Prospective, randomized, controlled trial comparing lightweight versus heavyweight mesh in chronic pain incidence after TEP repair of bilateral inguinal hernia

Varying convalescence recommendations after inguinal hernia repair: a systematic scoping review

PURPOSE

The most recent international guideline on inguinal hernia management recommends a short convalescence after repair. However, surgeons' recommendations may vary. The objective of this study was to give an overview of the current convalescence recommendations in the literature subdivided on the Lichtenstein and laparoscopic inguinal hernia repairs.

METHODS

In this systematic review, three databases were searched in August 2021 to identify studies on inguinal hernia repairs with a statement about postoperative convalescence recommendations. The outcome was convalescence recommendations subdivided on daily activities, light work, heavy lifting, and sport.

RESULTS

In total, 91 studies fulfilled the eligibility criteria, and 50 and 58 studies reported about convalescence recommendations after Lichtenstein and laparoscopic repairs, respectively. Patients were instructed with a wide range of convalescence recommendations. A total of 34 Lichtenstein studies and 35 laparoscopic studies recommended resumption of daily activities as soon as possible. Following Lichtenstein repairs, the patients were instructed to resume light work after median 0 days (interquartile range (IQR) 0-0), heavy lifting after 42 days (IQR 14-42), and sport after 7 days (IQR 0-29). Following laparoscopic procedures, the patients were instructed to resume light work after median 0 days (IQR 0-0), heavy lifting after 14 days (IQR 10-28), and sport after 12 days (IQR 7-23).

CONCLUSION

This study revealed a broad spectrum of convalescence recommendations depending on activity level following inguinal hernia repair, which likely reflects a lack of high-quality evidence within this field.

LAPAROSCOPIC APPROACH IN THE TREATMENT OF INGUINAL HERNIAS IN PATIENTS AFTER RADICAL PROSTATECTOMY: COMPARISON OF TARR AND TER RESULTS

Aim: To compare and evaluate the immediate and long-term results of performing transabdominal preperitoneal hernioplasty (TAPP) and total extraperitoneal hernioplasty (TEP) for the treatment of inguinal hernias after surgical treatment of prostate cancer;

Material and method: the study is a clinical analytical prospective study, with the use of randomization. The study included 88 patients with inguinal hernia, who were randomly divided into two groups (group A (n = 44) and group B (n = 44)). Patients in group A received TEP, those in group B received TAPP. The end points of the study were the results associated with the operation itself and the prognosis of the disease in the two groups.

Results: Group A: one patient had a scrotal hematoma, in 2 cases nosocomial pneumonia or infectious complications from the postoperative wound. The overall rate of early postoperative complications was 6.8%. In group B, the following postoperative complications were reported: in one case, intestinal injury, 1 case of acute urinary retention, 2 cases of scrotal hematoma. The overall incidence of early postoperative complications was 9.1%. There was no statistically significant difference in the incidence of postoperative complications between the two groups (χ = 0.009, P > 0.05).

Conclusion: During the analysis of the obtained results, no statistically significant difference was found in the duration of hospitalization, the volume of blood loss and the severity of the pain syndrome (P> 0.05); however, the comparison groups differed in the duration of the operation: the operation time in group A was longer than in group B. (P＜0.05).

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.

Polytetrafluoroethylene versus polypropylene mesh during laparoscopic totally extraperitoneal (TEP) repair of inguinal hernia: short- and long-term results of a double-blind clinical randomized controlled trial

PURPOSE

Aim of the study is to compare macroporous (> 1 mm²) polytetrafluoroethylene mesh (LP-PTFE) versus microporous (< 1 mm²) polypropylene mesh (SP-PPL) in terms of postoperative acute and chronic discomfort and pain, difficulty in mesh handling and long-term recurrence rate.

