Page 21 - International guidelines for groin hernia management

Hernia

Evidence in literature versus Lichtenstein in both primary and recurrent IHs. 192
Two meta-analyses, one systematic review and three RCTs Unpublished data were used and data were extracted from a
were identified out of 596 publications as suitable for four-arm study using only two relevant arms. The ‘‘TIPP
inclusion and analysis below. technique’’ was considered to be the Kugel approach, the
Cochrane Systematic Review 2009 actual TIPP technique and the Rives’ technique. The meta-
A 2009 Cochrane Systematic Review included three eli- analysis concluded that the ‘‘TIPP repair’’ was associated
191
gible trials with 569 patients. Due to methodological with a reduced risk of chronic groin pain (RR 0.48; 95% CI
limitations in the three trials considerable variations were 0.26, 0.89; z = 2.33; p \ 0.02) without increasing the
found in acute pain (risk range 38.67–96.51%) and chronic incidence of inguinal hernia recurrence (RR 0.18; 95% CI
pain (risk range 7.83–40.47%) across control groups. Two 0.36, 1.83; z = 0.51; p = 0.61). It was also concluded
trials involving 322 patients found less chronic pain after that—accounting for the significant heterogeneity amongst
pre-peritoneal repair (relative risk 0.18). These same two the different trials—the ‘‘TIPP technique’’ is comparable
trials also found less acute pain (relative risk 0.17). One with the Lichtenstein repair in terms of hernia recurrence
study of 247 patients found more chronic pain after pre- risk, postoperative complications, operation duration and
peritoneal repair (relative risk 1.17). This study reported postoperative pain intensity.
that acute pain was nearly omnipresent and thus compa- A second meta-analysis published in 2014, was judged
rable in both intervention arms (relative risk 0.997, NNT to be of low methodological quality according to SIGN
333). Early and late hernia recurrence rates were similar criteria and was withdrawn from analysis. 193
across the studies. Conflicting results were reported for RCT 2012
other early outcomes like infection and hematoma A 2012 study of TIPP versus Lichtenstein randomized 301
formation. patients and used chronic postoperative pain at 1 year as
Both pre-peritoneal and Lichtenstein repairs were seen the primary outcome measure. 194 Patients and outcome
as reasonable approaches since they resulted in similarly assessors were blinded. Significantly fewer TIPP patients
low hernia recurrence rates. There is some evidence that had continuous chronic pain, 3.5 versus 12.9% in the
pre-peritoneal repairs cause less, or at least comparable, Lichtenstein group (p = 0.004). No significant intergroup
acute and chronic pain when compared with the Lichten- differences were noted for other severe adverse events,
stein procedure. However, the Systematic Review authors including recurrence.
emphasized the need for homogeneous high-quality ran- Another RCT, comparing Kugel versus Lichtenstein
domized trials comparing elective pre-peritoneal IH repair repair, was withdrawn from analysis due to low method-
techniques with the Lichtenstein repair to assess chronic ological quality by SIGN criteria. 195 The same is true for
pain incidence. another RCT comparing TIPP versus Lichtenstein
Meta-analysis 2013 repair. 196
A 2013 meta-analysis of 12 RCTs involving 1437 patients
considered open trans-inguinal pre-peritoneal repair (TIPP)

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