Comparison of Absorbable Versus Nonabsorbable Tackers in Terms of Long-term Outcomes, Chronic Pain, and Quality of Life After Laparoscopic Incisional Hernia Repair: A Randomized Study

The association of permanent versus absorbable fixation on developing chronic post-herniorrhaphy groin pain in patients undergoing laparoscopic inguinal hernia repair

INTRODUCTION

Fixation of mesh during minimally invasive inguinal hernia repair is thought to contribute to chronic post-herniorrhaphy groin pain (CGP). In contrast to permanent tacks, absorbable tacks are hypothesized to minimize the likelihood of CGP. This study aimed to compare the rates of CGP after laparoscopic inguinal hernia repair between absorbable versus permanent fixation at maximum follow-up.

METHODS

This is a post hoc analysis of a randomized controlled trial in patients undergoing laparoscopic inguinal hernia repair (NCT03835351). All patients were contacted at maximum follow-up after surgery to administer EuraHS quality of life (QoL) surveys. The pain and restriction of activity subdomains of the survey were utilized. The primary outcome was rate of CGP, as defined by a EuraHS QoL pain domain score ≥ 4 measured at ≥ 1 year postoperatively. The secondary outcomes were pain and restriction of activity domain scores and hernia recurrence at maximum follow-up.

RESULTS

A total of 338 patients were contacted at a mean follow-up of 28 ± 11 months. 181 patients received permanent tacks and 157 patients received absorbable tacks during their repair. At maximum follow-up, the rates of CGP (27 [15%] vs 28 [18%], P = 0.47), average pain scores (1.78 ± 4.38 vs 2.32 ± 5.40, P = 0.22), restriction of activity scores (1.39 ± 4.32 vs 2.48 ± 7.45, P = 0.18), and the number of patients who reported an inguinal bulge (18 [9.9%] vs 15 [9.5%], P = 0.9) were similar between patients with permanent versus absorbable tacks. On multivariable analysis, there was no significant difference in the odds of CGP between the two groups (OR 1.23, 95% CI [0.60, 2.50]).

CONCLUSION

Mesh fixation with permanent tacks does not appear to increase the risk of CGP after laparoscopic inguinal hernia repair when compared to fixation with absorbable tacks. Prospective trials are needed to further evaluate this relationship.

Surgical techniques and effectiveness of laparoscopic resection of abdominal wall desmoid-type fibromatosis and defect reconstruction: a single-center retrospective analysis

PURPOSE

Although the treatment of abdominal wall desmoid-type fibromatosis (DF) has evolved over the past decades, surgical treatment remains an important approach. Previously, surgeries for abdominal DF were mostly performed by laparotomy, which involves massive dissection and significant trauma. Here, we report our single-center experience of the laparoscopic management of abdominal wall DF in young female patients.

METHODS

The clinical data of nine patients diagnosed with abdominal wall DF during January 2020-April 2022 at the Qilu Hospital of Shandong University were retrospectively analyzed. All patients underwent laparoscopic resection of abdominal wall DF and immediate abdominal wall reconstruction (AWR) with mesh augmentation via the intraperitoneal onlay mesh (IPOM) technique.

RESULTS

Laparoscopic DF resection and AWR were successfully performed in all patients. The mean operation time was 175.56 ± 46.20 min. The width of abdominal wall defect was 8.61 ± 3.30 cm. Full- and partial-thickness myofascial closure and reapproximation were performed in five, two, and two patients, respectively. The average mesh size was 253.33 ± 71.01 cm2. The total and postoperative lengths of hospital stay were 11.00 ± 3.46 and 4.89 ± 2.03 days, respectively. Tumor recurred in one patient after 20 months of the resection. Nonetheless, death, herniation, or bulging were not observed in any patient during a mean follow-up of 16.11 ± 8.43 months.

CONCLUSION

Laparoscopic resection of abdominal wall DF and immediate AWR with IPOM mesh reinforcement is safe and reliable for young female patients. Management of such patients should be decided according to the biological behavior, size, and location of tumors.

Evaluating mesh fixation techniques for ventral hernia repair: A systematic review and network meta-analysis of randomised control trials

INTRODUCTION

There is uncertainty regarding the optimal mesh fixation techniques for laparoscopic ventral and incisional hernia repair.

