The Comparison of Lichtenstein Procedure with and without Mesh-Fixation for Inguinal Hernia Repair

Interim analysis of single - centre randomised controlled trial on incisional hernia repair with vs without synthetic mesh fixation

INTRODUCTION

In a prospective randomised trial, we aimed to compare incisional hernia repair with mesh fixation versus incisional hernia repair without mesh fixation.

METHODS

The study was performed from June 2018 to August 2024 at a single centre in Vilnius, Lithuania. Fifty-seven patients with incisional abdominal wall hernia were randomly included into two groups: group one-"sublay" hernia repair with mesh fixation and the second - without mesh fixation. The duration of surgery, hospital stay, pain levels, quality of life and rate of complications were compared.

RESULTS

Of the 38 women and 19 men who were included in the study, 30 were with mesh fixation and 27 without mesh fixation. The median patient's body mass index was 31.57 ± 5.96 (19.5-49.6). The most common hernia width was W2 according to the European Hernia Society (EHS) classification. A significant difference between the groups was found in duration of surgery - 108.00 ± 47.35 (40-235) minutes in the mesh fixation group vs. 75.74 ± 30.25 (35-150)-without the mesh fixation group (p < 0.05). A higher pain level was observed on the 10th postoperative day-3.03 ± 2.54 in the mesh fixation group versus 1.67 ± 2.22 in the group without the mesh fixation group (p < 0.05). A statistically significant difference was also observed in seroma rate after 6 months (16.6% versus 0%, p < 0.05). There have been no hernia recurrences in either group so far.

CONCLUSIONS

No mesh fixation on "sublay" hernia repair does not worsen the patient's postoperative condition. It does not increase postoperative pain, worsen the quality of life, or increase the risk of postoperative complications. On the 10th postoperative day, the non-fixed mesh group had less postoperative pain, however, later the pain was equal. A lower number of seromas was also observed in this group after 6 months. However, the operative time in the group without mesh fixation was significantly shorter.

Meta-analysis of RCTs on the safety of non-fixation of mesh in TAPP inguinal hernia repair: an updated meta-analysis

OBJECTIVE

This meta-analysis aims to compare the clinical efficacy of mesh non-fixation and fixation in laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair, systematically evaluating the application value of the mesh non-fixation technique in clinical settings.

METHODS

A computerized search of PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov databases was conducted to identify randomized controlled trials (RCTs) comparing mesh non-fixation and fixation in TAPP inguinal hernia repair. Meta-analysis was performed using RevMan 5.3 software, and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) evidence grading system was employed for outcome quality assessment. Publication bias analysis was performed using Begg's test. A trial sequential analysis (TSA) was performed using TSA 0.9.5.10 Beta software.

RESULTS

A total of nine RCTs involving 1,879 inguinal hernia patients were included. Meta-analysis results demonstrated that, compared to the fixation group, the non-fixation group exhibited significantly lower seroma occurrence rate [RR = 0.43, 95% CI (0.20, 0.89), P = 0.02, heterogeneity P = 0.28, I²=22%], Visual Analog Scale (VAS) pain score at 6 months postoperatively [MD=-0.21, 95% CI (-0.29, -0.12), P < 0.00001, heterogeneity P = 0.34, I²=0%], and cost [MD=-3.23 thousand yuan, 95% CI (-4.26, -2.19), P < 0.00001, heterogeneity P = 0.0003, I²=92%]. There were no statistically significant differences in overall complication rate [RR = 0.88, 95% CI (0.62, 1.23), P = 0.45, heterogeneity P = 0.11, I²=44%], overall infection event rate [RR = 0.96, 95% CI (0.36, 2.56), P = 0.93, heterogeneity P = 0.62, I²=0%] and recurrence rate [RR = 0.75, 95% CI (0.28, 1.99), P = 0.56, heterogeneity P = 0.44, I²=0%] between the two groups. The results of the TSA indicated that the observed lower seroma occurrence rate in the non-fixation group compared to the fixation group requires further validation through the inclusion of additional RCTs.

CONCLUSION

Mesh non-fixation in TAPP inguinal hernia repair is deemed safe and does not elevate the risk of hernia recurrence. However, given certain limitations in this study, future comprehensive and reliable validation will require further multicenter, high-quality, large-sample double-blind RCTs.

