Page 20 - International guidelines for groin hernia management

Hernia

Ò
A large-pore version of the PHS, the Ultrapro Hernia amount of foreign material is higher than for a simple flat
System (UHS), was launched recently. One RCT compares mesh. And—in the case of a combined hernia—the
Lichtenstein and the UHS. 165 Another RCT compared the placement strategy for the device or plug is not standard-
Ò
plug-and-patch technique with a 4D Dome device in 95 ized. The additional cost of the device needs to be taken
patients. 166 The ‘‘dome device’’ consists of a largely into account as does the small chance of mesh migration/
resorbable dome-shaped plug (90% poly-L-lactic acid and erosion with the use of plugs. Therefore, the Lichtenstein
10% polypropylene) associated with a flat lightweight technique with a flat mesh is considered to be superior. See
polypropylene mesh. Because of poor methodological also Chapter 10 on mesh in which the problems of mesh-
quality (according to SIGN criteria), neither paper is fur- plug erosion and migration are described.
ther discussed here. Self-gripping mesh is an acceptable form of treatment for
Trabucco primary IHs, although only medium-term data are available
One RCT compared the Lichtenstein with the Trabucco and no specific information on the outcome in larger (direct)
technique in 108 patients under local anesthesia. 167 The hernias. It has no benefits over the Lichtenstein technique
Trabucco technique was an average of 10 min faster vs. other than a somewhat shorter operative time. Here also, the
Lichtenstein (p = 0.04). There were no differences in device’s additional cost must be considered.
postoperative pain (primary outcome) or groin discomfort For these reasons, the recommendations to use the
at 6 months. At an average follow-up of 8 years (only Lichtenstein technique with a standard flat mesh vs the use
telephone follow-up after 1 year), there were no recurrent of self-gripping mesh or three-dimensional implants are
hernias. upgraded to strong by the HerniaSurge Group.
Self-gripping mesh
KQ06.d Which is the preferred open mesh technique for
The first study on the use of the self-gripping Parietene
inguinal hernias: Lichtenstein or any open pre-peritoneal
ProgripÓ mesh (large-pore polypropylene with resorbable
technique?
polylactic acid micro-grips) found less pain on the first
F. Berrevoet, Th. Aufenacker and S. Tumtavitikul
postoperative day when compared with the use of another
large-pore non-gripping polypropylene mesh. 168 Subse-
Introduction
quently, four other RCTs comparing self-fixating large-
Open pre-peritoneal mesh techniques have gained more
pore mesh vs suture fixation in Lichtenstein have been
published up to 2013. 169–172 These studies have been attention in the repair of IHs during the last two decades as
a result of technical and commercial considerations. Sur-
evaluated in five different meta-analyses, all published in
173–177 geons should understand that ‘‘open pre-peritoneal tech-
2013 and 2014 in different journals. All confirmed
niques’’ as originally described by Nyhus, 183 include
no difference in acute or chronic pain and recurrence rates.
Three additional RCTs were published in 2014, 178–180 several different approaches including the trans-inguinal
184
pre-peritoneal repair described by Pe ´lissier (TIPP), the
and another two were published with long-term data from 185
an RCT published earlier. 181, 182 All confirmed comparable posterior Kugel technique, transrectus pre-peritoneal
187
186
approach (TREPP), Onstep approach, Ugahary tech-
recurrence rates and acute and chronic pain incidence in 188 189 190
nique, Wantz technique, and Rives’ technique, for
both groups. The self-fixation mesh is likely to be more
anterior pre-peritoneal repair. Note that TIPP, Onstep, and
expensive than standard fixation, but the operative time
Rives’ techniques approach the pre-peritoneal space
was shorter in the ProgripÓ group (by a range of
through an anterior dissection opening the inguinal canal.
1–12 min).
Kugel, TREPP, Ugahary and Wantz use a posterior
Since only data on medium-term follow-up are available
approach to open repair without entering the inguinal canal
(range 6–24 months), we advise the authors of the previ-
anteriorly.
ously mentioned trial data to follow-up their patients at
Onstep is comparable with the PHS/UHS system,
3–5 years and publish their updated results on chronic pain
although there is only one mesh layer reinforcing the
and recurrence rates.
medial side pre-peritoneally, and the lateral side as in the
Lichtenstein technique.
Discussion, consensus and grading clarification
There are no data comparing the open pre-peritoneal
Plug-and-patch and PHS are acceptable treatments for
techniques with each other, so no recommendation can be
primary IHs, but have no benefit vs. the Lichtenstein
made about the preferred open pre-peritoneal technique.
technique, except a somewhat shorter operative time for
However, we are able to make the following statements
the plug-and-patch technique. However, both the anterior
based on limited data about pre-peritoneal techniques. The
and posterior compartment are entered and scarred, making
use of these techniques is suggested to be performed in
a subsequent repair for recurrence more difficult. Also, the
research conditions.
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