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Heavy-weight, small-pore polypropylene mesh Light-weight, large-pore polypropylene mesh
Mesh Technology at Inguinal Hernia Repair
185
. Fig.15.1 Histological appearance of heavyweight, small-pore polypropylene mesh with bridging eect vs
lightweight, large-pore polypropylene mesh
compared with the heavyweight mesh group
(0.7%) (p= 0.001), and aer 2years this dierence remained signicant (p=0.03). ere were 4
(0.8%) recurrent hernias in the heavyweight
group and 13 (2.7%) in the lightweight group
(p=0.03). No dierence in foreign body feeling
or quality of life scores was detected.
e authors concluded that, in TEP hernia
surgery, there was no benet of lightweight over
heavyweight meshes observed 2years postoperatively [8].
15
15.1.2 Synthetic Absorbable
. Fig.15.2 Heavyweight, small-pore polypropylene
mesh (83g/m2) 5years after endoscopic implantation
e guidelines of the European Hernia Society
state, based on evidence-level 1A, that operation
techniques using mesh result in fewer recurrences
than techniques, which do not use mesh [4].
Although mesh repair appears to reduce the likelihood of chronic pain rather than increase it [4],
mesh can cause considerable pain and stiness
around the groin and aect physical functioning
[1]. is had led to various types of mesh being
engineered, with a growing interest in absorbable
and biological meshes [9]. To avoid complications, the use of absorbable meshes – such as
those made of lactic acid polymer or lactic and
glycolic acid copolymers – has been proposed.
is exposes the patient to inevitable hernia
recurrence because the inammatory response,
. Fig.15.3 10years after bilateral TEP repair with
titanized, lightweight, large-pore polypropylene mesh
through a hydrolytic reaction, completely digests
the implanted prosthetic material [9–11].
186
F. Köckerling et al.
15
In a pilot study ten patients underwent open
inguinal hernia repair with the use of a plug and
patch out of an absorbable polyglycolic acid/trimethylene carbonate mesh (BioA). ree years
aer the procedure, three patients (37.5%) were
diagnosed clinically with a recurrence [12].
A novel approach is to use long-term resorbable implants like TIGR Matrix surgical mesh. In
a pilot study at two sites in Sweden, 40 patients
with primary inguinal hernias were enrolled for
Lichtenstein repair using this new device. None of
the patients with an isolated lateral inguinal hernia had developed a recurrence, but 4 (44%) with
medial and 4 (33%) with combined hernias have
recurred at 36month follow-up [13].
In conclusion of the very limited number of
availably studies, the use of absorbable meshes in
laparo-endoscopic inguinal hernia repair is not
justied on a routine basis outside of a trial.
15.1.3 Biological
Another potential alternative to the synthetic
meshes is biological mesh which, unlike absorbable meshes, is not completely degraded; instead,
these induce a remodeling process, i.e., the biological mesh is incorporated into the host through
the reproduction of new site-specic tissue [9].
In three retrospective case series [9, 14–17]
with 10–38 patients, inguinal hernias were
repaired in a laparo-endoscopic technique (TEP,
TAPP) with Surgisis. During a mean follow-up
period of 12–14.5months, a recurrence rate of 2
and 9.1% was observed [14, 15]. However, for reliable estimation of long-term recurrence rate aer
implantation of a biological mesh, a follow-up
period of more than 24months is necessary. No
improvement in symptoms was seen in one patient
with a sports hernia following TEP operation with
Surgisis [16]. In another study, the biological
meshes (Surgisis) were used successfully even in a
potentially contaminated setting, i.e., with incarcerated/strangulated bowel within the hernia or
coincident with a laparoscopic cholecystectomy/
colectomy as well as in a grossly contaminated
eld (i.e., gross pus or fecal spillage) [9, 17].
In conclusion, inguinal hernias can be repaired
in laparo-endoscopic technique with biological
meshes with reasonable recurrence rate in short
term, also as an alternative in a potentially
contaminated eld [9]. But the higher costs do not
justify the routine use in inguinal hernia repair.
15.2 Size
Mesh size may have a greater impact on recurrence than surgical technique [5, 6]. A small mesh
has been shown to be an independent risk factor
for recurrence compared with a large one, irrespective of the type of mesh, i.e., light- or heavyweight mesh [5, 6].
In the guidelines of the International Endohernia
Society, the recommendation on an evidence- level
grade A is to use a mesh of at least 10×15cm for
TEP and TAPP inguinal hernia repair. On evidencelevel grade D for larger hernias (direct >3–4 cm,
indirect >4–5cm), a bigger mesh (i.e., 12×17cm or
greater) is recommended [5, 6].