AIM

To perform a systematic review and network meta-analysis of randomised control trials (RCTs) to investigate the advantages and disadvantages associated with absorbable tacks, non-absorbable tacks, non-absorbable sutures, non-absorbable staples, absorbable synthetic glue, absorbable sutures and non-absorbable tacks, and non-absorbable sutures and non-absorbable tacks.

METHODS

A systematic review was performed as per PRISMA-NMA guidelines. Odds ratios (ORs) and mean differences (MDs) were extracted to compare the efficacy of the surgical approaches.

RESULTS

Nine RCTs were included with 707 patients. Short-term pain was significantly reduced in non-absorbable staples (MD; -1.56, confidence interval (CI); -2.93 to -0.19) and non-absorbable sutures (MD; -1.00, CI; -1.60 to -0.40) relative to absorbable tacks. Recurrence, length of stay, operative time, conversion to open surgery, seroma and haematoma formation were unaffected by mesh fixation technique.

CONCLUSION

Short-term post-operative pain maybe reduced by the use of non-absorbable sutures and non-absorbable staples. There is clinical equipoise between each modality in relation to recurrence, length of stay, and operative time.

Laparoscopic treatment of ventral hernias: the Italian national guidelines

Primary and incisional ventral hernias are significant public health issues for their prevalence, variability of professional practices, and high costs associated with the treatment In 2019, the Board of Directors of the Italian Society for Endoscopic Surgery (SICE) promoted the development of new guidelines on the laparoscopic treatment of ventral hernias, according to the new national regulation. In 2022, the guideline was accepted by the government agency, and it was published, in Italian, on the SNLG website. Here, we report the adopted methodology and the guideline's recommendations, as established in its diffusion policy. This guideline is produced according to the methodology indicated by the SNGL and applying the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. Fifteen recommendations were produced as a result of 4 PICO questions. The level of recommendation was conditional for 12 of them and conditional to moderate for one. This guideline's strengths include relying on an extensive systematic review of the literature and applying a rigorous GRADE method. It also has several limitations. The literature on the topic is continuously and rapidly evolving; our results are based on findings that need constant re-appraisal. It is focused only on minimally invasive techniques and cannot consider broader issues (e.g., diagnostics, indication for surgery, pre-habilitation).

Laparoscopic Intraperitoneal Onlay Mesh (IPOM): Short- and Long-Term Results in a Single Center

The laparoscopic intraperitoneal onlay mesh repair (IPOM) approach has become the most widely adopted technique in the last decade. The role of laparoscopic IPOM in the last years has been resizing due to several limitations. The aim of the present study is to evaluate short- and long-term outcomes in patients who underwent laparoscopic IPOM. This retrospective single-center study describes 170 patients who underwent laparoscopic IPOM for ventral hernia at the General Surgery Unit of Parma University Hospital from 1 January 2016 to 31 December 2020. We evaluated patient, hernia, surgical and postoperative characteristics. According to the defect size, we divided the patients into Group 1 (Ø < 30 mm), Group 2 (30 < Ø < 50 mm) and Group 3 (Ø > 50 mm). A total of 167 patients were included. The mean defect diameter was 41.1 ± 16.3 mm. The mean operative time was different among the three groups (p < 0.001). Higher Charlson Comorbidity Index, obesity and incisional hernia were related to postoperative seroma and obesity alone with SSO. p < 0.001 Recurrence was significantly higher in larger defects (Group 3) and incisional hernia. p < 0.001. This retrospective study suggests that laparoscopic IPOM is a feasible and safe surgical technique with an acceptable complication rate, especially in the treatment of smaller defects up to 5 cm.

The effect of mesh fixation on migration and postoperative pain in laparoscopic TEP repair: prospective randomized double-blinded controlled study

PURPOSE

The development of chronic pain is one of the major post-surgery problems after inguinal hernia repair. Although the possibility of chronic pain formation decreases with laparoscopic methods, pain may develop due to the staples used. It is thought that absence of mesh fixation in total extra-peritoneal (TEP) repair does not increase the recurrence rate. This study aims to investigate the absence of mesh fixation in the TEP on the development of postoperative pain, mesh displacement, and recurrence rate.

METHODS

Between December 2019 and December 2020, 100 patients who underwent TEP repair due to unilateral inguinal hernia in the General Surgery Clinic of Hitit University were included in the study. Study was registered at http://Clinicaltrials.gov (NCT05152654). Patients were divided into two groups as repairs in which the mesh was fixed with a tacker and no-fixation (NF) was used. The mesh is marked with radiopaque clips. Patients were compared in terms of postoperative pain, mobilization time, hospital stay, return to work, chronic pain, early-late mesh displacement, and recurrence.

