Laparoscopic Inguinal Hernia Repair in Men With Lightweight Meshes May Significantly Impair Sperm Motility: A Randomized Controlled Trial

Impact of titanium-coated polypropylene mesh on functional outcome and quality of life after inguinal hernia repair

Objective

This study aims to compare the clinical outcomes of complications, quality of life, and chronic pain between titanium-coated polypropylene mesh and polypropylene mesh after Lichtenstein or TAPP surgery.

Methods

A retrospective cohort study was conducted, involving patients who underwent inguinal hernia repair using Timesh light®, Optilene LP®, or 3DMax™ meshes between January 2020 and May 2022. Based on the surgical method, patients were divided into Lichtenstein and TAPP groups, and further categorized according to the type of mesh used. The primary endpoints assessed postoperative complications, postoperative pain, and postoperative quality of life. Secondary endpoints included postoperative sensation in the surgical area and postoperative recurrence rate.

Results

A total of 180 Lichtenstein procedures and 478 TAPP procedures were included in the analysis after propensity score matching. The findings revealed that patients with titanium-coated polypropylene mesh did not exhibit significant advantages in perioperative data. Within three months to one year after TAPP surgery, patients with the titanium-coated polypropylene mesh reported improved foreign body sensation during activities (P = 0.002) and a lower incidence of chronic pain (P = 0.008). However, after one year, these advantages of titanium-coated polypropylene mesh were no longer significant during activity or at rest. In the TAPP group, the titanium-coated polypropylene mesh depicted advantages in the single score of the SF-36 questionnaire.

Conclusions

The utilization of titanium-coated polypropylene mesh resulted in reduced foreign body sensation and chronic pain in activity within one year after TAPP surgery, significantly enhancing certain aspects of the patient's quality of life compared to polypropylene mesh.

Definition of Mesh Weight and Pore Size in Groin Hernia Repair: A Systematic Scoping Review of Randomised Controlled Trials

Introduction: Groin hernia literature often uses the terms light- and heavyweight and small or large pores to describe meshes. There is no universal definition of these terms, and the aim of this scoping review was to assess how mesh weight and pore sizes are defined in the groin hernia literature. Methods: In this systematic scoping review, we searched PubMed, Embase, and Cochrane CENTRAL. We included randomised controlled trials with adults undergoing groin hernia repair with the Lichtenstein or laparoscopic techniques using a flat permanent polypropylene or polyester mesh. Studies had to use the terms lightweight, mediumweight, or heavyweight to be included, and the outcome was to report how researchers defined these terms as well as pore sizes. Results: We included 48 studies with unique populations. The weight of lightweight meshes ranged from 28 to 60 g/m2 with a median of 39 g/m2, and the pore size ranged from 1.0 to 4.0 mm with a median of 1.6 mm. The weight of heavyweight meshes ranged from 72 to 116 g/m2 with a median of 88 g/m2, and the pore size ranged from 0.08 to 1.8 mm with a median of 1.0 mm. Only one mediumweight mesh was used weighing 55 g/m2 with a pore size of 0.75 mm. Conclusion: There seems to be a consensus that meshes weighing less than 60 g/m2 are defined as lightweight and meshes weighing more than 70 g/m2 are defined as heavyweight. The weight terms were used independently of pore sizes, which slightly overlapped between lightweight and heavyweight meshes.

Heavyweight Mesh Is Superior to Lightweight Mesh in Laparo-endoscopic Inguinal Hernia Repair: A Meta-analysis and Trial Sequential Analysis of Randomized Controlled Trials

OBJECTIVE

This meta-analysis and trial sequential analysis aims to provide an update on the available randomized controlled trials (RCTs) and recommendations on using lightweight mesh (LWM) or heavyweight mesh (HWM) in laparo-endoscopic inguinal hernia repair.

BACKGROUND

LWM might reduce chronic pain through improved mesh flexibility and less fibrosis formation. However, in laparo-endoscopic repair chronic pain is already rare and LWM raise concerns of higher recurrence rates.

METHODS

A literature search was conducted in May 2019 in MEDLINE, Embase, and the Cochrane library for RCTs that compared lightweight (≤50 g/m2) and heavyweight (>70 g/m2) mesh in patients undergoing laparo-endoscopic surgery for uncomplicated inguinal hernias. Outcomes were recurrences, chronic pain, and foreign-body sensation. The level of evidence was assessed using GRADE. Risk ratios (RR) and 95% confidence intervals (CI) were calculated by random effect meta-analyses. Trial-sequential-analyses were subsequently performed.

RESULTS

Twelve RCTs, encompassing 2909 patients (LWM 1490 vs HWM 1419), were included. The follow-up range was 3 to 60 months. Using LWM increased the recurrence risk (LWM 32/1571, HWM 13/1508; RR 2.21; CI 1.14-4.31), especially in nonfixated mesh direct repairs (LWM 13/180, HWM 1/171; RR 7.27; CI 1.33-39.73) and/or large hernia defects. No difference was determined regarding any pain (LWM 123/1362, HWM 127/1277; RR 0.79; CI 0.52-1.20), severe pain (LWM 3/1226, HWM 9/1079; RR 0.38; CI 0.11-1.35), and foreign-body sensation (LWM 100/1074, HWM 103/913; RR 0.94; CI 0.73-1.20).