Insucient dissection of the preperitoneal
space makes it dicult to place a large mesh properly and avoid folds and wrinkles [5, 6]. erefore,
the dissection should be thorough with a complete parietalization and a wide exposure of the
entire preperitoneal space to ensure a at positioning of the mesh [5, 6]. Fixation does not compensate for inadequate mesh size [5, 6].
In the EAES consensus development conference on endoscopic repair of groin hernias, it was
stated that sucient overlap of the mesh is more
important than xation of the mesh (level of consensus: 82%). e mesh in groin hernia repair
measures minimally 15x10cm (level of consensus: 89%) [7]. e use of a heavyweight mesh,
larger mesh size, mechanical xation, and reduction of dead space (i.e., xation of the transversalis fascia to Cooper’s ligament) could be
considered in patients with a large medial (i.e.,
direct) hernia (level of consensus: 85%) [7].
15.3 Slit: Yes or No?
ere is no convincing evidence in the literature to
support use of a slit or to use no-slit in the mesh for
laparo-endoscopic inguinal hernia repair [5, 6].
erefore, the International Endohernia Society
give a recommendation on evidence-level grade B
in the guidelines that based on the available evidence, a slit should not be cut in the mesh, although
cutting does not compromise testis perfusion [5, 6].
Mesh Technology at Inguinal Hernia Repair
187
15
15.4 Fixation (René H. Fortelny)
Recurrence
Neither six randomized controlled trials (RCTs)
15.4.1 Non-xation
nor three case control studies could demonstrate
a signicant risk of recurrence following mesh
e systematic review of Sajid etal. [20] including
1386 patients of 8 RCT with a follow-up of
6–36 months revealed no signicant dierences
in the rates of recurrence or postoperative pain
between permanent tack xation and non- xation
in either TEP or TAPP.
. Table15.2 Meta-analyses, systematic reviews, randomized control trials, and clinical control studies on
recurrence comparing xation to non-xation in endo-/laparoscopic mesh repairs
Bibliographic
citation
Sajid etal.
2012 [20]
Teng etal.
2011 [21]
Tam etal.
2010 [22]
Garg etal.
2011 [31]
Garg etal.
2009 [34]
Taylor etal.
2008 [35]
Koch etal.
2006 [41]
Parshad etal.
2005 [49]
Moreno- Egea
etal. 2004 [44]
Lau etal.
2003 [45]
Khajanchee
etal. 2001 [46]
Smith etal.
1999 [47]
Ferzli etal.
1999 [48]
Type of
study
MA TAPP/TEP 6–36months
MA TEP 6–36months
MA TEP 6–36months
RCT TEP 26,2 (25–29)
CCS TEP 17 (6–40) months
RCT TEP 8(6–13) months* 1/247 0/253 1+ Moderate
RCT TEP 19 (6–30) months* 0/20 0/20 1+ Low
RCT TEP 23.2±9.3month
RCT TEP 36±12months
CCS TEP 1year
CCS TEP 15(1–23) months
RCT TAPP 16(1–32) months* 3/273 0/263 1+ Moderate
RCT TEP 8months
Type of
repair
Follow-up Recurrence Level of
(8 RCT)
(8 RCT)
(8 RCT)
months*
non-xation in TEP repair (. Table 15.2). One
RCT by Smith etal. [47] showed no signicant
dierence in recurrence rates comparing tack
xation with non-xation in TAPP repair. All
these RCTs contain limited information on her-
nia defect size and type especially regarding the
Fix Non-x
§
§
§
#
#
n.s. n.s. 1++ Moderate
n.s. n.s. 1++ Moderate
n.s. n.s. 1++ Moderate
0/41 0/43 1++ Moderate
§
1/61 2/1692 2− Low
∞
0/25 0/25 1+ Low
∞
0/118 3/111 1+ Moderate
0/100 0/100 2− Low
§
2/67 4/105 2− Low
0/50 0/50 1+ Low
evidence
Quality
rating
#
Mean
*Median (range)
§
Mean (range)
∞
Mean±SD
n.s. not signicant
188
F. Köckerling et al.
15
percentage of large direct hernias (type M3, EHS
classication).
In addition to the results of the RCTs, a
Herniamed registry study published by Mayer
et al. [51] based on the results of a multivariate
analysis of 11,230 cases aer TAPP repair detected
a signicant risk of recurrence in cases of direct
hernias as well as combined hernias (combined
versus medial, OR 1.137 (95% CI 0.656-1.970); lateral versus medial, OR 0.463 (95% CI 0.303–0.707);
p<0.001) in the group of non-xated meshes.