RESULTS

While there was no significant difference between the groups in terms of mesh displacement and recurrence, it was observed that the NF group developed significantly less pain in the early and late postoperative period compared to the other group. The time-dependent reduction rate of postoperative pain was higher in NF group than in other group. In addition, operation time was shorter in the NF group.

CONCLUSION

While the absence of mesh fixation in TEP hernia repair does not increase the recurrence rate, it can be used safely, because it causes less acute and chronic pain.

TRAIL REGISTRATION

Clinicaltrials number: NCT05152654.

Patient-reported outcomes of laparoscopic versus robotic primary ventral and incisional hernia repair: a systematic review and meta-analysis

BACKGROUND

Patient-Reported Outcome Measures (PROM's) are increasingly used to assess surgical outcomes in low-risk surgeries such as minimally invasive primary ventral and incisional hernia repair. The purpose of this meta-analysis was to systematically summarize the available evidence for the effect of laparoscopic versus robotic primary ventral and incisional hernia repair on PROM's.

METHODS

A systematic review and meta-analysis were performed in accordance with PRISMA guidelines. Randomised control trials, retrospective and prospective studies were included. Medline, Embase, SCOPUS, Web of Science, and Cochrane CENTRAL, and two trial registers were searched. Pooled effect sizes and 95% confidence intervals were calculated using the Mantel-Haenszel method. The overall quality of evidence was assessed using GRADE.

RESULTS

Of the 2728 titles screened, eight studies involving 41,205 participants were included. Return to activities of daily living, return to work day and recurrence rate were statistically better in the robotic group. Length of stay, readmission, postoperative pain, quality of life, body image, and patient satisfaction were similar in both groups. The GRADE rating of the quality of evidence was moderate for postoperative pain and low to very low for the quality of life, length of stay, recurrence and readmission.

CONCLUSION

The available data of PROM's of laparoscopic and robotic primary ventral and incisional hernia repair is scarce and highly heterogeneous, thus making it difficult to assess the superiority of the laparoscopic technique over the robotic technique. Further studies with uniform reporting of PROM's in laparoscopic and robotic primary ventral and incisional hernia repair are needed.

Comparison of extended totally extra peritoneal (eTEP) vs intra peritoneal onlay mesh (IPOM) repair for management of primary and incisional hernia in terms of early outcomes and cost effectiveness-a randomized controlled trial

BACKGROUND

There are no randomized controlled trials comparing the eTEP with IPOM repair and this randomized study was designed to compare the two techniques in terms of early pain, cost effectiveness, and quality of life.

METHOD

This was a prospective randomized trial with intention to treat analysis. The primary outcome was immediate post-operative pain scores. Operative time, conversions, peri operative morbidity, hospital stay, return to daily activities, incremental cost effectiveness ratio and quality of life (WHO-QOL BREF) were secondary outcomes.

RESULTS

Sixty patients were randomized equally. Early post-operative pain scores and seroma rates were significantly lower and with a significantly earlier return to activity in eTEP group (p value < 0.05). With negative costs and positive effects, eTEP group was 2.4 times more cost effective.

CONCLUSION

eTEP repair is better in terms of lesser early post-operative pain, earlier return to activities and cost effectiveness in small and medium size defects.

Quality of Life After Umbilical Hernia Repair

Background: Mesh is beneficial in the repair of umbilical hernias. But it may cause chronic pain due to inflammatory reactions, which may impair the patient's quality of life.

Objectives: To assess and compare the quality of life of patients following umbilical hernia repair with and without mesh.

Methods: During the study period, 45 patients underwent umbilical hernia repair. The study was conducted at King Abdul-Aziz University Hospital (KAUH), KSA. Data were collected using medical records, and each patient was contacted by telephone, to fill the “Carolina Comfort Scale (CCS)” survey. The survey assesses the grade of pain, sensation of mesh, and movement limitation in different situations.

Results: A non-significant difference was found between mean quality of life (QOL) scores of mesh and non-mesh groups. The relationship between CCS and gender was not significant in both groups. However, males had significantly higher CCS scores in mesh-treated cases. There was no statistically significant relationship between CCS and comorbidity, nationality, or symptoms. The overall CCS score did not differ statistically between mesh-treated and non-mesh-treated cases. 