CONCLUSION

HWM should be used in laparo-endoscopic repairs of direct or large inguinal hernias to reduce recurrence rates. LWM provide no benefit in indirect hernias.

[Association of tension-free inguinal hernia repair and pathospermia in fertile men]

OBJECTIVE

To reveal the association of tension-free inguinal hernia repair and pathospermia in fertile men.

MATERIAL AND METHODS

We have retrospectively analyzed medical records of 512 men who appealed to andrologist with complaints of the absence of pregnancy in wife in 2018. We evaluated duration and features of infertility, presence/absence of previous inguinal hernia repair, spermogram data (according to WHO criteria, 2010) in all patients.

RESULTS

Duration of infertility in men after inguinal hernia repair persists for 4.2±2.1 years. Right-sided hernia repair was performed in 36 (48.6%) patients, left-side - 23 (31%), bilateral repair - 15 (20.2%) patients. Men with impaired sperm motility prevailed among patients after right-sided inguinal hernia repair (17 (47.2%) people). Left-sided hernia repair was followed by asthenozoospermia in 8 (34.7%) cases, bilateral hernia repair - in 3 (20%) cases. The most severe abnormalities in semen analysis (azoospemia) develop after bilateral hernia repair.

CONCLUSION

Inguinal tension-free hernia repair is a risk factor for male infertility in 14.4% of cases. It is very important to examine a man in case of infertile marriage. Previous surgical interventions including inguinal hernia repair should be considered.

A prospective randomized comparison of sexual function and semen analysis following laparoscopic totally extraperitoneal (TEP) and transabdominal pre-peritoneal (TAPP) inguinal hernia repair

BACKGROUND

With standardization of laparoscopic technique of groin hernia repair, the focus of surgical outcome has shifted to lesser studied parameters like sexual function and fertility.

METHODS

This prospective randomized study was conducted in a single surgical unit at a tertiary care hospital. A sample size of 144 was calculated with 72 in each group (Group 1 TEP and Group 2 TAPP). Primary outcomes measured included comparison of sexual function using BMFSI, qualitative semen analysis and ASA levels between patients undergoing TEP or TAPP repair. Semen analysis and ASA was measured pre-operatively and 3 months post-operatively.

RESULTS

A total of 145 patients were randomized into two groups, TAPP (73) and TEP (72) patients. Both the groups were comparable in terms of demographic profile and hernia characteristics with majority of the patients in both the groups having unilateral inguinal hernia (89.0% in TAPP group and 79.2% in TEP group). Both the groups showed statistically significant improvement in overall sexual function score (BMFSI) at 3 months; however, there was no inter group difference. Both the groups were also comparable in terms of ASA and qualitative semen analysis.

CONCLUSION

Both TEP and TAPP repair are comparable in terms of sexual function and effect on semen analysis. Laparoscopic repair improves the overall sexual functions in patients with groin hernia.

A three-arm randomized study to compare sexual functions and fertility indices following open mesh hernioplasty (OMH), laparoscopic totally extra peritoneal (TEP) and transabdominal preperitoneal (TAPP) repair of groin hernia

BACKGROUND

With evolving technology, the focus of groin hernia repair has shifted to sexual function and fertility outcomes.

METHODS

This three-arm randomized study was conducted in tertiary care hospital from 1st July 2017 to 30th March 2019. Consecutive patients of groin hernia were randomized into 3 groups, TAPP (Group 1), TEP (Group 2), and OMH (Group 3). Demographic profile and hernia characteristics were assessed preoperatively. Sexual functions (using BMSFI) and fertility (using surrogate fertility indices, viz., semen analysis and anti-sperm antibodies (ASA)) were assessed preoperatively at 3 months after the surgery.

RESULTS

A total of 121 patients were included in the study with 41 patients in TAPP (Group 1) and 40 each in TEP (Group 2) and OMH (Group3) group. All the 3 groups were comparable in terms of demographic profile, hernia characteristics, intra-operative and early post-operative outcomes. Significant improvement was found in most of the domains of BMSFI score in the study population (p value < 0.001) with no intergroup difference. There was significant increase of anti-sperm antibody level in OMH group as compared to TAPP and TEP (p = 0.001), however, the levels were within normal limit.

CONCLUSIONS

In conclusion, this study has shown that inguinal hernia repair whether open or laparoscopic (TEP or TAPP) leads on to improvement in sexual functions and fertility indices and can have a significant impact on pre-op counseling of the patient in terms of choice of repair, depending on the available expertise in a given center.

Lightweight mesh versus heavyweight mesh for laparo-endoscopic inguinal hernia repair: a systematic review and meta-analysis

PURPOSE

This study aimed to determine if the prognoses of inguinal hernia patients improved with the application of lightweight mesh (LWM).

