Mesh fixation technique in totally extraperitoneal inguinal hernia repair - A network meta-analysis

Outcomes of laparoscopic inguinal hernia repair using tail-anchor mesh fixation method: A retrospective study

BACKGROUND

Laparoscopic inguinal hernia repair (LIHR) has become increasingly popular, but recurrence remains a concern. This study introduces a novel tail-anchor mesh (TAM) fixation method for LIHR and evaluates the safety, feasibility and clinical outcomes of this technique in patients undergoing LIHR.

PATIENTS AND METHODS

Between June 2018 and June 2020, 412 patients with inguinal hernias were included in the study. LIHR with the TAM method was performed in 210 patients (Group A), whereas 202 patients underwent LIHR with conventional mesh fixation (Group B). Statistical analysis was used to compare clinical data between the two groups.

RESULTS

The recurrence rate and incidence of seroma were significantly lower in Group A (0.48% and 1.90%, respectively) than in Group B (3.96% and 9.41%, respectively) (P < 0.05). There were no significant differences between the groups in terms of demographic indicators, intraoperative blood loss, operation time, hospital stay or patient costs (all P > 0.05). Follow-ups at 24 and 53 months after discharge revealed no cases of wound infection, chronic pain or testicular atrophy in either group.

CONCLUSIONS

The TAM fixation method is a safe, feasible and reproducible technique for LIHR and offers superior outcomes compared with conventional mesh fixation, particularly in reducing recurrence and seroma formation.

Penetrating versus non-penetrating mesh fixation in laparoscopic groin hernia repair

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of penetrating versus non-penetrating mesh fixation in adults receiving laparoscopic groin hernia repair.

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.

Efficacy and safety of mesh non-fixation in patients undergoing laparo-endoscopic repair of groin hernia: a systematic review and meta-analysis

PURPOSE

To examine updated evidence on the efficacy and safety of mesh non-fixation in patients undergoing laparo-endoscopic repair of groin hernias.

METHODS

We searched MEDLINE, Cochrane Central Library, Embase, ClinicalTrials. gov, and ICTRP databases to identify randomized controlled trials. The primary outcomes were recurrence, chronic pain, and return to daily life. The certainty of evidence (CoE) was assessed by grading recommendations, assessments, developments, and evaluations. We performed a subgroup analysis based on the surgical type. This study was registered with PROSPERO (CRD 42022368929).

RESULTS

We included 25 trials with 3,668 patients (4,038 hernias) were included. Mesh non-fixation resulted in little to no difference in hernia recurrence (relative risk [RR]:1.40, 95% confidence interval [CI]:0.59-3.31; I2 = 0%; moderate CoE) and chronic pain (RR:0.48, 95% CI:0.13-1.78; I2 = 77%; moderate CoE), but reduced return to daily life (mean difference [MD]: - 1.79 days, 95% CI: - 2.79 to -0.80; I2 = 96%; low CoE). In subgroup analyses, the transabdominal preperitoneal approach (TAPP) (MD: - 2.97 days, 95% CI: - 4.87 to - 1.08; I2 = 97%) reduced return to daily life than total extraperitoneal inguinal approach (MD: - 0.24 days, 95% CI - 0.71 to 0.24; I2 = 61%) (p = 0.006).

CONCLUSIONS

Mesh nonfixation improves the return to daily life without increasing the risk of hernia recurrence or chronic pain. Surgeons and patients may discuss mesh nonfixation options to accommodate a patient's desired return to daily life. Further trials focusing on TAPP are required to confirm these findings.

A novel high accuracy model for automatic surgical workflow recognition using artificial intelligence in laparoscopic totally extraperitoneal inguinal hernia repair (TEP)

INTRODUCTION

Artificial intelligence and computer vision are revolutionizing the way we perceive video analysis in minimally invasive surgery. This emerging technology has increasingly been leveraged successfully for video segmentation, documentation, education, and formative assessment. New, sophisticated platforms allow pre-determined segments chosen by surgeons to be automatically presented without the need to review entire videos. This study aimed to validate and demonstrate the accuracy of the first reported AI-based computer vision algorithm that automatically recognizes surgical steps in videos of totally extraperitoneal (TEP) inguinal hernia repair.

METHODS

Videos of TEP procedures were manually labeled by a team of annotators trained to identify and label surgical workflow according to six major steps. For bilateral hernias, an additional change of focus step was also included. The videos were then used to train a computer vision AI algorithm. Performance accuracy was assessed in comparison to the manual annotations.