Conclusion: The CCS score did not differ between mesh-treated and non-mesh-treated cases. It is suggested that future multicentric studies with a larger sample size be conducted.

Strategies for Mesh Fixation in Abdominal Wall Reconstruction: Concepts and Techniques

SUMMARY

Ventral hernias have numerous causes, ranging from sequelae of surgical procedures to congenital deformities. Patients suffering from these hernias experience a reduced quality of life through pain, associated complications, and physical disfigurement. Therefore, it is important to provide these patients with a steadfast repair that restores functionality and native anatomy. To do this, techniques and materials for abdominal wall reconstruction have advanced throughout the decades, leading to durable surgical repairs. At the cornerstone of this lies the use of mesh. When providing abdominal wall reconstruction, a surgeon must make many decisions with regard to mesh use. Along with the type of mesh and plane of placement of mesh, a surgeon must decide on the method of mesh fixation. Fixation of mesh provides an equal distribution of tension and a more robust tissue-mesh interface, which promotes integration. There exist numerous modalities for mesh fixation, each with its own benefits and drawbacks. This Special Topic article aims to compare and contrast methods of mesh fixation in terms of strength of fixation, clinical outcomes, and cost-effectiveness. Methods included in this review are suture, tack, fibrin glue, mesh strip, and self-adhering modes of fixation.

Mesh fixation techniques in primary ventral or incisional hernia repair

BACKGROUND

The use of a mesh in primary ventral or incisional hernia repair lowers the recurrence rate  and is the accepted standard of care for larger defects. In laparoscopic primary ventral or incisional hernia repair the insertion of a mesh is indispensable. Different mesh fixation techniques have been used and refined over the years. The type of fixation technique is claimed to have a major impact on recurrence rates, chronic pain, health-related quality of life (HRQOL) and complication rates.

OBJECTIVES

To determine the impact of different mesh fixation techniques for primary and incisional ventral hernia repair on hernia recurrence, chronic pain, HRQOL and complications.

SEARCH METHODS

On 2 October 2020 we searched CENTRAL, MEDLINE (Ovid MEDLINE(R)) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R)), Ovid Embase, and two trials registries. We also performed handsearches, and contacted experts from the European Hernia Society (EHS).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) including adults with primary ventral or incisional hernia that compared different types of mesh fixation techniques (absorbable/nonabsorbable sutures, absorbable/nonabsorbable tacks, fibrin glue, and combinations of these techniques).

DATA COLLECTION AND ANALYSIS

We extracted data in standardised piloted tables, or if necessary, directly into Review Manager 5. We assessed risks of bias with the Cochrane 'Risk of bias' tool. Two review authors independently selected the publications, and extracted data on results. We calculated risk ratios (RRs) for binary outcomes and mean differences (MDs) for continuous outcomes. For pooling we used an inverse-variance random-effects meta-analysis or the Peto method in the case of rare events. We prepared GRADE 'Summary of findings' tables. For laparoscopic repair we considered absorbable tacks compared to nonabsorbable tacks, and nonabsorbable tacks compared to nonabsorbable sutures as key comparisons.