METHODS

Medline, Embase, and Cochrane library were searched for randomized controlled trails related to laparo-endoscopic inguinal hernia repair with different prosthetic meshes. Data were extracted and analyzed using the guidelines of the Cochrane handbook. The primary endpoints were recurrence and chronic postoperative inguinal pain. The second endpoints encompassed acute postoperative pain, foreign body sensation, seroma, infection, and numbness. Data were processed using Review Manager 5.3.

RESULTS

The heavyweight mesh (HWM) had a distinctive advantage for recurrence (RR 2.30; 95% CI 1.21-4.38; P = 0.01), with comparable results for postoperative pain (RR 0.91; 95% CI 0.37-2.22; P = 0.83), foreign body sensation (RR 1.18; 95% CI 0.91-1.51; P = 0.21), seroma(RR 0.87; 95% CI 0.75-1.01; P = 0.06), infection (RR 0.85; 95% CI 0.31-2.34; P = 0.75), and numbness, compared to LWM.

CONCLUSION

HWM had a distinctive advantage over LWM with regard to recurrence. The two types of prosthetic meshes had equivalent outcomes for postoperative pain, seroma, foreign body sensation, infection, and numbness. Studies focused on defect sizes and fixation methods are warranted for further stratification.

Lightweight Versus Heavyweight Mesh in Laparoscopic Inguinal Hernia Repair: An Updated Systematic Review and Meta-Analysis of Randomized Trials

Background: There is no consensus on whether lightweight mesh (LWM) is better than heavyweight mesh (HWM) in laparoscopic inguinal hernia repair (LIHR). This study aims to update the previous reviews and to analyze present randomized controlled studies comparing LWM versus HWM in LIHR systematically. Methods: We searched PubMed, Embase, and Cochrane Library for randomized controlled trials (RCTs), which compared LWM with HWM in adults with LIHR. All eligible data of outcomes were quantitatively analyzed using Revman 5.3 software or qualitatively described. The outcomes included chronic pain, moderate-severe chronic pain, recurrence, foreign body sensation, influence on sexual life and male fertility (pain with ejaculation, testicular pain, etc.). Results: We included 12 RCTs that analyzed 3092 hernias. The difference between LWM and HWM groups at any follow-up time was not significant in chronic pain and foreign body sensation. Compared with HWM group, patients in LWM group had a similar risk of postoperative moderate-severe chronic pain at 3 and 12 months follow-up, a slightly increased risk of developing moderate-severe chronic pain at >12 months follow-up (risk ratio [RR] = 3.20, 95% confidence interval [CI] 1.05-9.75, P = .04), and a higher risk of recurrence rate (RR = 2.28, 95% CI 1.17-4.44, P = .02). At long-term follow-up, the influences of LWM and HWM on sexual life and male fertility were comparable. Conclusion: LWMs do not show advantages in chronic pain, foreign body sensation as well as the influence on sexual life and male fertility, and may increase hernia recurrence rates for LIHR. In addition, a higher incremental cost and lower incremental effect of LWMs make conventional HWMs preferred choice for LIHR.

Meta-Analysis of Randomized Controlled Trials Comparing Lightweight and Heavyweight Mesh for Laparoscopic Total Extraperitoneal Inguinal Hernia Repair

The aim of this study was to compare the outcomes of lightweight and heavyweight mesh on postoperative recovery in laparoscopic total extraperitoneal (TEP) inguinal hernia repair. PubMed, Embase, Science Citation Index, and the Cochrane Library were used to search for published clinical randomized controlled trials, which compared lightweight meshes with heavyweight meshes in TEP inguinal hernia repair. The outcomes were calculated as risk ratios with 95 per cent confidence intervals using RevMan 5.2. Eight randomized controlled trials were included. Compared with a heavyweight mesh, the lightweight mesh led to a higher incidence of recurrence (risk ratio = 2.52, 95% confidence interval 1.10–5.81; P = 0.03). There was no significant difference in chronic moderate to severe pain, foreign body sensation, and seroma. The use of lightweight mesh is not recommended for TEP inguinal hernia repair.

TEP for elective primary unilateral inguinal hernia repair in men: what do we know?

INTRODUCTION

Based on the new international guidelines for groin hernia management, there is no one surgical technique that is suited to all patient characteristics and diagnostic findings. Therefore, a tailored approach should be used. Here, a distinction must be made between primary unilateral inguinal hernia in men and in women, bilateral inguinal hernia, scrotal inguinal hernia, inguinal hernia following pelvic and lower abdominal procedures, patients with severe cardiopulmonary complications, recurrent inguinal hernias and incarcerated inguinal and femoral hernias. This paper now explores the relevant studies on TEP for elective primary unilateral inguinal hernia in men, which constitutes the most common indication for repair.

MATERIAL

A systematic search of the available literature was performed in February 2019 using Medline, PubMed, Scopus, Embase, Springer Link and the Cochrane Library. Only meta-analyses, systematic reviews, RCTs and comparative registry studies were considered. 117 publications were identified as relevant.

