Page 114 - International guidelines for groin hernia management

Hernia

Europe prior to market release. 252 Clearly these approved The LDPE net was less than 0.03% the cost of commercial
meshes are suitable for use in LRSs but are generally mesh. 257
unaffordable there and therefore not used. A recently published RCT comparing LDPE mesh with
The use of mosquito net as an alternative to commercial commercial mesh including 302 male patients concluded
prosthetics was pioneered in India by Dr. Tongaonkar. 224 that there was no significant difference in recurrence or
The first multicenter trial was performed there, using complication rates. 223 The follow-up rate was 97.3% after
indigenous autoclaved and sterilized mosquito net mesh 2 weeks and 95.6% after 1 year. Recurrence occurred in 1
composed of polyethylene and polypropylene. The study patient (0.7%) assigned to LDPE mesh and in no patients
reported a 6.9% incidence of complications, comparable to assigned to commercial mesh (absolute risk difference 0.7
complications seen with Prolene mesh, with only one percentage points; 95% confidence interval [CI] - 1.2 to
recurrence (0.27%) and no adverse mesh reactions at up to 2.6; p = 1.0). Postoperative complications occurred in 44
5-year follow-up. More recently, a number of studies in patients (30.8%) assigned to the low-cost mesh and in 44
developing countries have examined hernia repair with patients (29.7%) assigned to the commercial mesh (abso-
locally available mosquito net of various lute risk difference, 1.0 percentage point; 95% CI, - 9.5 to
types. 227, 231, 232, 253–257 Mosquito nets vary in construc- 11.6; p = 1.0).
tion, but most commonly consist of cotton, polyethylene, When mosquito net is used, tension-free IH repair is
nylon and polyester polymers. 258 approximately one-third the cost of repair with a conven-
Net pore size must be less than 1.2 mm to stop mos- tional alternative. 227, 229, 233 This finding is supported by a
quitoes. However, many nets use a pore size of 0.6 mm to meta-analysis, which also found no increase in septic
stop other biting insects. 258 Several studies have demon- complications or recurrences. 259
strated that mosquito net can be implanted with low com- Mosquito net steam sterilization at 121 °C has been
plication rates, but not all mosquito nets are the same. In recommended but long-term follow-up data confirming
addition to pore size differences, some are constructed of sterility is lacking. Most of the currently used LDPE net is
unsuitable polymers, have coatings such as DEET, and sterilized with ethylene oxide. 222
have biomechanical properties that may produce intense Cost-effectiveness analyses have estimated the overall
inflammation, all of which may lead to mesh cost associated with mesh repair to be 12.88 USD per
complications. DALY averted (assuming 120.02 USD/hernia repair and
There are legitimate concerns about infection risk, for- 9.3 DALYs averted/person). 197, 233 Based on this figure,
eign-body reaction, the effectiveness of sterilization pro- hernia repair using low-cost mesh is a more cost-effective
cedures in LRS hospitals, and the safe use of locally intervention than oral dehydration or at-home HIV/AIDS
sourced and prepared mosquito net for implantation. treatment with antiretroviral therapy. 202
A 2013 study compared the characteristics of mosquito Before universal acceptance of mosquito net for IH
net to other FDA- and MHRA-approved commercial repair can be achieved; however, careful audit and follow-
meshes. 230 The tested mosquito net was a low-density up studies are required, which may be difficult to do in
polyethylene homo-polymer (LDPE), knitted from LRSs.
monofilament fibers, the mean pore diameter was 1.9 mm, KQ28.g What is the best way to sustainably educate sur-
2
with a 91.2% porosity, 53.7 g/m mean mesh weight, and geons in LRSs?
linear mass density of 152 denier, comparable to the ‘‘large Groin hernia surgery is the most common surgery per-
pore’’ (class I) commercial meshes. The bursting force for formed in LRSs even though access to surgical services is
polyethylene mosquito net was greater than that for very limited. A lack of skilled healthcare personnel exac-
UltraPro and Vypro (43.0 vs 35.5 and 27.2 N/cm, respec- erbates this access problem. In sub-Saharan Africa, for
tively). The mosquito net exhibited less anisotropy when example, most surgical and anesthesia services are pro-
compared with commercial meshes. vided by general physicians or non-physician clinicians
A randomized trial of nylon mosquito net versus com- rather than specialists. 260, 261 Hernia is a neglected condi-
mercial mesh in 40 IH patients from Burkina Faso found no tion in LRSs. Strategies to provide education, training, and
difference in short-term 30-day follow-up outcomes. 232 resources and reorder priorities are necessary to change this
A 10-year retrospective analysis was done of consecu- situation.
tive patients who underwent a total of 651 IH LDPE net Many surgical skill educational programs exist but are
repairs and were followed for 12–18 months. Thirty-two not especially focused on hernia surgery. It is known that
patients were lost to follow-up. Six superficial surgical site continuing education improves patient safety. 261 A con-
infections occurred (0.9%), as did one seroma (0.1%), and ceptual hernia surgery education program could focus on
two hematomas (0.3%). Two patients reported chronic pain three groups of LRS surgeons.
(0.3%). No recurrences or mesh rejections were reported.

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