MAIN RESULTS

We included 10 trials with a total of 787 participants. The number of randomised participants ranged from 40 to 199 per comparison. Eight studies included participants with both primary and incisional ventral hernia. One study included only participants with umbilical hernia, and another only participants with incisional hernia. Hernia size varied between studies. We judged the risk of bias as moderate to high. Absorbable tacks compared to nonabsorbable tacks Recurrence rates in the groups were similar (RR 0.74, 95% confidence interval (CI) 0.17 to 3.22; 2 studies, 101 participants). It is uncertain whether there is a difference between absorbable tacks and nonabsorbable tacks in recurrence because the certainty of evidence was very low. Evidence suggests that the difference between groups in early postoperative, late follow-up, chronic pain and HRQOL is negligible. Nonabsorbable tacks compared to nonabsorbable sutures At six months there was one recurrence in each group (RR 1.00, 95% CI 0.07 to 14.79; 1 study, 36 participants). It is uncertain whether there is a difference between nonabsorbable tacks and nonabsorbable sutures in recurrence because the certainty of evidence was very low. Evidence suggests that the difference between groups in early postoperative, late follow-up and chronic pain is negligible. We found no study that assessed HRQOL. Absorbable tacks compared to absorbable sutures No recurrence was observed at one year (very low certainty of evidence). Early postoperative pain was higher in the tacks group (VAS 0 - 10: MD -2.70, 95% CI -6.67 to 1.27; 1 study, 48 participants). It is uncertain whether there is a difference between absorbable tacks compared to absorbable sutures in early postoperative pain because the certainty of evidence was very low. The MD for late follow-up pain was -0.30 (95% CI -0.74 to 0.14; 1 study, 48 participants). We found no study that assessed HRQOL. Combination of different fixation types (tacks and sutures) or materials (absorbable and nonabsorbable) There were mostly negligible or only small differences between combinations (e.g. tacks plus sutures) compared to a single technique (e.g. sutures only), as well as combinations compared to other combinations (e.g. absorbable sutures combined with nonabsorbable sutures compared to absorbable tacks combined with nonabsorbable tacks) in all outcomes. It is uncertain whether there is an advantage for combining different fixation types or materials for recurrence, chronic pain, HRQOL and complications, because the evidence certainty was very low or low, or we found no study on important outcomes. Nonabsorbable tacks compared to fibrin sealant The two studies showed different directions of effects: one showed higher rates for nonabsorbable tacks, and the other showed higher rates for fibrin sealant. Low-certainty evidence suggests that the difference between groups in early postoperative, late follow-up, chronic pain and HRQOL is negligible. Absorbable tacks compared to fibrin sealant One recurrence in the tacks group and none in the fibrin sealant group were noted after one year (low certainty of evidence). Early postoperative pain might be slightly lower using tacks (VAS 0 - 100; MD -12.40, 95% CI -27.60 to, 2.80;1 study, 50 participants; low-certainty evidence). The pattern of pain and HRQOL course over time (up to 1 year) was similar in the groups (low certainty of evidence).

AUTHORS' CONCLUSIONS

Currently none of the techniques can be considered superior to any other, because the certainty of evidence was low or very low for all outcomes.

Measuring quality of life in patients with abdominal wall hernias: a systematic review of available tools

INTRODUCTION

Abdominal wall herniation (AWH) is an increasing problem for patients, surgeons, and healthcare providers. Surgical-site specific outcomes, such as infection, recurrence, and mesh explantation, are improving; however, successful repair still exposes the patient to what is often a complex major operation aimed at improving quality of life. Quality-of-life (QOL) outcomes, such as aesthetics, pain, and physical and emotional functioning, are less often and less well reported. We reviewed QOL tools currently available to evaluate their suitability.

METHODS

A systematic review of the literature in compliance with PRISMA guidelines was performed between 1st January 1990 and 1st May 2019. English language studies using validated quality-of-life assessment tool, whereby outcomes using this tool could be assessed were included.

RESULTS

Heterogeneity in the QOL tool used for reporting outcome was evident throughout the articles reviewed. AWH disease-specific tools, hernia-specific tools, and generic tools were used throughout the literature with no obviously preferred or dominant method identified.

CONCLUSION

Despite increasing acknowledgement of the need to evaluate QOL in patients with AWH, no tool has become dominant in this field. Assessment, therefore, of the impact of certain interventions or techniques on quality of life remains difficult and will continue to do so until an adequate standardised outcome measurement tool is available.

Chinese expert consensus on adult ventral abdominal wall defect repair and reconstruction

BACKGROUND

Surgical management of patients with ventral abdominal wall defects, especially complex abdominal wall defects, remains a challenging problem for abdominal wall reconstructive surgeons. Effective surgical treatment requires appropriate preoperative assessment, surgical planning, and correct operative procedure in order to improve postoperative clinical outcomes and minimize complications. Although substantial advances have been made in surgical techniques and prosthetic technologies, there is still insufficient high-level evidence favoring a specific technique. Broad variability in existing practice patterns, including clinical pre-operative evaluation, surgical techniques and surgical procedure selection, are still common.

DATA SOURCES

With the purpose of providing a best practice algorithm, a comprehensive search was conducted in Medline and PubMed. Sixty-four surgeons considered as experts on abdominal wall defect repair and reconstruction in China were solicited to develop a Chinese consensus and give recommendations to help surgeons standardize their techniques and improve clinical results.

CONCLUSIONS

This consensus serves as a starting point to provide recommendations for adult ventral abdominal wall repair and reconstruction in China and may help build opportunities for international cooperation to refine AWR practice.