RESULTS

RCTs and comparative registry analyses demonstrated the advantages of TEP with regard to postoperative complications, complication-related reoperations, and postoperative and chronic pain compared with Lichtenstein repair for elective primary unilateral inguinal hernia repair in men. No relevant differences were found compared with TAPP. Mesh fixation is not needed in TEP, but heavyweight meshes result in a lower recurrence rate. Extraperitoneal bupivacaine analgesia vs placebo does not demonstrate any advantages, but drainage is advantageous for seroma prophylaxis. The risk of chronic pain is negatively influenced by small defects, younger patient age, preoperative pain, higher BMI, postoperative complications, higher ASA score and risk factors.

CONCLUSION

For the subgroup of elective primary unilateral inguinal hernia in men, accounting for a proportion of less than 50% of the total collective, advantages were identified for TEP compared with open Lichtenstein repair but not versus TAPP.

Self-fixing parietex progrip versus the standard sutured prolene mesh in tension-free repair of inguinal hernia: effect on testicular volume and testicular blood flow

Our study was conducted to compare self-fixing lightweight polyester mesh (group I) to the standard heavy weight polypropylene mesh (group II) using tension-free Lichtenstein hernioplasty as regard to the effect of mesh implantation and perimesh fibrosis on testicular blood flow. 80 patients with uncomplicated inguinal hernia were divided in two groups. Doppler ultrasonography measured testicular volume, testicular artery velocity preoperative and 3rd month post operative. Blood flow in the testicles was represented by resistive index (RI). No case of testicular atrophy occurred in either group, however, in both groups a significant postoperative decrease in testicular volume (p = 0.001 in group I and p < 0.001 in group II) was accompanied by a significant increase in RI as compared to their pre-operative values (p < 0.001 in group I and p = 0.009 in group II). Comparing the two groups, patients in group I showed higher values of decrease in testicular volume accompanied by more increase in RI values postoperatively compared to group II patients, but these values did not reach a significant value (p = 0.107, p = 0.136). There was a significant increase in the number of post-operative varicocele and hydrocele in group I compared to group II. Mesh implantation has an effect on testicular size and blood flow by decreasing the testicular size and increasing the RI. This effect was more obvious in the parietex progrip. Although there is an indirect relation between RI and the sperm count, testicular blood flow alone is not enough to judge fertility.

Does the use of hernia mesh in surgical inguinal hernia repairs cause male infertility? A systematic review and descriptive analysis

Objective

The aim of this study was to systematically review the available clinical trials examining male infertility after inguinal hernias were repaired using mesh procedures.

Methods

The Cochrane Library, PubMed, Embase, Web of Science, and Chinese Biomedical Medicine Database were investigated. The Jada score was used to evaluate the quality of the studies, “Oxford Centre for Evidence-based Medicine-Levels of Evidence” was used to assess the level of the trials, and descriptive analysis was used to evaluate the studies.

Results

Twenty nine related trials with a total of 36,552 patients were investigated, including seven randomized controlled trials (RCTs) with 616 patients and 10 clinical trials (1230 patients) with mesh or non-mesh repairs. The Jada score showed that there were six high quality RCTs and one low quality RCT. Levels of evidence determined from the Oxford Centre for Evidence-based Medicine further demonstrated that those six high quality RCTs also had high levels of evidence. It was found that serum testosterone, LH, and FSH levels declined in the laparoscopic group compared to the open group; however, the testicular volume only slightly increased without statistical significance. Testicular and sexual functions remained unchanged after both laparoscopic transabdominal preperitoneal hernia repair (TAPP) and totally extra-peritoneal repair (TEP). We also compared the different meshes used post-surgeries. VyproII/Timesh lightweight mesh had a diminished effect on sperm motility compared to Marlex heavyweight mesh after a one-year follow-up, but there was no effect after 3 years. Additionally, various open hernia repair procedures (Lichtenstein, mesh plug method, posterior pre-peritoneal mesh repair, and anterior tension-free repair) did not cause infertility.

Conclusions

This systematic review suggests that hernia repair with mesh either in an open or a laparoscopic procedure has no significant effect on male fertility.

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.

Bilateral endoscopic totally extraperitoneal (TEP) inguinal hernia repair does not impair male fertility

PURPOSE

Endoscopic totally extraperitoneal (TEP) hernia repair with polypropylene mesh has become a well-established technique. However, since the mesh is placed in close contact with the spermatic cord, mesh-induced inflammation may affect its structures, possibly resulting in impaired fertility. The aim of this observational prospective cohort study was to assess fertility after bilateral endoscopic TEP inguinal hernia repair in male patients.

METHODS

Fifty-seven male patients (22-60 years old) with primary, reducible, bilateral inguinal hernias underwent elective bilateral endoscopic TEP hernia repair with use of polypropylene mesh. The primary outcome was testicular perfusion; secondary outcomes were testicular volume, endocrinological status, and semen quality. All patients were assessed preoperatively and 6 months postoperatively.