According to the IESH guidelines for the
endoscopic repair of groin hernias by Bittner etal.
[55] published in 2011, mesh xation in TEP is
not necessary apart from large medial defects
(recommendation grade A). For TAPP repair,
non-xation is feasible for medial and lateral hernias up to a diameter of 3cm (grade II in EHS
classication). In case xation is required, an
atraumatic glue application should be preferred
(recommendation grade B) (. Fig15.4).
Acute andChronic Pain
In all three meta-analyses [20, 21, 22] including
eight RCTs [21, 22, 31], no signicant dierences
whether in acute nor in chronic postoperative
pain were detected. Only in the TEP repair study
of Taylor et al. [35] a signicant reduction of
chronic pain in the non-xation group was
reported. e only RCT on TAPP repair of Smith
et al. [47] detected no signicant dierence
regarding chronic pain in the non-xation
group. However, all studies lack the detailed
quantication of preoperative pain, which would
be helpful for the identication of high-risk
patients for the development of postoperative
chronic pain.
. Fig.15.4 TAPP-brin glue xation
15.4.2 Glue Fixation
Permanent Versus Nonpermanent Fixation (Staple/Tack Versus Glue)
Recurrence
Regarding TEP repair, two meta-analyses [18, 19]
found no signicant dierence in recurrence rates
between staple and glue xation methods. e
results of three RCTs [23, 29, 42] included in the
meta-analyses by Sajid etal. [18], as well as four
case control studies [25, 40, 43, 50], conrmed
these ndings (. Table15.3).
For TAPP repair, one meta-analysis addressed
glue versus staple xation [18] including four
RCTs [32, 36, 38, 39] and reported no signicant
intergroup dierence (. Table15.3).
ese results were conrmed by six RCTs [24,
28, 32, 36, 38, 39] and three case control trials [26,
33, 37].
Acute andChronic Pain
e impact of mesh xation on chronic pain in
TEP repair for primary inguinal hernia repair in
men was analyzed using data from the Swedish
Hernia Register. Permanent xation (PF) was compared with no xation (NF) or nonpermanent xation (NPF) [52] in 1110 patients during a 7.5-year
follow-up period. e results showed no dierence
regarding primary endpoint pain (P< 0.462) using
Inguinal Pain Questionnaire and SF-36 subscales
as well as no dierence between PF and NF groups
including subgroups of medial hernias.
One systematic review by Sajid etal. [18] analyzed three RCTs on TAPP repairs [32, 38, 39] and
one RCT on TEP repair [42]. Concerning acute
pain the result of the review analysis detected no
signicant dierence between staple and brin
sealant group. However, a signicant dierence
was found for the incidence of chronic pain in
favor of the brin sealant group.
Another review by Kaul etal. [19] included
one RCT [42] and three case control studies [40,
43, 50] focusing on chronic pain incidence. Both
reviews [18, 19] revealed signicant advantages of
glue xation in lessening the incidence of chronic
pain.
In contrary to the published reviews, three
RCTs on TEP [23, 29, 42], which were not all
included in the above mentioned reviews,
detected no signicant dierence in chronic pain
Mesh Technology at Inguinal Hernia Repair
. Table15.3 Meta-analyses, systematic reviews, randomized control trials, and clinical control studies on
recurrence comparing stapling to glue xation in endo-/laparoscopic mesh repairs
189
15
Study Type of
study
Sajid etal.
MA TAPP/TEP 1–27months
2013 [18]
Kaul etal.
SR/MA TEP 7–47months
2012 [19]
Melissa etal.
RCT TEP 1year 0/64 0/65
Type of
repair
Follow-up Recurrence Level of
(5RCT)
(3CCS)
2014 [23]
Tolver etal.
RCT TAPP 6months 0/50 2/50
2013 [24]
Horisberger etal.
2013 [25]
CCS TEP 28.2 (±7.4)
months*
19.5 (±7.1)
months*
Wang etal.
CCS TAPP Tacks vs glue
2013 [26]
Bruegger etal.
2012 [28]
Subwongcharoen
RCT TAPP 38 (13–56)
months*
RCT TAPP 1year 1/30 0/30
etal. 2013 [29]
Fortelny etal.
RCT TAPP 1year 1/45 1/44
2012 [32]
Bittner etal.
CCS TAPP 6months 0/64 0/212
2010 [33]
Boldo etal.
RCT TAPP 6months 2/11 3/11
2008 [36]
Ceccarelli etal.
2008 [37]
Olmi etal.
CCS TAPP 19 (4–40)
months*
RCT TAPP 1month 0/450 0/150
2007 [38]
Lovisetto etal.