Laparoscopic intraperitoneal onlay mesh (IPOM) repair using n-butyl-2-cyanoacrylate (Liquiband Fix8™) for mesh fixation: learning experience and short-medium term results

AIM

The purpose of this study was to evaluate a novel hernia repair glue fixation device (LiquibandFix8™) in laparoscopic IPOM repair for incisional hernias.

METHODS

All ventral incisional hernia patients requiring laparoscopic IPOM repair were included in the study. A retrospective review of the data was performed.

RESULTS

137 patients underwent 138 laparoscopic IPOM repairs for incisional hernias using n-butyl-2-cyanoacrylate (LiquibandFix8™) for mesh fixation over a 40-month period by a single experienced laparoscopic surgeon. There were 70 males and 67 females, median age 54 years (range 23-80 years). Defects were predominantly midline n = 123/138 (89%) and were closed by transfascial sutures in 126/138 (91%) prior to IPOM repair (IPOM plus). Mesh fixation was successful in all 138 repairs. Synthetic meshes (Symbotex™ [polyester/collagen composite, Medtronic] n = 80, and Dynamesh^® [polypropylene/PVDF composite, FEG Textiltechnik mbH] n = 5) and biologic meshes (Surgimend^® [bovine collagen dermal matrix, Integra] n = 53) were used. Median follow-up was 32 months (range 12-48 months). There were 16 adverse events in 12 patients (9%): conversion to open surgery (inadvertent enterotomy) 2 (1.5%), bladder perforation 1, intraperitoneal bleeding 2, port-site haematoma 2, port site wound infection 1, post-op ileus 2, chest infection 1, seroma 1 (1%), hernia recurrence 3 (2%) and chronic pain 2 (1.5%).

CONCLUSION

This retrospective study shows that mesh fixation in laparoscopic IPOM using cyanoacrylate glue with the Liquiband Fix8™ device is feasible, safe, easy to learn, and is associated with a low risk of seroma, hernia recurrence and chronic pain with short-medium term follow-up.

Seroma prevention strategies in laparoscopic ventral hernia repair: a systematic review

BACKGROUND

Laparoscopic ventral hernia repair (LVHR) has been increasing in popularity over the years. Seroma formation is a common complication of LVHR. The aim of this study is to review the current evidence on seroma prevention strategies following LVHR.

METHODS

A systematic search of PubMed, Embase (1946-13 February 2019) and Medline (1946-13 February 2019) databases was conducted using terms which include "seroma", "hernia, ventral" and "laparoscopy". All studies are comparative retrospective or prospective human adult studies in peer-reviewed journals describing at least one intra-operative intervention designed to decrease the rate of seroma formation in laparoscopic ventral hernia repair.

RESULTS

The database searches identified 3762 citations, and 21 studies were included for final analysis. Five studies compared the different methods of mesh fixation, nine studies compared primary defect closure (PFC) and bridged repair, two studies compared the effect of different types of meshes, two studies looked into the use of electrical cauterization, one study compared single- site laparoscopy with conventional laparoscopy, one study looked into the use of fibrin sealant and one study compared transabdominal preperitoneal placement of mesh with conventional repair. PFC appears to be the most promising with large studies showing a low rate of seroma formation with additional benefits of decreasing wound infection and recurrence rate. Cauterisation of hernia sac and injection of fibrin sealant also show promising results but are mainly derived from small studies. Other strategies did not demonstrate benefit.

CONCLUSION

Currently, primary fascial closure appears to be the most promising strategy available to decrease seroma formation after LVHR based on the results of large studies. Other promising strategies that decrease dead space such as cauterisation of the sac and fibrin sealant injection will require further multicentre trials to confirm benefit before an increase in operative time and cost can be justified for their routine use.

Absorbable versus non-absorbable tacks for mesh fixation in laparoscopic ventral hernia repair: A systematic review and meta-analysis

OBJECTIVES

To investigate the outcomes of absorbable versus non-absorbable tacks in patients undergoing laparoscopic ventral hernia repair.

METHODS

We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. We conducted a search of electronic information sources, including MEDLINE; EMBASE; CINAHL; the Cochrane Central Register of Controlled Trials (CENTRAL); the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; and ISRCTN Register, and bibliographic reference lists to identify all randomised controlled trials (RCTs) and observational studies investigating outcomes of absorbable versus non-absorbable tacks for mesh fixation in patients undergoing laparoscopic ventral hernia repair. We used the Cochrane risk of bias tool and the Newcastle-Ottawa scale to assess the risk of bias of RCTs and observational studies, respectively. Fixed-effect or random-effects models were applied to calculate pooled outcome data.