RESULTS

Follow-up was completed in 44 patients. No statistically significant differences in measurements of testicular blood flow parameters or testicular volume were found. Postoperative LH levels were significantly higher [preoperative median 4.3 IU/L (IQR 3.4-5.3) versus postoperative median 5.0 IU/L (IQR 3.6-6.5), p = 0.03]. Levels of inhibin B were significantly lower postoperatively [preoperative median 139.0 ng/L (IQR 106.5-183.0) versus postoperative median 27.0 ng/L (IQR 88.3-170.9), p = 0.01]. No significant changes in FSH or testosterone levels were observed. There were no differences in semen quality.

CONCLUSIONS

Our data suggest that bilateral endoscopic TEP hernia repair with polypropylene mesh does not impair fertility, as no differences in testicular blood flow, testicular volume, or semen quality were observed. Postoperative levels of LH and inhibin B differed significantly from preoperative measurements, yet no clinical relevance could be ascribed to these findings.

Patient-reported outcomes (PROs) after total extraperitoneal hernia repair (TEP)

BACKGROUND

Patient-reported outcomes (PROs) such as quality of life (QoL), patient satisfaction, and work impairment, are arguably the most important outcomes of any medical treatment. In 2011, Staerkle and Villiger developed the Core Outcome Measurements Index (COMI) to standardise PROs and PRO measurement for inguinal hernia patients, in an attempt to increase inter-study comparability. The aim of this study is to prospectively evaluate the short- and long-term postoperative QoL, function, patient well-being, pain, and social/work disability, after total extraperitoneal (TEP) inguinal hernia repair and to provide the first clinical experience with the COMI-hernia questionnaire.

METHODS

Between January 2013 and December 2014, all patients ≥18 years that were scheduled for elective uni- or bilateral TEP in a regional hospital were approached to participate in this study. Measurements were taken preoperatively, and 6 weeks and 1 year postoperatively.

RESULTS

One hundred and twenty patients (113 men, 7 women), mean age 59 years (SD ±12), completed the follow-up of 1 year. Ninety-seven percent of the population reported that the operation improved their complaints. QoL, function, well-being, and pain all improved after 6 weeks and 1 year after surgery. Patients experienced more social and work-related limitations 6 weeks after surgery compared to baseline measurements, though this improved to normal 1 year postoperatively. The incidence of chronic pain was 14% (VAS ≥ 2), which had a negative impact on the patients' sense of well-being.

CONCLUSION

Patients recovered well after TEP repair with a good quality of life and fast restore of function. Patient well-being was lower than expected due to a 14% incidence of chronic pain. The COMI-hernia scale provided reasonable insight into the patients' experience, though it was difficult to interpret for both patient and physician.

Effects of single-port laparoscopic percutaneous extraperitoneal closure on the orientation of the vas deferens and testicular perfusion and volume: Experience from a single center

OBJECTIVE

To investigate the influence of single-port laparoscopic percutaneous extraperitoneal closure (LPEC) on the orientation of the vas deferens and testicular perfusion and volume in pediatric patients undergoing inguinal hernia repair.

METHODS

A total of 92 consecutively enrolled boys preoperatively diagnosed with a unilateral inguinal hernia underwent single-port LPEC between June 2013 and June 2014. The orientation of the vas deferens and the testicular perfusion and volume of these patients were ultrasonographically assessed preoperatively, one month after surgery and six months after surgery.

RESULTS

The surgical procedures were performed successfully without conversion or serious perioperative complications. Ultrasonography showed no angulation or distortion of the vas deferens on the surgical side during a six-month follow-up period. Similarly, there were no perioperative changes in testicular perfusion or volume.

CONCLUSION

Our experience suggests that the single-port LPEC technique can be safe and effective in pediatric patients with an inguinal hernia and that this technique does not affect the orientation of the vas deferens or testicular perfusion or volume.

A prospective randomised controlled trial comparing chronic groin pain and quality of life in lightweight versus heavyweight polypropylene mesh in laparoscopic inguinal hernia repair

BACKGROUND

The aim of our study was to compare chronic groin pain and quality of life (QOL) after laparoscopic lightweight (LW) and heavyweight (HW) mesh repair for groin hernia.

MATERIALS AND METHODS

One hundred and forty adult patients with uncomplicated inguinal hernia were randomised into HW mesh group or LW mesh group. Return to activity, chronic groin pain and recurrence rates were assessed. Short form-36 v2 health survey was used for QOL analysis.

RESULTS

One hundred and thirty-one completed follow-up of 3 months, 66 in HW mesh group and 65 in LW mesh group. Early post-operative convalescence was better in LW mesh group in terms of early return to walking (P = 0.01) and driving (P = 0.05). The incidence of early post-operative pain, chronic groin pain and QOL and recurrences were comparable.

CONCLUSION

Outcomes following laparoscopic inguinal hernia repair using HW and LW mesh are comparable in the short-term as well as long-term.

