Self-gripping versus sutured mesh fixation methods for open inguinal hernia repair: A systematic review of clinical trials and observational studies

Chronic inguinal pain post-hernioplasty. Laparo-endoscopic surgery vs lichtenstein repair: systematic review and meta-analysis

PURPOSE

Annually, over 20 million patients worldwide undergo inguinal hernia repair procedures. Surgery stands as the recommended treatment, however, a consensus on the optimal method is lacking. This study aims to conduct an updated systematic review and meta-analysis to compare the risk of chronic inguinal pain and recurrence between laparo-endoscopic mesh repair (TAPP and TEP) versus Lichtenstein repair for inguinal hernia.

METHODS

Searches were conducted in Ovid MEDLINE, PubMed, EBSCO, Cochrane, and Google Scholar. Inclusion criteria encompassed randomized controlled trials (RCTs) involving adults, published in English and Spanish, comparing surgical outcomes among the Lichtenstein open technique, TAPP, and/or TEP. Adherence to the PRISMA guidelines was maintained in the methodology, and the CASP tool was employed to assess the quality of the articles. Statistical analysis involved mean [± standard deviation (SD)], Odds Ratio (OR), and Confidence Interval (CI).

RESULTS

Eight RCTs encompassing 1,469 patients randomized to Lichtenstein repair (n = 755) and laparo-endoscopic repair (n = 714) were included. Laparo-endoscopic repair was associated with a lower likelihood of chronic inguinal pain compared to Lichtenstein repair (OR = 0.28, 95% CI [0.30-0.56], p = 0.0001). There were no significant differences in recurrence rates between the laparo-endoscopic and the Lichtenstein group (OR = 1.03, 95% CI [0.57-1.86], p = 0.92).

CONCLUSIONS

This systematic review and meta-analysis demonstrate that laparo-endoscopic hernia surgery leads to a lower incidence of chronic inguinal pain compared to Lichtenstein repair, while maintaining similar rates of recurrence.

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.

Comparison of Postoperative Chronic Groin Pain After Repair of Inguinal Hernia Using Nonabsorbable Versus Absorbable Sutures for Mesh Fixation

BACKGROUND

Inguinal hernia repair is one of the most common operations performed in general surgery. Lichtenstein mesh hernioplasty is a commonly practiced technique for open inguinal hernia repair. Out of many other complications postoperatively, chronic groin pain is one of the patients' most common postoperative complaints. There is no direct evidence to explain the cause of post-mesh hernioplasty pain. Only a few studies have been done to judge the effect of suture material used for mesh fixation on chronic groin pain.

AIMS AND OBJECTIVES

To compare the postoperative groin pain level in mesh hernioplasty using nonabsorbable versus absorbable sutures for mesh fixation at predetermined intervals using a visual analog scale (VAS) score.

METHODS

 A prospective, single-center, non-randomized, observational study was conducted. All patients per inclusion and exclusion criteria of inguinal hernia planned for surgery were admitted electively on the day of surgery and were operated on in minor OT under local anesthesia for open mesh hernioplasty. The VAS score assessed the postoperative pain level.

RESULTS

 This observational study was done to look for any difference in postoperative chronic groin pain after mesh fixation with either nonabsorbable, prolene sutures (PS) or absorbable vicryl sutures (VS). One hundred and ten patients fulfilling the department of general surgery inclusion criteria were admitted to the study. In our study, postoperatively, the incidence of chronic groin pain was assessed and followed up to six months. After six months, 25%of patients had pain. Of this 25%, the majority (70%) of patients had mild pain, 15% had moderate pain, and 15% had severe pain. There was no statistically significant difference between the two groups of mesh fixation by nonabsorbable versus absorbable sutures.

CONCLUSION

Inguinal hernia is one of the most typical conditions seen in general surgery clinics with male predominance. Definitive management of inguinal hernia is surgery. There is no difference in postoperative chronic groin pain with either type of suture material i.e., nonabsorbable or absorbable (prolene vs vicryl) sutures. To conclude, fixation material for mesh does not influence chronic inguinodynia. However, further studies are required for the same.

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.

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.

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.

Long-term follow-up of a randomized controlled trial of Lichtenstein repair vs the Valenti technique for inguinal hernia

Purpose

The aim of the study was to offer a prospective comparative assessment of long-term outcomes for inguinal hernia repair using Valenti and Lichtenstein techniques.

Materials and methods

568 surgical procedures for unilateral inguinal hernia repair using the Valenti (group V) or the Lichtenstein technique (group L) were performed. After the mean follow-up time of 9 years (8–12), 185 patients (70.1%) treated using Valenti method and 186 patients (71.3%) treated using Lichtenstein method were clinically assessed. All clinical data were registered in National Hernia Registry. The rate of recurrence was assessed as primary outcome. The secondary outcome involved chronic pain (VAS).

Results

9-year recurrence rate was 2.2% in both groups. No significant difference in recurrence rate was demonstrated in analysis adjusted for surgeon’s education, type of hernia, hernia size, hernia duration, or BMI between two groups (OR 1.0; 95% CI 0.69–1.67; p = 1.0). In follow-up the majority of patients reported no pain (71.9% in V; 73.7% in L). A constant pain was reported by four patients in each group. Severe pain was reported by 1.6% in V and 2.1% in L (p = 0.192).

Conclusions

Inguinal hernia repairs using Valenti and Lichtenstein methods show high, long-term effectiveness and do not significantly differ in the recurrence rate. Both methods ensure a low rate of chronic pain. The use of a single mesh size with a precisely defined shape and of a uniform mesh fixation method ensures the standardization of surgical technique. The Valenti method is an uncomplicated, technically reproducible procedure with a low learning curve.

Factors predicting chronic pain after open inguinal hernia repair: a regression analysis of randomized trial comparing three different meshes with three fixation methods (FinnMesh Study)

BACKGROUND

Chronic pain after inguinal hernioplasty is the foremost side-effect up to 10-30% of patients. Mesh fixation may influence on the incidence of chronic pain after open anterior mesh repairs.

METHODS

Some 625 patients who underwent open anterior mesh repairs were randomized to receive one of the three meshes and fixations: cyanoacrylate glue with low-weight polypropylene mesh (n = 216), non-absorbable sutures with partially absorbable mesh (n = 207) or self-gripping polyesther mesh (n = 202). Factors related to chronic pain (visual analogue scores; VAS ≥ 30, range 0-100) at 1 year postoperatively were analyzed using logistic regression method. A second analysis using telephone interview and patient records was performed 2 years after the index surgery.

RESULTS

At index operation, all patient characteristics were similar in the three study groups. After 1 year, chronic inguinal pain was found in 52 patients and after 2 years in only 16 patients with no difference between the study groups. During 2 years' follow-up, three (0.48%) patients with recurrences and five (0.8%) patients with chronic pain were re-operated. Multivariate regression analysis indicated that only new recurrent hernias and high pain scores at day 7 were predictive factors for longstanding groin pain (p = 0.001). Type of mesh or fixation, gender, pre-operative VAS, age, body mass index or duration of operation did not predict chronic pain.

CONCLUSION

Only the presence of recurrent hernia and early severe pain after index operation seemed to predict longstanding inguinal pain.