RESULTS

We identified three RCTs and two observational studies enrolling a total of 1149 patients. The included patients were comparable in terms of age [Mean difference (MD) 0.28, 95% confidence intervals (CI) -1.45-2, P = 0.75], male gender (MD 0.81, 95% CI 0.63-1.04, P = 0.10), body mass index (MD -041, 95% CI -1.28-0.46, P = 0.36) and hernia defect size (MD 0.12, 95% CI -0.26-0.49, P = 0.54). The mean and median follow-up period was 30 months and 13 months, respectively There was no difference between the two mesh fixation techniques in terms of recurrence [Risk difference (RD) 0.03, 95% CI -0.04, 0.09, P = 0.47], chronic pain [Odds ratio (OR) 0.91, 95% CI 0.62-1.33, P = 0.64], seroma (OR 0.98, 95% CI 0.37-2.60, P = 0.96), haematoma (RD -0.00, 95% CI -0.04- 0.04, P = 0.99), prolonged ileus (OR 0.99, 95% CI 0.24-4.03, P = 0.99), length of hospital stay (MD 0.10, 95% CI -0.36-0.56, P = 0.68) and port-site hernia (OR 0.98, 95% CI 0.13-7.16, P = 0.98). The operative time was longer in absorbable tack group (MD 7.53, 95% CI 1.49-13.58, P = 0.01). The results remain consistent when randomised trials were analysed separately.

CONCLUSIONS

We found no difference in clinical outcomes between absorbable and non-absorbable tacks for mesh fixation in patients undergoing laparoscopic ventral hernia repair. The quality of the available evidence is moderate with a possibility of type 2 error. High quality RCTs with adequate statistical power are required to provide more robust basis for definite conclusions. Considering the similarity of both techniques in terms of clinical outcomes, the cost-effectiveness of each technique would be an important outcome determining which technique should be used; this needs to be considered as an outcome of interest in future studies.

Comparison of mesh fixation devices for laparoscopic ventral hernia repair: an experimental study on human anatomic specimens

BACKGROUND

As there is a lack of clarity in terms of the tensile strength of mesh fixation for laparoscopic ventral hernia repair (LVHR), our aim was to investigate the immediate tensile strength of currently available mesh fixation devices on human anatomic specimens.

METHODS

Sixteen recently deceased body donators (mean body mass index of 24.4 kg/m²) were used to test the immediate tensile strength (Newton) of 11 different LVHR mesh fixation devices.

RESULTS

Each of the 11 different laparoscopic fixation devices was tested 44 times. Non-articulating tackers provided higher fixation resistance to tensile stress in comparison to articulating tackers (5.1-mm ReliaTack™: 16.9 ± 8.7 N vs. 12.2 ± 5.6 N, p = 0.013; 7-mm ReliaTack™: 19.8 ± 9.4 N vs. 15.0 ± 7.0 N, p = 0.007). Absorbable tacks with a greater length, i.e. ≥6 mm (7-mm ReliaTack™, 6-mm SorbaFix™ and 7.2-mm SecureStrap™) had significantly higher fixation tensile strength than tacks with a shorter length, i.e. < 6 mm (5.1-mm ReliaTack™ and 5.1-mm AbsorbaTack™) (p < 0.001). Furthermore, transfascial sutures (PDS 2-0 sutures 26.3 ± 5.6 N) provided superior fixation tensile strength than 5.1-mm AbsorbaTack™ (13.6 ± 7.3 N) and cyanoacrylate glues such as LiquiBand FIX8™ (3.5 ± 2.4 N) (p < 0.001, respectively). There was a significant deterioration in fixation capacity in obese body donators with a body mass index > 30 kg/m² (13.8 ± 8.0 vs. 17.9 ± 9.7 N, p = 0.044).

CONCLUSIONS

Although articulating laparoscopic tackers improve accessibility and facilitate the utilization of tacks within the fixation weak spot adjacent to the trocar placement, an articulating shaft that is not ergonomic to use may limit mechanisms of force transmission. For mesh fixation in LVHR, transfascial sutures and tacks with a longer length provide better immediate fixation tensile strength results.