METHODS

Fifty-two patients with bilateral hernia were enrolled in this double-blind randomized controlled trial (NCT02023203). Each hernia, in the same patient, was randomized to implant LP-PTFE or SP-PPL mesh during totally extraperitoneal laparoscopic hernia repair. Patients were followed at 7 days, 1, 3, 6, 12 and 60 months after surgery. Visual analog scale (VAS) score was employed to evaluate the outcomes. Student's t test was used in case of normally distributed continuous variables, while the nonparametric Mann-Whitney U test was used in case of not normally distributed variables. Chi square test was used for analysis of categorical variables.

RESULTS

Median VAS discomfort score with SP-PPL was significantly higher than LP-PTFE at 1 and 3 months after surgery (p = 0.003 in both cases). LP-PTFE showed significantly lower median score than SP-PPL at 7 days after surgery (p = 0.025) regarding pain at movement. Testicular pain was lower in case of LP-PTFE than SP-PPL at 7 days, 1 and 3 months after surgery (p = 0.005, p = 0.004 and p = 0.004, respectively). LP-PTFE was significantly more difficult to handle (p = 0.001). At 60 months, one recurrence was observed in the LP-PTFE group (p = 1.0000).

CONCLUSIONS

LP-PTFE has less postoperative discomfort and pain up to 3 months after surgery, without differences after that period, although it shows more difficulty in handling and recurrences occur even if not statistically significant.

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.

Long-term assessment of surgical and quality-of-life outcomes between lightweight and standard (heavyweight) three-dimensional contoured mesh in laparoscopic inguinal hernia repair

BACKGROUND

Mesh weight is a possible contributor to quality-of-life outcomes after inguinal hernia repair. This study compares lightweight mesh versus heavyweight mesh in laparoscopic inguinal hernia repair.

METHODS

A prospective, single-center, hernia-specific database was queried for all adult laparoscopic inguinal hernia repair with three-dimensional contoured mesh (3-D Max, Bard, Inc, New Providence, NJ) from 1999 to June 2016. Demographics and outcomes were analyzed. Quality of life was evaluated preoperatively and after 2 weeks, 4 weeks, 6 months, 12 months, and 24 months, using the Carolinas Comfort Scale. Univariate analysis and multivariate logistic regression were performed.

RESULTS

A total of 1,424 laparoscopic inguinal hernia repair were performed with three-dimensional contoured mesh, with 804 patients receiving lightweight mesh and 620 receiving heavyweight mesh. Patients receiving lightweight mesh were somewhat younger (52.6 ± 14.8 years vs 56.3 ± 13.7 years, P < .0001), with slightly lower body mass indices (26.4 ± 9.9 vs 27.1 ± 4.3, P < .0001). Lightweight mesh was used less often in incarcerated hernias (12.5% vs 16.8%, P = .02). There were a total of 3 surgical site infections. There were no differences in complications between groups except for seroma. Although on univariate analysis, seromas appeared to occur more frequently with heavyweight mesh (21.5% vs 7.9%). On multivariate analysis, heavyweight mesh was not independently associated with seroma formation. Average follow-up was 20 months. Recurrence rates were similar between lightweight mesh and heavyweight mesh (0.7 vs 0.6% P > .05). At all points of follow-up (4 week to 3 years), quality-of-life outcomes of discomfort, mesh sensation, and movement limitation scores were similar between lightweight mesh and heavyweight mesh.

CONCLUSION

Contoured lightweight mesh and heavyweight mesh in laparoscopic inguinal hernia repair yield excellent recurrence rates and no difference in postoperative complications or quality of life. Considering the lack of outcome difference with long-term follow-up, heavyweight mesh may be considered for use in laparoscopic inguinal hernia repair patients.

