Page 46 - International guidelines for groin hernia management

Hernia

Evidence in literature repair 573, 575, 579, 581, 583 only one 575 detected significantly
Pubmed and Cochrane databases were systematically less acute and chronic pain in the non-fixation group. The
searched, yielding a total of 67 papers of which 34 were sole RCT on TAPP repair 582 showed no significant dif-
included after applying strict inclusion (SIGN) criteria. ference for chronic pain in the non-fixation group. Of three
Following the GRADE approach for Guidelines the case control TEP repair studies, 593, 594, 596 only one 596
reviews by Scha ¨fer et al., 562 Morales-Conde. 563 and For- revealed a significantly lower rate of acute postoperative
telny. 549 were excluded. Of the 34 included papers, five are pain in the non-fixation group.
systematic reviews/meta-analyses, 550, 564–567 17 are Reporting on preoperative pain is one of the greatest
RCTs, 568–584 and 12 are case control studies (CCS). 581–594 shortcomings of almost all studies. This information is
essential to identify patients at high risk for postoperative
Fixation versus non-fixation in TEP and TAPP chronic pain. Furthermore, the pain assessment within the
The systematic review and meta-analyses 565–567 —all different studies displays significant heterogeneity.
judged to be of moderate quality per GRADE guidelines— The Swedish Hernia Register study on the impact of
revealed no significant differences in the rates of recur- mesh fixation on chronic pain in TEP in primary IH repair
rence or postoperative pain between permanent tack fixa- in men enrolled 1110 patients. It compared permanent
tion and non-fixation in either TEP or TAPP. fixation (PF) with no fixation (NF) or non-permanent fix-
597
Recurrence ation (NPF) and revealed no difference regarding the
For TEP repair, the results of six RCTs, 573, 575, 579, 581, 583, 584 primary endpoint of pain (p \ 0.462) using Inguinal Pain
three case control studies, 573, 593, 594 and two meta-analy- Questionnaire and SF-36 subscales as well as no difference
566, 567
ses demonstrate no significant risk of recurrence fol- between PF- and NF-groups including subgroups of medial
lowing mesh non-fixation. hernias during a 7.5-year follow-up.
For TAPP repair, one RCT of moderate quality, com- Operative time
paring tack fixation with non-fixation demonstrated no In several meta-analyses, including data from both TEP-
significant difference in recurrence risk. and TAPP-RCTs, no significant differences in operative
297, 565, 566, 573, 575, 579, 581, 583
Notably, the RCTs cited above contain only limited times have been reported. A
information on hernia-defect size and type. This is espe- separate meta-analysis including three TEP-
579, 581, 593
cially true regarding the percentage of large direct hernias RCTs revealed a significant reduction in oper-
(type M3, EHS classification). ative time when mesh non-fixation was used.
Based on the results of a multivariate analysis of 11,230 Surgical site infection
581, 582 594
595
cases from a Herniamed registry study, a significant risk Two RCTs and one CCS on SSI demonstrated no
of recurrence is found not only in the group of non-fixation difference between fixation and non-fixation groups.
in case of direct hernias but also for combined hernias
[combined versus medial: OR 1.137 (95% CI Permanent versus non-permanent fixation
0.656–1.970); lateral versus medial: OR 0.463 (95% CI (staple/tack vs glue) in TEP repair
0.303–0.707); p \ 0.001].
Acute and chronic pain Recurrence 550, 564
The three meta-analyses 565–567 of eight RCTs revealed no Two meta-analyses of moderate quality found no
significant differences in acute and chronic postoperative significant recurrence rate difference between staple and
568, 572, 580
pain 566, 567, 573 Of the RCTs studying TEP glue fixation methods. The results of three RCTs

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