RESULTS

A total of 619 full-length TEP videos were analyzed: 371 were used to train the model, 93 for internal validation, and the remaining 155 as a test set to evaluate algorithm accuracy. The overall accuracy for the complete procedure was 88.8%. Per-step accuracy reached the highest value for the hernia sac reduction step (94.3%) and the lowest for the preperitoneal dissection step (72.2%).

CONCLUSIONS

These results indicate that the novel AI model was able to provide fully automated video analysis with a high accuracy level. High-accuracy models leveraging AI to enable automation of surgical video analysis allow us to identify and monitor surgical performance, providing mathematical metrics that can be stored, evaluated, and compared. As such, the proposed model is capable of enabling data-driven insights to improve surgical quality and demonstrate best practices in TEP procedures.

Efficacy and safety of glue mesh fixation for laparoscopic inguinal hernia: A meta-analysis of randomized controlled trials

It is still controversial whether glue can be used for mesh fixation in laparoscopic inguinal hernia repair. The aim of this meta-analysis was used to systematically evaluate the effectiveness and safety of glue mesh fixation in laparoscopic tension-free inguinal hernia repair. The PubMed database, EMBASE database and Cochrane Library were searched to collect published randomized controlled trials (RCTs) on laparoscopic tension-free inguinal hernia repair with glue mesh fixation. Sixteen RCTs and 2409 patients with inguinal hernia were included. The meta-analysis showed that compared with the mechanical mesh fixation group(MMFG), the glue mesh fixation group(GMFG) had significantly reduced incidences of chronic pain[relative risk (RR) = 0.40, 95% confidence interval (CI) (0.28,0.57), P < 0.00001], urinary retention[RR = 0.53, 95% CI(0.29,0.97), P = 0.04], haematoma[RR = 0.23, 95% CI(0.09,0.58), P = 0.002] and total complications[RR = 0.28, 95% CI(0.18,0.44), P < 0.00001]; there were no significant differences in pain score on postoperative day 1[MD = -1.33, 95% CI(-2.93,0.26), P = 0.10], operation time[MD = 1.46, 95% CI(-3.97,6.88), P = 0.60] and recurrence rate[RR = 0.72, 95% CI(0.35,1.47), P = 0.37] between the two groups. In conclusion, the application of glue mesh fixation in laparoscopic inguinal hernia repair is safe and reliable with fewer complications. Moreover, it can reduce the incidence of chronic pain without increasing the recurrence rate. However, due to the small number of cases in this analysis and limitations in the quality of the included studies, the findings need to be further verified by multicentre, large-sample and high-quality RCTs in the future.

Chronic pain following totally extra-peritoneal inguinal hernia repair: a randomized clinical trial comparing glue and absorbable tackers

PURPOSE

Chronic pain following inguinal hernia repair occurs in up to 20% of patients. The underlying mechanism probably involves sensory nerve damage and abnormal healing that might be influenced by the materials chosen for mesh fixation. The main objective of this study was to compare glue and absorbable tackers on the rate of chronic pain after surgery in patients undergoing totally extraperitoneal inguinal hernia repair (TEP).

METHODS

Patients undergoing (TEP) inguinal hernia repair were enrolled in a single-blind randomized clinical trial and were randomized for mesh fixation with glue (LIQUIBAND FIX 8 Neopharm) or absorbable tackers (SECURE STRAP Johnson & Johnson). Pain was assessed using a validated 4-point verbal-rank scale (none, mild, moderate, and severe) at 1 week, 1 month, 6 months, and 1 year postoperatively. Chronic pain was defined as pain persisting beyond 3 months.

RESULTS

Two hundred and eight patients were analyzed. The groups were similar in age, gender, and hernia side. Chronic pain of any intensity was reported in 31.7% (66/208) after 6 months and in 13% (29/208) after 12 months. No differences in postoperative pain were observed between the two forms of mesh fixation. Still, when only those with severe pain were considered, mesh fixation with glue resulted in less pain compared to fixation by tackers (log-rank p = 0.025). At 1 year, 4 symptomatic recurrent hernias were identified in patients whose mesh was fixated with absorbable tackers.

CONCLUSIONS

Patients who underwent TEP inguinal hernia repair with mesh fixated by glue suffered from less pain.

Mesh fixation techniques in Lichtenstein tension-free repair: a network meta-analysis

BACKGROUNDS

To compare the clinical effectiveness of different mesh fixation techniques in Lichtenstein tension-free repair using network meta-analysis.

