of bias in at least one of the investigated domains. Two studies were quasi-randomised controlled trials and the allocation sequence of one trial was not concealed. Nearly half of the included trials either did not provide adequate information or had high risk of bias regarding blinding processes. The risk of bias for incomplete outcome data of all the included studies varied from low to high risk of bias. Two trials did not report on some important outcomes. One study was funded by the manufacturer producing the fibrin sealant. Therefore, according to the 'Summary of findings' tables, the quality of the evidence (GRADE) for the outcomes is moderate to low.

AUTHORS' CONCLUSIONS

Based on the short-term results, glue may reduce postoperative chronic pain and not simultaneously increase the recurrence rate, compared with sutures for mesh fixation in Lichtenstein hernia repair. Glue may therefore be a sensible alternative to suture for mesh fixation in Lichtenstein repair. Larger trials with longer follow-up and high quality are warranted. The difference between synthetic glue and biological glue should also be assessed in the future.

Mesh fixation methods in open inguinal hernia repair: a protocol for network meta-analysis and trial sequential analysis of randomised controlled trials

INTRODUCTION

Randomised clinical trials (RCTs) have been used to compare and evaluate different types of mesh fixation usually employed to repair open inguinal hernia. However, there is no consensus among surgeons on the best type of mesh fixation method to obtain optimal results. The choice often depends on surgeons' personal preference. This study aims to compare different types of mesh fixation methods to repair open inguinal hernias and their role in the incidences of chronic groin pain, risk of hernia recurrence, complications, operative time, length of hospital stay and postoperative pain, using Bayesian network meta-analysis and trial sequential analysis of RCTs.

METHODS AND ANALYSIS

A systematic search will be performed using PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Chinese Biomedical Literature Database (CBM) and Chinese Journal Full-text Database, to include RCTs of different mesh fixation methods (or fixation vs no fixation) during open inguinal hernia repair. The risk of bias in included RCTs will be evaluated according to the Cochrane Handbook V.5.1.0. Standard pairwise meta-analysis, trial sequential analysis and Bayesian network meta-analysis will be performed to compare the efficacy of different mesh fixation methods.

ETHICS AND DISSEMINATION

Ethical approval and patient consent are not required since this study is a meta-analysis based on published studies. The results of this network meta-analysis and trial sequential analysis will be submitted to a peer-reviewed journal for publication.

PROTOCOL REGISTRATION NUMBER

PROSPERO CRD42015023758.

Meta-analysis of randomized trials comparing nonpenetrating vs mechanical mesh fixation in laparoscopic inguinal hernia repair

BACKGROUND

Evidence for open groin hernia repair demonstrates less pain with bioglue mesh fixation compared with invasive methods. This study aimed to assess the short- and long-term effects of laparoscopic groin hernia repair with noninvasive and invasive mesh fixation.

DATA SOURCES

A systematic review of MEDLINE, CENTRAL, and OpenGrey was undertaken. Randomized trials assessing the outcome of laparoscopic groin hernia repair with invasive and noninvasive fixation methods were considered for data synthesis. Nine trials encompassing 1,454 patients subjected to laparoscopic hernia repair with mesh fixation using biologic or biosynthetic glue were identified. Short-term data were inadequate for data synthesis. Chronic pain was less frequently reported by patients subjected to repair with biologic glue fixation than with penetrating methods (odds ratio .46, 95% confidence interval .22 to .93). Duration of surgery, incidence of seroma/hematoma, morbidity, and recurrence were similar.

CONCLUSIONS

Laparoscopic groin hernia repair with bioglue mesh fixation was associated with a reduced incidence of chronic pain compared with mechanical fixation, without increasing morbidity or recurrence. Longer term data on recurrence are necessary.

Effect of peritoneal incision on immediate pain after inguinal hernia repair: A Prospective Cohort Study

OBJECTIVE

Hernia repair is a common surgical procedure, and postoperative pain is an inevitable result of hernia surgery. The prevention of postoperative pain is of considerable importance in terms of patient comfort and early discharge. In this study, we evaluated the effects of a peritoneal incision on pain in the early postoperative period.