Outcome of the "Manchester Groin Repair" (Laparoscopic Totally Extraperitoneal Approach With Fibrin Sealant Mesh Fixation) in 434 Consecutive Inguinal Hernia Repairs

Introduction: This study looks at the outcome of 352 patients that underwent the "Manchester groin repair" in the period from 2007 to 2016. The effect of laterality on chronic groin pain and the reduction of pain scores post-surgery are evaluated as well as the rate of hernia recurrence for the inguinal hernia repairs. Methods: The "Manchester groin repair" is a modification of a laparoscopic totally extra-peritoneal approach with fibrin sealant mesh fixation. Data were collected prospectively. In addition to demographic data and the European Hernia Society classification grading of each hernia, pain scores were assessed prior to surgery and at 4-6 weeks post-operatively using a ten-point visual analog pain scale. Data were collected on a bespoke database and differences between time-points analyzed by non-parametric Wilcoxon signed rank tests with Kruskal-Wallis rank sum test for three-group comparisons. Significance was at the P < 0.05 level. The study was undertaken as an institutional audit. Results: Three hundred and fifty two patients underwent TEP repair as per the "Manchester Groin Repair" modification during the period of interest with a median follow-up period of 109.5 (IQR 57.0-318.5) weeks. Of these 274 (77.8%) were for the repair of true hernias and 78 (22.2%) were for inguinal disruptions. All inguinal hernia repairs patients were evaluated (254 m, 20 f); median [interquartile range] age 50 (39-65) years. There were 75 right inguinal hernias (27.4%), 39 Left inguinal hernias (14.2%), and 160 bilateral inguinal hernias (58.4%), giving a total of 434 hernia repairs. During follow-up there were 6 recurrences (1.4%).Of the 274 patients evaluated, 145 (52.9%) had both pre and post-operative pain scores available. Median pre-operative pain score was 5 [IQR 4-7]. Median post-operative pain score was 1 [IQR 1-2]. This difference was significant (P < 0.001). Pre-operative pain scores were higher for those with a bilateral hernia (median 6 vs. 5 and 4, respectively; P = 0.005), but there was no difference in post-operative scores (P = 0.347). One patient (0.3%) presented with chronic groin pain (pain after 3 months). Conclusion: This study demonstrates that the "Manchester groin repair" provides an excellent repair with a low rate of recurrence and low incidence of chronic pain. Longer-term evaluation and larger patient series will add to the understanding of the role of this procedure in groin hernia repair.

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.

Efficacy and safety of a novel partially absorbable mesh in totally extraperitoneal hernia repair

Purpose

Partially absorbable mesh has been introduced and used for inguinal hernia repair for the purpose of minimizing pain and improving abdominal wall compliance. In this study, we evaluate the efficacy and safety of ProFlex mesh, a partially absorbed mesh with new structural architecture.

Methods

We retrospectively reviewed 64 cases of totally extraperitoneal herniorrhapy (TEP) from January 2013 to December 2014 for their clinical features, including operation time, pain, postoperative complications, and recurrence.

Results

There were no significant differences in operation time, hospital stay, postoperative pain, or complications between the 28 patients who received the ProFlex mesh and the 36 who received nonabsorbable lightweight mesh, although one patient who received the nonabsorbable had a recurrence during follow-up. There were differences in operation time, complications, and hospital stay according to the surgeon's previous operation volume.

Conclusion

This study showed that there were significant differences in the fixation strength of different polypropylene meshes in combination with various fibrin glues. ProFlex, a partially absorbable mesh with new architecture, was feasible and safe in TEP.

Risk factors of chronic pain after inguinal hernia repair: a systematic review

Introduction

Chronic postoperative inguinal pain (CPIP) is the most common complication after inguinal hernia operation. Eighteen percent (range, 0.7%-75%) of patients suffered from CPIP after open inguinal hernia repair and 6% (range, 1%-16%) reported CPIP after laparoendoscopic groin hernia repair. The incidence of clinically significant CPIP with impact on daily activities ranged between 10% and 12%. Debilitating CPIP with severe impact on normal daily activities or work was reported in 0.5%-6% of the cases.

Materials and methods

PubMed, Medline, Embase, and the Cochrane Database were searched for studies on risk factors for chronic pain after open and endoscopic hernia repair. A systematic review of the literature was conducted using the grading of recommendations, assessment, development, and evaluations (GRADE) methodology.