Cost-utility analysis comparing heavy-weight and light-weight mesh in laparoscopic surgery for unilateral inguinal hernias

BACKGROUND

Hernioplasty is one of the most frequent surgeries in the UK. Light-weight mesh (LWM) has the potential to reduce chronic groin pain but its cost-effectiveness compared with heavy-weight mesh (HWM) is unknown.

OBJECTIVE

Our objective was to conduct a cost-utility analysis between laparoscopic hernioplasty with HWM and LWM for unilateral inguinal hernias.

METHODS

A Markov model simulated costs and health outcomes over a period of 1 year (2012) from the societal and National Health Service (NHS) perspective (England). The main outcome was cost per quality-adjusted life-year (QALY) gained. Surgery results were gleaned from the randomized control trial by Bittner et al. Other input parameters were drawn from the literature and public sources of the NHS.

RESULTS

From the societal perspective, LWM induces lower incremental costs (-£88.85) than HWM but yields a slightly smaller incremental effect (-0.00094 QALYs). The deterministic incremental cost-effectiveness ratio (ICER) for HWM compared with LWM amounts to £94,899 per QALY, while the probabilistic ICER is £118,750 (95 % confidence interval [CI] £57,603-180,920). Owing to the withdrawal of productivity losses from the NHS perspective, LWM causes higher incremental costs (£13.09) and an inferior incremental effect (-0.00093), resulting in a dominance of HWM over LWM (ICER 95 % CI -£12,382 to -£21,590).

CONCLUSIONS

There is no support for the adoption of LWM as standard treatment from an NHS perspective. However, given the small differences between HWM and LWM, LWM has at least the potential of improving patient outcomes and reducing expenditure from the societal perspective.

Early and late postoperative inflammatory and collagen deposition responses in three different meshes: an experimental study in rats

PURPOSE

Although meshes reduce abdominal hernia recurrence, they increase the risk of inflammatory complications. This study aimed to compare the early and late postoperative inflammation and collagen deposition responses induced by three meshes.

METHODS

Rats were allocated into three groups. In group I, a polypropylene (PP) mesh was implanted in the abdominal wall. In groups II and III, PP + polyglactin (PP + PG) and PP + titanium (PP + TI) meshes were employed, respectively. On the seventh (7th) postoperative day, collagen deposition and inflammation were evaluated, and immunohistochemistry was performed on abdominal wall biopsies. These data were compared with those obtained on the fortieth (40th) postoperative day in a previous study.

RESULTS

The early inflammatory responses were the same in all groups. With time, it decreased in group I (p = 0.047) and increased in group II (p = 0.003). Group I exhibited early elevated VEGF (p < 0.001), COX2 (p < 0.001), and collagen (p = 0.023) levels, and group II exhibited the most severe inflammatory tissue response. On the 40th postoperative day, the VEGF (p < 0.001) and collagen (p < 0.005) were reduced as compared with the 7th postoperative day in all groups.

CONCLUSIONS

Belatedly, the inflammatory reaction decreased in PP mesh group and increased in PP + PG mesh group. The PP mesh induced early great elevations in VEGF, COX2 and collagen levels, whereas the PP + PG mesh caused severe tissue inflammation with small elevation in these levels. PP + TI mesh induced inflammatory response levels between the others. In conclusion, the inflammatory response depends on the mesh density and also the mesh material with clinical implications.

What do we know about titanized polypropylene meshes? An evidence-based review of the literature

PURPOSE

Despite the vast selection of brands available, nearly all synthetic meshes for hernia surgery continue to use one or other of three basic materials: polypropylene, polyester and ePTFE. These are used in combination with each other or with a range of additional materials such as titanium, omega 3, monocryl, PVDF and hyaluronate. This systematic review of all experimental and clinical studies is aimed at investigating whether titanized meshes confer advantages over other synthetic meshes in hernia surgery.

MATERIALS AND METHODS

A search of the medical literature from 2002 to 2012, as indexed by Medline, was performed, using the PubMed search engine (http://www.pubmed.gov). The search terms were: hernia mesh, titanium coating, lightweight mesh, TiMesh, mesh complications. All papers were graded according to the Oxford hierarchy of evidence.

RESULTS

Patients operated on with the Lichtenstein technique performed using the lightweight titanium-coated mesh have a shorter convalescence than those with the heavy-weight mesh Prolene. For inguinal hernias operated on with the TAPP technique and using a lightweight titanium-coated mesh in comparison to a heavy-weight Prolene mesh, the early postoperative convalescence seems to improve. Titanized meshes do exhibit a negative effect on sperm motility 1 year after a TEP operation, but not after 3 years. The laparoscopic IPOM technique with a titanium-coated polypropylene mesh was associated with less postoperative pain in the short term, lower analgesic consumption and a quicker return to everyday activities compared with the Parietex composite mesh.

CONCLUSION

In clinical studies, the titanium-coated polypropylene mesh shows in inguinal hernia repair certain benefits compared with the use of older heavy-weight meshes.

