Page 44 - International guidelines for groin hernia management

Hernia

nerve damage through entrapment. Mesh fixation compli- fibrin sealant to sutures, one compared tacks to sutures,
cations include: mesh migration, adhesions, erosion and and one compared absorbable sutures to non-absorbable
hernia recurrence, 531–535 ‘‘meshoma’’ formation, 536 tack sutures. Per GRADE guidelines, none of the RCTs were
hernias, 537 chronic pain, 538–543 and infection. 544, 545 A rated as high quality. The most common reasons for low
number of RCTs—also summarized in meta-analyses— or very low study grading were: lack of power calcula-
have compared different mesh fixation methods in both tions, small subject numbers, short follow-up periods, and
open and laparo-endoscopic IH repair. Various mesh fixa- poorly matched groups (for age, hernia size and
tion methods exist including: tacks, staples, self-fixing, comorbidities).
fibrin sealants (FSs), glues and sutures. However, consen- Recurrence
sus does not exist about a ‘‘best’’ fixation method, so Thirteen of 26 recurrences were reported in one study with
methods used are based on surgeons’ preferences. Evi- a 5-year follow-up utilizing NB2C glue. 552 There were no
dence that a particular fixation method improves patient- significantly different recurrence rates found between fix-
based or surgical outcome measures may have a significant ation methods in any of the RCTs, although long-term
impact on clinical practice. Analyses below covers two recurrence rates have not been determined and large her-
topics: fixation in open hernia repair and fixation in laparo- nias often have been excluded.
endoscopic hernia repair. Special patient-related circum- Infection rates
stances are also highlighted. Surgical site infection (SSI) data were included in eight of
Open inguinal/femoral primary hernia repair the studies. No study distinguished between superficial and
deep SSI. SSI diagnostic criteria were infrequently docu-
Key question mented. Overall infection rates ranged from 0 to 3.5%; and
infection resulted in three mesh explantations. Choice of
KQ11.a fixation method did not result in any significant difference
Which fixation methods are appropriate in primary open in infection rates.
anterior mesh inguinal and femoral hernia repairs?

Evidence in literature Chronic pain
The search yielded eight systematic reviews on the subject All studies included chronic pain data. Most defined
of mesh fixation in primary open IH chronic pain as pain persisting beyond 3 months a range of
173, 175, 177, 546–551
repair. Seven of these reviews assessed definitions was though used (range 3–12 months). One
IH repair using an anterior mesh repair while one assessed study did not include a chronic pain definition. 553 Five
both open anterior and laparoscopic repairs. studies measured chronic pain incidence at
3 months, 552, 554–557 two only at 6 months, 168, 409 and three
Systematic reviews on fixation methods only at 1 year. 171, 558, 559 One study used a composite
Mesh fixation methods were assessed in one moderate- endpoint of pain, numbness, and groin discomfort at 1 year
quality systematic review of 12 RCTs involving 1992 (at 6 months if 1-year data were not available).
primary IH repairs. 551 Data heterogeneity precluded per- Overall, chronic pain rates ranged from 0 to 36.3%. The
formance of a meta-analysis. Four studies compared n- combined chronic pain rates for mesh fixation of various
butyl-2 cyanoacrylate (NB2C) glues to sutures, two types were: 14.7% for sutures, 7.6% for NB2C glue, 3.7%
compared self-fixing meshes to sutures, four compared for FS, and 18.2% for self-fixing meshes.

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