Page 45 - International guidelines for groin hernia management

Hernia

Nine studies reported no significant difference in after atraumatic fixation, the clinical significance of small
chronic pain between fixation methods. Three identified a changes in VAS scores in unclear. 182
significant reduction with NB2C glue 556 or FS 409, 560 Operative time
compared with sutures. One RCT of moderate quality Operative times were reported in 10 RCTs. Five reported
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randomized 316 patients to either Tisseel /Tissucol Ò or significantly shorter operative times with non-suture mesh
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2/0 Prolene sutures and reported a significant reduction in fixation. Two of these studies compared self-fixing meshes
chronic pain at 6 months (defined as VAS [ 3) with FS with suture fixation and reported 9-min (p = 0.01) 171 and
560 168
versus sutures (8.1 vs. 14.8%, p = 0.035). A very low- 12-min (p = 0.008) reductions in mean operative times.
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quality RCT of 148 patients randomized to either Quixil Similarly, reduced mean operative times of 6 min were
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FS fixation of lightweight mesh or Vicryl suture fixation reported in two studies comparing NB2C glue with suture
of a heavyweight mesh found chronic pain at 6-month fixation. 552, 556 A reduced mean operative time of 18 min
follow-up (determined by mean VAS scores) was lower in (p \ 0.001) was reported in one study comparing FS with
the FS/lightweight mesh group (0 vs. 7.8%, p \ 0.001). 409 suture fixation. 409 Three meta-analyses, all published in
Two further RCTs, the first comparing suture fixation with 2013—two of moderate. 546, 547 and one of low quality
self-gripping ProGrip mesh and the second comparing 548 —have examined glue versus suture fixation in open
suture fixation with fibrin glue reported no difference in anterior mesh IH repair. Despite methodological differ-
chronic pain. 182, 561 ences, all three meta-analyses reported an approximate
Pain within the first week postoperatively 2–3 min shorter operative time with glue compared with
Six RCTs reported on pain in the first postoperative week. sutures. The clinical significance of this small difference is
Three studies noted significantly lower mean VAS scores at debatable. One of the meta-analyses reported no difference
409
one or more assessment times within week one, with FS, in other outcomes including chronic pain (RR 1.60; 95% CI
NB2C glue, 555 or self-fixing mesh 168 compared with suture 0.78, 3.28; z = 1.28; p = 0.20), while the other two
fixation. Two RCTs reported no significant difference in reported reduced postoperative pain (RR 0.46, 95% CI
mean VAS scores between fixation methods. 557, 560 A 0.22–0.97; p = 0.01) and chronic pain (RR 0.51, 95% CI
significant reduction in postoperative pain within the first 0.31–0.87; p = 0.01). These differences are remarkable,
24 h was observed with non-suture compared with suture given that the articles were all published within the same
fixation in three RCTs. The mean difference in VAS scores year, and may reflect selection criteria for included studies
was 0.80 (p \ 0.001) with FS, 409 1.44 (p = 0.031) with and the meta-analysis methods used.
self-fixing mesh, 168 and 0.90 (p = 0.003) with NB2C Three additional meta-analyses, all published in
555
glue. Notably, all these RCTs were graded as very low 2013/2014, and all of low quality, have examined self-
quality because of small patient numbers or confounding fixing meshes compared with suture fixation in open
variables. Furthermore, only one of these studies (FS ver- anterior mesh IH repair. 173, 175, 177 All reviewed data from
sus suture fixation) showed a sustained difference in pain the same primary studies of 1353 patients. No inter-group
scores 1 week postoperatively. 409 A subsequent moderate- differences in recurrence, chronic pain or SSI were found.
quality RCTs comparing fibrin glue fixation with suture However, shorter operative times (range of 1–9 min) were
fixation in 102 randomized patients, reported lower post- noted with self-fixing mesh.
operative pain measured on a VAS of 1–10 with fibrin glue Laparo-endoscopic inguinal/femoral primary hernia repair
fixation at 1 week (VAS 0.28 lower than with suture fix-
ation, p \ 0.05) and at 1 month (VAS 0.26 lower than with Key questions
suture fixation, p \ 0.05). 561 A high-quality RCT including
557 men randomized to open anterior repair with suture KQ11.b Is mesh fixation necessary in endoscopic TEP
fixation versus self-gripping ProGrip mesh reported that inguinal/femoral hernia repair in adults?
early postoperative pain scores were lower with self-grip- KQ11.c Are there specific indications for mesh fixation in
ping mesh than with sutured lightweight mesh: mean VAS endoscopic TEP inguinal/femoral hernia repair in adults?
(0–150) pain score relative to baseline 1 1.3 and 1 8.6, KQ11.d Is mesh fixation ever recommended in laparo-
respectively, at discharge (p = 0.033), and mean surgical scopic TAPP inguinal/femoral hernia repair in adults?
pain scale score relative to baseline 1 4.2 and 1 9.7 KQ11.e If using mesh fixation, what types should be used
respectively on day 7 (p = 0.027). Although the results of in TEP and TAPP inguinal/femoral hernia repairs?
these studies reveal statistically significant reduced pain

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