Transabdominal preperitoneal versus totally extraperitoneal repair of inguinal hernia: a meta-analysis of randomized studies

BACKGROUND

The aim of the present study was to comparatively evaluate the outcomes of laparoscopic transabdominal preperitoneal inguinal hernia repair and totally extraperitoneal repair.

METHODS

The electronic databases of Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were searched, and a meta-analysis of randomized clinical trials was undertaken.

RESULTS

Seven studies comprising 516 patients with 538 inguinal hernia defects were identified. A shorter recovery time (P = .02) was found for totally extraperitoneal repair in comparison with transabdominal preperitoneal inguinal hernia repair (weighted mean difference = -.29; 95% confidence interval [CI], -.71 to .07) although the length of hospitalization (P = .89) was similar in the 2 treatment arms (weighted mean difference = .01; 95% CI, -.13 to .15). Operative morbidity (P = .004) was higher for the preperitoneal approach (odds ratio = 2.15; 95% CI, 1.29 to 3.61). No differences were found with regard to the incidence of recurrence, long-term neuralgia, and operative time.

CONCLUSIONS

Current evidence suggests similar operative results for endoscopic and laparoscopic inguinal hernia repair, with a trend toward higher morbidity for the preperitoneal approach. Randomized trials with a longer-term follow-up are needed in order to assess the effect of each approach on the prevention of recurrence.

A systematic review and meta-analysis evaluating the effectiveness of lightweight mesh against heavyweight mesh in influencing the incidence of chronic groin pain following laparoscopic inguinal hernia repair

BACKGROUND

A systematic analysis was conducted of randomized controlled trials (RCTs) comparing lightweight mesh (LWM) with heavyweight mesh in laparoscopic inguinal hernia repair.

METHODS

Data extracted from the included RCTs were analyzed according to the principles of meta-analysis.

RESULTS

Eleven RCTs encompassing 2,189 patients were analyzed. In a fixed-effects model, operating time, postoperative pain, and recurrence rate were statistically similar between LWM and heavyweight mesh. LWM was associated with fewer perioperative complications and a reduced risk for developing chronic groin pain. There was also a reduced risk for developing other groin symptoms, such as foreign body sensations, but it was not statistically significant.

CONCLUSIONS

The use of LWM for laparoscopic inguinal hernia repair is not associated with an increased risk for hernia recurrence. LWM reduces the incidence of chronic groin pain, groin stiffness, and foreign body sensations. Therefore, LWM may routinely be used in laparoscopic inguinal hernia repair. However, high-quality RCTs with longer follow-up periods are required to validate these findings.

Sperm motility after laparoscopic inguinal hernia repair with lightweight meshes: 3-year follow-up of a randomised clinical trial

PURPOSE

To analyse the effects of lightweight meshes in laparoscopic inguinal hernia repair on male fertility aspects, chronic pain development and recurrence at 3-year follow-up.

METHODS

Fifty-nine male patients with a primary, unilateral or bilateral inguinal hernia were randomised to laparoscopic inguinal hernia repair using a standard polypropylene (Marlex(®)) or lightweight mesh (VyproII(®), TiMesh(®)). Patients attended clinical follow-up 3 years postoperatively, at which male fertility aspects, by semen analysis and scrotal ultrasound, chronic pain status (McGill Pain Questionnaire), quality of life (SF-36) and recurrence were assessed, or completed quality of life, pain and hernia-specific questionnaires at home.

RESULTS

In total, 49 patients (83.1 %) completed follow-up (median follow-up = 39.1 months), by questionnaire and/or clinical follow-up. As other semen parameters and scrotal ultrasound results, sperm motility was unchanged compared to 1 year postoperatively, but not significantly different between VyproII(®) and TiMesh(®) versus Marlex(®) patients (-8.5 % and -8 % vs. -2.8 %; P = 0.23). Pain perception and quality of life were comparable between the heavyweight and lightweight groups, and no change was noted in comparison with 1 year postoperatively. Chronic pain incidence was 6.1 % (3 patients), without occurrence of disabling pain. Three patients were clinically diagnosed with a recurrent hernia (5.9 %).

CONCLUSIONS

The decrease in sperm motility in patients operated on with a lightweight mesh compared to patients operated on with a heavyweight mesh 1 year after laparoscopic inguinal hernia repair could not be confirmed at 3 years follow-up. Furthermore, heavyweight and lightweight groups were comparable regarding quality of life, chronic pain and recurrence rate.

Male infertility after endoscopic Totally Extraperitoneal (Tep) hernia repair (Main): rationale and design of a prospective observational cohort study

Background

To describe the rationale and design of an observational cohort study analyzing the effects of endoscopic Totally Extraperitoneal (TEP) hernia repair on male fertility (MAIN study).