Results

Risk factors for CPIP with strong evidence include female gender, young age, high intensity of preoperative pain, high early postoperative pain intensity, history of chronic pain other than CPIP, operation for a recurrent hernia, and open repair technique. Risk factors for CPIP with moderate evidence include postoperative complications, neurolysis, and preservation of the ilioinguinal nerve in Lichtenstein repair. Risk factors for CPIP with low evidence include genetic predisposition (DQB1*03:02 HLA haplotype), lower preoperative optimism, high pain intensity to tonic heat stimulation, inadequate suture/staple/clip mesh fixation, ignorance of the inguinal nerves, less experienced surgeon, sensory dysfunction in the groin, and worker's compensation.

Conclusion

Detailed knowledge of the risk factors, meticulous operative technique with profound knowledge of the anatomy, proper nerve identification and handling, optimization of prosthetic materials, and careful fixation are of utmost importance for the prevention of CPIP.

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.

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.

PREVENTion of a parastomal hernia with a prosthetic mesh in patients undergoing permanent end-colostomy; the PREVENT-trial: study protocol for a multicenter randomized controlled trial

BACKGROUND

Parastomal hernia is a common complication of a colostomy. Ultimately, one-third of patients with a parastomal hernia will need surgical correction due to frequent leakage or life-threatening bowel obstruction or strangulation. However, treatment remains a challenge resulting in high recurrence rates. Two single center trials demonstrated that the frequency of parastomal hernias decreases by prophylactic placement of a mesh around the stoma at the time of formation. Unfortunately, both studies were small-sized, single-center studies and with these small numbers less common complications could be missed which were the reasons to initiate a prospective randomized multicenter trial to determine if a retromuscular, preperitoneal mesh at the stoma site prevents parastomal hernia and does not cause unacceptable complications.

METHODS

One hundred and fifty patients undergoing open procedure, elective formation of a permanent end-colostomy will be randomized into two groups. In the intervention group an end-colostomy is created with placement of a preperitioneal, retromuscular lightweight monofilament polypropylene mesh, and compared to a group with a traditional stoma without mesh. Patients will be recruited from 14 teaching hospitals in the Netherlands during a 2-year period. Primary endpoint is the incidence of parastomal hernia. Secondary endpoints are stoma complications, cost-effectiveness, and quality of life. Follow-up will be performed at 3 weeks, 3 months and at 1, 2, and 5 years. To find a difference of 20% with a power of 90%, a total number of 134 patients must be included. All results will be reported according to the CONSORT 2010 statement.

DISCUSSION

The PREVENT-trial is a multicenter randomized controlled trial powered to determine whether prophylactic placement of a polypropylene mesh decreases the incidence of a parastomal hernia versus the traditional stoma formation without a mesh.

TRIAL REGISTRATION

The PREVENT-trial is registered at: http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2018.

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

PURPOSE

The aim of this article is to compare the outcomes of lightweight mesh and heavyweight mesh in inguinal hernia repair.

METHOD

A comprehensive literature search was undertaken to identify studies comparing the influence of lightweight and heavyweight meshes on inguinal hernia.

RESULTS

The present meta-analysis pooled the effects of outcomes of a total 5,389 patients enrolled into 16 randomized controlled trials and 5 comparative studies. Lightweight mesh repair was associated with a significant less incidence of chronic postoperative pain [OR = 0.72, 95 % CI (0.57, 0.91)] and less feeling of foreign body than heavyweight mesh repair [OR = 0.50, 95 % CI (0.37, 0.67)]. Recurrence at 12 months was marginally increased in lightweight group (p = 0.05) [RD = 0.01, 95 % CI (0.00, 0.02)]. However, statistically there was no difference in the incidence of seroma [OR = 0.80, 95 % CI (0.52, 1.23)], infection [RD = -0.00, 95 % CI (-0.01, 0.00)], and testicular atrophy [RD = 0.01, 95 % CI (-0.01, 0.02)].