SUMMARY OF BACKGROUND DATA

This was a prospective clinical study with 75 patients undergoing inguinal hernia repair.

METHODS

Patients were divided into five groups: group 1: indirect hernia, Lichtenstein repair with peritoneal incision, group 2: indirect hernia, Lichtenstein repair without peritoneal incision, group 3: all hernias, trans-abdominal preperitoneal(TAPP) repair, group 4: all hernias, total extraperitoneal (TEP) repair, and group 5: direct hernia, Lichtenstein repair with no peritoneal incision. Groups were compared in terms of postoperative pain scores at three different times and complications.

RESULTS

There were 62 males and 13 females; their average age was 51.25 years. The visual analog scale (VAS) scores were lower in groups 2, 4, and 5, and there were differences among groups and within each group according to VAS changes assessed at all time points (p < 0.05). There was no difference, according to VAS analysis, between open and laparoscopic surgery groups. There was a difference according to VAS changes in each group between hernia sides (p < 0.001).

CONCLUSION

Peritoneal incision is a significant risk factor for postoperative pain after inguinal hernia repair. But, surgical procedure was not a risk factor although VAS scores were higher in open than laparoscopic surgery.

Pain control following inguinal herniorrhaphy: current perspectives

Inguinal hernia repair is one of the most common surgeries performed worldwide. With the success of modern hernia repair techniques, recurrence rates have significantly declined, with a lower incidence than the development of chronic postherniorrhaphy inguinal pain (CPIP). The avoidance of CPIP is arguably the most important clinical outcome and has the greatest impact on patient satisfaction, health care utilization, societal cost, and quality of life. The etiology of CPIP is multifactorial, with overlapping neuropathic and nociceptive components contributing to this complex syndrome. Treatment is often challenging, and no definitive treatment algorithm exists. Multidisciplinary management of this complex problem improves outcomes, as treatment must be individualized. Current medical, pharmacologic, interventional, and surgical management strategies are reviewed.

Reduced postoperative chronic pain after tension-free inguinal hernia repair using absorbable sutures: a single-blind randomized clinical trial

BACKGROUND

Chronic pain after inguinal hernia repair occurs in 16% to 62% of patients. The underlying mechanism probably involves sensory nerve damage and abnormal healing that might be influenced by the materials chosen for the procedure. We hypothesize that nonabsorbable sutures used for mesh fixation to the surrounding tissues are associated with higher rates of chronic groin pain after surgery.

STUDY DESIGN

We conducted a single-blind randomized clinical trial to compare the effect of absorbable braided sutures (Vycril; Ethicon) and nonabsorbable monofilament sutures (Prolene; Ethicon) used in inguinal hernia repair on the rate of chronic pain. We assessed chronic pain using a 4-point verbal-rank scale during a 1-year postoperative follow-up period.

RESULTS

Study groups included 100 patients in each group. No age, sex, or hernia-side differences were observed between the study groups. Chronic pain rate after surgery was higher in the nonabsorbable monofilament suture group compared with the absorbable braided suture group (37 vs 26 patients; p = 0.056). Time to pain disappearance was longer in the nonabsorbable monofilament suture vs the absorbable braided suture group (115.3 days; 95% CI, 88-142.7 vs 77.4 days; 95% CI, 54.3-100.3; p = 0.038, respectively). A 1-year age increment reduces the risk for chronic pain occurrence by 2.2% (odds ratio = 0.978%; 95% CI, 0.961-0.995; p = 0.013). The use of nonabsorbable sutures increases the risk for chronic pain in 94.9% compared with absorbable sutures (odds ratio = 1.949; 95% CI, 1.039-3.658; p = 0.038).

CONCLUSIONS

Nonabsorbable suture use in inguinal hernia repair is associated with a higher rate of chronic pain and a longer time to pain disappearance as compared with absorbable sutures.