Methods and design

The MAIN study is an observational cohort study designed to assess fertility after endoscopic TEP hernia repair. The setting is a high-volume single center hospital, specialized in TEP hernia repair. Male patients of 18-60 years of age, with primary, reducible, bilateral inguinal hernias and no contraindications for endoscopic TEP repair are eligible for inclusion in this study. Patients with an ASA-classification ≥ III and patients with recurrent and/or scrotal hernias and/or a medical history of pelvic surgery and/or radiotherapy, known fertility problems, diabetes and/or other diseases associated with a risk of fertility problems, will be excluded. The primary outcome is the testicular perfusion before and 6 months after TEP hernia repair (assessed by means of a scrotal ultrasonography). Secondary endpoints are the testicular volume (Ultrasound), semen quality and quantity and the endocrinological status, based on serum levels of the sexual hormones follicle-stimulating hormone (FSH), luteinizing hormone (LSH), testosterone and inhibin B before and 6 months after TEP hernia repair.

Discussion

The use of polypropylene mesh is associated with a strong foreign body reaction which could play a role in chronic groin pain development. Since the mesh in (endoscopic) inguinal hernia repair is placed in close contact to the vas deferens and spermatic vessels, the mesh-induced inflammatory reaction could lead to a dysfunction of these structures. Relevant large and prospective clinical studies on the problem are limited. This study will provide a complete assessment of fertility in male patients who undergo simultaneous bilateral endoscopic TEP hernia repair, by analyzing testicular perfusion and volume, semen quantity and quality and endocrinological status before and 6 months after TEP repair.

Trial registration

The MAIN study is registered in the Dutch Trial Register (NTR2208)

Lightweight versus heavyweight mesh in laparoscopic inguinal hernia repair: a meta-analysis

BACKGROUND

Reinforcement of inguinal hernia repair with prosthetic mesh is standard practice but can cause considerable pain and stiffness around the groin and affect physical functioning. This has led to various types of mesh being engineered, with a growing interest in lighter-weight mesh. Minimally invasive approaches have also significantly reduced postoperative recovery from inguinal hernia repair. The aim of this systematic review was to compare the outcomes after laparoscopic inguinal repair using new lightweight or traditional heavyweight mesh in published randomised controlled trials.

METHODS

Medline, Embase, trial registries, conference proceedings, and reference lists were searched for controlled trials of heavyweight versus lightweight mesh for laparoscopic repair of inguinal hernias. The primary outcomes were recurrence and chronic pain. Secondary outcomes were visual analogue pain score at 7 days postoperatively, seroma formation, and time to return to work. Risk differences were calculated for categorical outcomes and standardised mean differences for continuous outcomes.

RESULTS

Eight trials were included in the analysis of 1,667 hernias in 1,592 patients. Mean study follow-up was between 2 and 60 months. There was no effect on recurrence [pooled analysis risk difference 0.00 (95% CI -0.01 to 0.01), p = 0.86] or chronic pain [pooled analysis risk difference -0.02 (95% CI -0.04 to 0.00); p = 0.1]. Lightweight and heavyweight mesh repair had similar outcomes with regard to postoperative pain, seroma development, and time to return to work.

CONCLUSION

Both mesh options appear to result in similar long- and short-term postoperative outcomes. Further long-term analysis may guide surgeon selection of mesh weight for laparoscopic inguinal hernia repair.

Testicular functions, chronic groin pain, and quality of life after laparoscopic and open mesh repair of inguinal hernia: a prospective randomized controlled trial

BACKGROUND

Laparoscopic inguinal hernia repair is still not the gold standard for patients with inguinal hernia. The aim of this study was to compare testicular dysfunction, incidence and factors influencing chronic groin pain, and quality of life after laparoscopic and open mesh repair.

METHODS

One hundred twenty patients were studied in a prospective randomized trial. One hundred seventeen patients completed the required follow-up, 60 following laparoscopic repair and 57 following open repair. Testicular functions were assessed by testicular volume, blood flow, and hormones, and quality of life was assessed with Short Form 36 version 2 preoperatively and postoperatively at 3 months. Pain was assessed at different time intervals preoperatively and postoperatively.

RESULTS

Preoperative profiles of both groups were well matched. A significant decrease in testicular volume (p = 0.01) and less improvement in blood flow (p = 0.048) was seen after open repair. There was also a significant reduction in serum testosterone level (p = 0.02) with a significant increase in FSH and LH level (p < 0.001); however, there was no testicular atrophy. Incidence and severity of chronic groin pain were significantly less after laparoscopic repair during normal and strenuous activities, though they were similar to those after open repair during rest after 3 months postoperatively. Age, preoperative pain, pain at 1 week, and open repair were found to be independent risk factors for chronic pain on multivariate analysis. Quality of life was significantly better postoperatively in terms of physical functions, role physical, bodily pain, and general health after laparoscopic repair.

CONCLUSION

Laparoscopic repair seems favorable in terms of better preservation of testicular functions, lower incidence of acute and chronic groin pain, and significant improvement in quality of life when compared to open repair. Younger age, preoperative pain, pain after 1 week postoperatively, and open mesh repair were found to be significant risk factors for chronic groin pain.