Comparing stapler and sutured mesh fixation techniques for laparoscopic TAPP repair: a study on chronic groin pain on 3-year follow-up

Trans-abdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repairs are the available surgeries for inguinal hernias, with both methods of laparoscopic repairs requiring mesh applications. This study analyzes the correlation between sutured versus stapler mesh fixation in a laparoscopic TAPP for unilateral groin hernia regarding chronic pain during 3-year follow-up. A total of 130 patients with laparoscopic hernia undergoing TAPP repair were randomized into 2 groups based on their fixation technique-one with sutures and the other with stapler. Postoperative complications and chronic groin pain were noted for each technique. Equal number of participants was present in the stapler and suture groups, with the majority having an ASA score of one. The mean age was 42.50 ± 13.86 years, and the body mass index (BMI) was 27.47 ± 5.88. The stapler group presented a shorter mean operative time than the suture group. However, the stapler group had a significantly higher mean VAS score than the suture group. Most participants in the suture group (89.2%) had LOS for 1 day, while a 2-day LOS was significantly higher in the stapler group (12.3%) than in the suture group (9.2%). No patient reported mesh erosion, conversion, recurrence, testicular atrophy, and mesh infection. Early postoperative pain was more in stapler group along with long hospital stay, but both were non-significant. Chronic postoperative pain results and recurrence incidences over 3-year follow-up were also similar. Re-admission rates were minimal, no significant complications occurred.

Safety of unfixed mesh in laparoscopic total extraperitoneal inguinal hernia repair: A meta-analysis of randomized controlled trials

BACKGROUND

Whether the effect of the unfixed mesh during laparoscopic total extraperitoneal (TEP) inguinal hernia repair can lead to hernia recurrence remains controversial.

METHODS

The PubMed, Cochrane Library, and EMBASE databases were searched to retrieve clinical randomized controlled trials (RCTs) comparing nonfixation of mesh and fixation of mesh in TEP inguinal hernia repair, and we performed a metaanalysis with RevMan 5.3 software.

RESULTS

Fifteen RCTs were included in the metaanalysis, which showed that the operation time (P = 0.001) of the unfixed mesh group was shorter than that of the fixed mesh group; additionally, the postoperative 24-h pain score (P = 0.04) and incidence of urinary retention (P = 0.001) were lower in the unfixed mesh group. There was no significant difference between the unfixed mesh group and the fixed mesh group in terms of hospital stay (P = 0.47), time to resume normal activities (P = 0.51), incidence of haematoma (P = 0.96), incidence of chronic pain (P = 0.20), and recurrence rate (P = 0.09).

CONCLUSION

Unfixed mesh in TEP inguinal hernia repair shows no elevated recurrence rates compared to fixed mesh and is clinically safe.

A Prospective Comparative Study of 3-Stitch Mesh Hernioplasty with Conventional Lichtenstein Repair

Background

Hernioplasty, in which a mesh is used to strengthen a weakness or defect in the inguinal wall, has replaced simple tissue repair. As it is associated with low recurrence, it is considered the gold standard and is one of the most common general surgical procedures. The ideal repair should be rapid, safe and simple to do, requires minimal dissection to create sufficient space, be cost-effective and be accompanied by a brief hospital stay, reduced pain, and fewer recurrences. The aim of the present study was to compare the efficacy of 3-stitch mesh fixation with that of traditional Lichtenstein mesh fixation of inguinal hernia repair.

Materials and Methods

Between July 2018 and December 2019, 59 cases of primary, uncomplicated inguinal hernias were surgically treated. Both the classical Lichtenstein technique (group A, n = 30) and the Lichtenstein technique with the three-stitch fixation method (group B, n = 29) were used on patients with inguinal hernias. Between the two groups, the mean operative times, post-surgical pain scores, average hospital stays and postoperative complications including recurrence rates were compared.

Results

With a P-value of 0.001, the 3-point fixation group (group B) took 3.41 ± 0.58 min less time to fix the mesh than the Lichtenstein group (group A, 5.52 ± 0.59 min). The pain after surgery was much less for participants who had 3-point mesh fixation than for those who had conventional mesh fixation in the early (1, 3, 7 and 15 days after surgery) and late (1 month and 3 months) postoperative periods, with a P-value of 0.0001. When compared to the classical mesh fixation group, the 3-point mesh fixation group had less urinary retention, seroma and swelling. Both groups had the same number of other complications.