METHODS

Cochrane Library, Medline, EMBASE, and Web of Science databases were searched until 1 December 2020, and randomized controlled trials (RCTs) comparing outcomes between different mesh fixation techniques were included. The primary endpoints were chronic postoperative inguinal pain (CPIP) and hernia recurrence. The second endpoint was seroma and infection. Data were processed using Stata MP16.0, and R x64 3.6.1.

RESULTS

The results demonstrated that 32 RCTs (n = 6362) were eligible for pooling. Six types of mesh fixation techniques were used: non-absorbable suture, absorbable suture, chemical glue, fibrin glue, self-gripping mesh, and staple fixation. Network meta-analysis indicated that the incidence of CPIP with fibrin glue was lower than that with non-absorbable sutures (relative risk [RR] = 0.23, 95% credibility interval [95%CrI] [0.09, 0.50]), absorbable sutures (RR = 0.24, 95%CrI [0.08, 0.60]), chemical glue (RR = 0.36, 95%CrI [0.13, 0.87]), and self-gripping mesh (RR = 0.27 95%CrI [0.09, 0.62]). Self-gripping mesh was superior to non-absorbable sutures (RR = 0.44, 95%CrI [0.23, 0.74]) in reducing postoperative infection.

CONCLUSION

This network meta-analysis suggests that fibrin glue might be best for reducing CPIP and recurrence. However, a large-scale RCT is warranted to confirm the results.

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 techniques for inguinal hernia repair: an overview of systematic reviews of randomised controlled trials

PURPOSE

Inguinal hernia repair using surgical mesh is a very common surgical operation. Currently, there is no consensus on the best technique for mesh fixation. We conducted an overview of existing systematic reviews (SRs) of randomised controlled trials to compare the risk of chronic pain and recurrence following open and laparoscopic inguinal hernia repairs using various mesh fixation techniques.

METHODS

We searched major electronic databases in April 2020 and assessed the methodological quality of identified reviews using the AMSTAR-2 tool.

RESULTS

We identified 20 SRs of variable quality assessing suture, self-gripping, glue, and mechanical fixation. Across reviews, the risk of chronic pain after open mesh repair was lower with glue fixation than with suture and comparable between self-gripping and suture. Incidence of chronic pain was lower with glue fixation than with mechanical fixation in laparoscopic repairs. There were no significant differences in recurrence rates between fixation techniques in open and laparoscopic mesh repairs, although fewer recurrences were reported with suture. Many reviews reported wide confidence intervals around summary estimates. Despite no clear evidence of differences among techniques, two network meta-analyses (one assessing open repairs and one laparoscopic repairs) ranked glue fixation as the best treatment for reducing pain and suture for reducing the risk of recurrence.

CONCLUSION

Glue fixation may be effective in reducing the incidence of chronic pain without increasing the risk of recurrence. Future research should consider both the effectiveness and cost-effectiveness of fixation techniques alongside the type of mesh and the size and location of the hernia defect.

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.

Fixation versus no fixation in laparoscopic totally extraperitoneal repair of primary inguinal hernia-a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

The necessity of mesh fixation in laparoscopic totally extraperitoneal (TEP) inguinal hernia repair remains controversial. We performed a systematic review and meta-analysis to compare the effectiveness of mesh fixation versus no fixation in laparoscopic TEP repair for primary inguinal hernia.

MATERIALS AND METHODS

PubMed, EMBASE, and Cochrane databases were searched for relevant articles from January 1992 until May 2020. All trials that compared fixation versus no fixation in TEP repairs for inguinal herniae were included. Recurrent and femoral herniae were excluded from the current analysis. The primary outcome measure was recurrence while secondary outcomes included postoperative pain at 24 h, mean operative time, urinary retention, and seroma rates. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also carried out.

RESULTS

Eight randomized controlled trials were included capturing 557 patients and 715 inguinal herniae. On random effects analysis, there were no significant differences between fixation and no fixation with respect to recurrence (RD 0.00, 95% CI = - 0.01 to 0.01, p = 1.00), operative time (MD 1.58 min, 95% CI = - 0.22 to 3.37, p = 0.09), seroma (OR = 0.70, 95% CI = 0.28 to 1.74, p = 0.44), or urinary retention (RD 0.09, 95% CI = - 0.18 to 0.36, p = 0.53). However, fixation was associated with more pain at 24 h (MD 0.93, 95% CI = 0.20 to 1.66, p = 0.01).

CONCLUSIONS

Mesh fixation in laparoscopic TEP repair for primary inguinal herniae is associated with increased postoperative pain at 24 h but similar recurrence, seroma, and urinary retention. Therefore, it may be omitted.

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.