CONCLUSION

There was no difference regarding the incidence of seroma, infection, and testicular atrophy between lightweight mesh versus heavyweight mesh for inguinal hernia. There is a concern on the recurrence when lightweight mesh is used in large inguinal hernias. However, lightweight mesh repair do have advantages in terms of chronic postoperative pain and feeling of foreign body, and further well-structured trials with improved standardization of hernia types, operative techniques are necessary.

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.

[Predictors of chronic pain following surgery. What do we know?]

Chronic postoperative pain is known to be a significant clinical and economic problem. The estimated mean incidence is high and varies between 10 and 50%, with variations mostly related to procedure-specific conditions. High-risk types of surgeries are e.g. thoracotomy, breast or inguinal hernia surgery and amputations. Although there is increasing knowledge about the incidence of chronic postoperative pain after certain types of surgical procedures, there are only limited data related to the mechanisms and pathophysiology leading to chronic pain after surgery. Neuropathic pain components have been discussed, especially following operations with a high incidence of nerve damage (for example axillary lymphadenectomy). Besides surgical factors it seems that there are a number of other factors which likely increase the risk of chronic postoperative pain. These predictors for the development of chronic postoperative pain are multiple and include individual genetic factors, age and sex of the individual patient, preoperative chronic pain, psychosocial factors, neurophysiological factors, intraoperative nerve and muscle damage, postoperative complications and acute pain in the early postoperative period. Quantitative sensory testing including tests of inhibitory circuits like DNIC might help to predict the risk of individual patients even before surgery has started. The perioperative identification of patients who are at high risk for developing chronic pain after surgery is therefore a major goal for the future. This may help to develop preventive treatment strategies and avoid treatments with side effects for patients who are not at risk for developing chronic pain after surgery. Due to a lack of appropriate data for sufficient preventive approaches an effective postoperative acute pain management and a nerve-conserving surgical technique are the major keys in the prophylaxis of chronic postoperative pain.

Physicomechanical evaluation of polypropylene, polyester, and polytetrafluoroethylene meshes for inguinal hernia repair

BACKGROUND

For meshes to be used effectively for hernia repair, it is imperative that engineers and surgeons standardize the terminology and techniques related to physicomechanical evaluation of these materials. The objectives of this study were to propose standard techniques, perform physicomechanical testing, and classify materials commonly used for inguinal hernia repair.

STUDY DESIGN

Nine meshes were evaluated: 4 polypropylene, 1 polyester, 1 polytetrafluoroethylene, and 3 partially absorbable. Physical properties were determined through image analysis, laser micrometry, and density measurements. Biomechanical properties were determined through suture retention, tear resistance, uniaxial, and ball burst testing with specimens tested in 2 different orientations. A 1-way ANOVA with Tukey's post-test or a t-test were performed, with p < 0.05.

RESULTS

Significant differences were observed due to both mesh type and orientation. Areas of interstices ranged from 0.33 ± 0.01 mm² for ProLite (Atrium Medical Corp) and C-QUR Lite (Atrium Medical Corp) Large to 4.10 ± 0.06 mm² for ULTRAPRO (Ethicon), and filament diameters ranged from 99.00 ±8.1 μm for ProLite Ultra (Atrium Medical Corp) and C-QUR Lite Small to 338.8 ± 3.7 μm for Parietex Flat Sheet TEC (Covidien). These structural characteristics influenced biomechanical properties such as tear resistance and tensile strength. ProLite Ultra, C-QUR Lite Small, ULTRAPRO and INFINIT (WL Gore & Associates) did not resist tearing as effectively as the others. All meshes exhibited supraphysiologic burst strengths except INFINIT and ULTRAPRO.

CONCLUSIONS

Significant differences exist between the physicomechanical properties of polypropylene, polyester, polytetrafluoroethylene, and partially absorbable mesh prostheses commonly used for inguinal hernia repair. Orientation of the mesh was also shown to be critical for the success of meshes, particularly those demonstrating anisotropy.