Conclusions

The three-point hernioplasty is a simple procedure that is easier to adopt, less time-consuming, causes less trauma and has a lower risk of postoperative discomfort including chronic groin pain.

Comparison between self-gripping, semi re-absorbable meshes with polyethylene meshes in Lichtenstein, tension-free hernia repair: preliminary results from a single center

Even tough inguinal hernia repair is among the commonest operations in general surgery, the choice for an optimal approach continues to be a controversial topic. Because of the low recurrence rates and low prevalence of complications, tension-free mesh augmented operation has become the standard technique in inguinal hernia surgery, significantly reducing hernia recurrence rates. On the contrary, prevalence of chronic postoperative groin pain (CPGI) i.e. pain beyond a three month-postoperative period still remains significant: as rates of CPGI may range between 15% and 53%, surgical approaches aimed to avoid chronic post-hernioplasty pain have been extensively debated, and the avoidance of CPGI has become one of the primary endpoints of surgical research on inguinal hernia repair). Recently, a sound base of evidence suggested that the entrapment of peripheral nervous fibers innervating part of the structures in the inguinal canal and stemming from ilioinguinal (Th12), iliohypogastric (L1) nerves as well as from the genital branch of the genito-femoral nerve (L1, L2), may eventually elicit CPGI (1-10). Consequently, innovative fixation modalities (e.g. self-gripping meshes, glue fixation, absorbable sutures), and new material types (e.g. large-pored meshes) with self-adhesive sticking or mechanical characteristics, have been developed in order to avoid penetrating fixings such as sutures, clips and tacks. However, some uncertainties still remain about the pros and cons of such meshes in terms of chronic pain, as new, innovative mesh apparently does not significantly reduce the rate of CPGI. Parietex ProGrip® (Medtronics^TM) is a bicomponent mesh comprising of monofilament polyester and a semi re-absorbable polylactic acid gripping system that allows sutureless fixation of prosthetic mesh to the posterior inguinal wall. As ProGrip® does not requires additional fixation, inguinal canal may be closed within minutes after adequate groin dissection, ultimately shortening operating time. In other words, ProGrip® has the potential for significant savings, in terms of surgical and post-operating costs as well (10). The aim of our study is therefore to compare the results of the same technique with two different mesh materials (ProGrip® mesh vs. polyethylene mesh), in terms of operative time, post-operative pain, complications, and recurrence rates. (www.actabiomedica.it)

Comparison of mesh fixation and non-fixation in laparoscopic totally extraperitoneal inguinal hernia repair

PURPOSE

The purpose of this study was to compare laparoscopic total extraperitoneal (TEP) hernia repair procedures with or without mesh fixation for non-recurrent inguinal hernia.

METHODS

100 male patients with non-recurrent inguinal hernia (62 unilateral and 38 bilateral) were included in the study. The patients were randomly assigned to either the mesh fixation group (n = 50) or the mesh non-fixation group (n = 50). The operative and follow-up data of the two groups were analyzed and compared in terms of recurrence rates, postoperative pain, length of hospital stay, and postoperative changes in testicular arterial blood flow.

RESULTS

Pain scores were significantly higher in the mesh fixation group prior to discharge and at the 1st postoperative month (p = 0.034 and 0.001, respectively). Necessity to use narcotic analgesics was higher in the fixation group prior to discharge (p = 0.025). Urinary retention was significantly more frequent in the fixation group than in the non-fixation group. (p = 0.007). The mean operative time and length of hospital stay were similar in both groups. Preoperative and postoperative measurements of testicular arterial blood flow showed a substantial but not statistically significant difference for the frequency of impairment (14.2% in the fixation group and 5.8% in the non-fixation group) (p = 0.176). At long-term follow-up, no recurrence and no nerve injury were determined.

CONCLUSION

Fixation of the mesh to the abdominal wall has been associated with various postoperative complications for no additional benefit in lowering recurrence rates. For non-recurrent inguinal hernia, non-fixation of the mesh is safe and reliable. Further studies with larger sample sizes are necessary for subgroup analyses.