RCT TAPP 11.7months 0/98 1/99
2007 [39]
Schwab etal.
2006 [40]
Novik etal.
CCS TEP 23.7 (11–47)
months*
CCS TEP 40months 0/96 0/9
2006 [50]
Lau etal. 2005 [42] RCT TEP 1.2years
Topart etal.
2005 [43]
CCS TEP 28.3±10.9
months*
23.9±11.3
months*
Quality
evidence
rating
Stapling Glue
n.s 1++ Moderate
n.s. 1+ Moderate
b
1++ Moderate
b
1+ Moderate
b
0/100 0/101
a
0/89 0/552 2+ Moderate
1/35 2/32
0/87 0/83
5/87 2/86
#
0/94 0/92
3/117 1/81
2+ Low
a
1+ Moderate
a
1+ Moderate
b
1+ Moderate
b
2+ Moderate
b
1+ Low
b
2+ Low
b
1+ Moderate
b
1+ Low
b
2+ Moderate
b
2- Low
b
1+ Moderate
b
2+ Low
#
Mean
*Median (range)
a
Cyanoacrylate glue
b
Fibrin glue
190
F. Köckerling et al.
15
when glue was compared to staple xation.
Regarding TAPP, ve RCTs [24, 28, 36, 38, 39] and
three case control studies [26, 33, 37] found signicantly less acute pain using glue versus staple
xation.
In conclusion based on the recently published
studies, the benet of glue xation has to be seen
predominantly in the reduction of acute postoperative pain.
e updated IEHS [55] and EHS guidelines
[56] recommend atraumatic mesh xation by glue
in case xation is required in order to minimize
the risk of acute postoperative pain (recommendation grade B).
15.4.3 Nonabsorbable and
Absorbable Clips/Tacks
Currently, there is no RCT for TAPP or TEP repair
regarding the comparison of absorbable and nonabsorbable clips or tacks. One recent published
cohort study by Agresta et al. [53] comparing
absorbable tacks and brin glue xation in TAPP
repair detected signicant benet for operating
time using tacks but no dierences in terms of
recurrence and pain. Another aspect in this study
was the signicant higher costs for the tacks.
In a multicenter prospective study comparing postoperative quality of life in TEP and
TAPP, Belyansky et al. [54] reported a twofold
increase of early postoperative pain in cases
when more than ten tacks were used for mesh
xation while having no eect on recurrence
rates. Absorbable tacks seemed to be associated
with a signicantly higher frequency of postoperative pain compared to nonabsorbable tacks at
1month (25.7% vs 11.5%, P=0.015) due to the
signicantly greater number of tacks used by the
surgeon when xation was done with absorbable
tacks. At 6months and 1year, there were no differences between permanent and absorbable
tack groups in terms of the frequency of symptomatic patients.
15.4.4 Self–Fixating Mesh
Regarding new atraumatic mesh xation techniques, one RCT for TAPP repair by Cambal etal.
[27] compared self-xing mesh to glue xation. In
the short-term follow-up at 3 months, no hernia
recurrences and no signicant dierences in postoperative pain between groups were found.
Similar results were described in a case control
study for TAPP repair by Fumagalli etal. [30] in a
follow- up of 6months.
15.5 Summary
In TEP and TAPP inguinal/femoral hernia repair,
non-xation of the mesh is recommended in
almost all hernia types except large medial defects
(M3 EHS classication) where mesh is recommended to be xated.
If xation is mandatory the use of atraumatic
xation techniques by glue (brin glue, cyanoacrylate) should be considered to minimize the risk
of acute postoperative pain.
e use of absorbable or nonabsorbable tacks
is associated with an increase of early postoperative pain compared to glue xation, which correlates with the number of applied tacks.
e recommendation for self-xating meshes
in TAPP and TEP repair needs further evidence
from RCTs and data from registries.
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195
Aftercare andRecovery
inLaparoscopic Inguinal
Hernia Surgery
RalfM.Wilke, Andrewde Beaux, andJulianeBingener-Casey
16.1 Introduction – 196
16.2 Postoperative Follow-up inMy Practice:
How IDo It – 196
16.2.1 Postoperative Pain Syndromes – 196
16.2.2 Postoperative Activity – 196
16.2.3 Postoperative Visit intheClinic – 196
16
16.3 Postoperative Follow-up:
What Is Evidence Based? – 197
16.3.1 Postoperative Pain Syndromes fromthe
Open Groin Hernia Surgery – 197
16.3.2 Postoperative Activity – 198
16.3.3 Postoperative Visit intheClinic – 198
References – 198
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_16