Page 47 - International guidelines for groin hernia management

Hernia

included in the meta-analyses, 550 as well as another four groups. However, five RCTs 569, 571, 576–578 and three
CCSs 585, 591, 592, 598 confirmed these findings. CCSs 586, 588, 589 found significantly less acute pain after
Acute and chronic pain glue versus staple fixation.
One systematic review 550 analyzed only RCTs including One systematic review 550 revealed a significantly higher
TAPP repairs 574, 577, 578 and one TEP repair 580 Concerning incidence of chronic pain when the staple group was com-
acute pain, the review analysis detected no significant pared with the glue group. In contrast, three of six
difference between staple and fibrin sealant groups. A RCTs 571, 574, 576 and two of three case control trials 588, 589
significant difference was found, however, in the incidence reported no significant difference. An important criticism of
of chronic pain favoring the fibrin sealant group. Another the systematic review 550 was that it included 1-month follow-
564 580 591, 592, 598 574
review included one RCT and three CCSs up data from one study as chronic pain data. Another study
and reported on chronic pain incidence only. Both showing no difference was excluded for unknown reasons.
reviews 550, 564 revealed significant advantages of glue Operative time
fixation in lessening the incidence of chronic pain. How- No significant difference was seen between fixation
ever, as noted, only one RCT 580 was included in these two methods in the systematic review. 550
systematic reviews. In total, three RCTs have been pub- Surgical site infection
lished 568, 572, 580 and detected no significant difference in Two RCTs 571, 578 and two CCSs 586, 589 reported on sur-
chronic pain when glue was compared to staple fixation. gical site infection and no significant difference in SSI risk
Three case control trials, 591, 592, 598 however, found sig- was detected between fixation methods.
nificantly less chronic pain in the glue fixation group.
Operative time Self-fixing mesh in TAPP
550, 564
Two systematic reviews failed to demonstrate an One moderate-quality RCT compared self-fixing mesh to
operative time difference between groups undergoing dif- glue fixation in TAPP repair. 570 Short-term follow-up at
ferent fixation methods. Similarly, one RCT 580 and one 3 months found no hernia recurrences and no significant
case control trial 598 also noted no significant difference differences in postoperative pain between groups. A CCS
although a different case control trial 585 revealed longer had similar results. 587
operative times in the glue group.
Surgical site infection Discussion
SSI rates were not significantly impacted by different fix- In open primary groin hernia repair beyond the use of sutures
ation methods across a systematic review, 564 two (non- or late-resorbable) for mesh fixation new atraumatic
568, 580 591, 592
RCTs and two case control trials that exam- devices (e.g. fibrin glue, cyanoacrylate, self-fixating meshes)
ined the subject. are safe in terms of recurrence (1 year) and reduce the risk of
acute postoperative pain (weak suggestion). Self-gripping
Permanent versus non-permanent fixation mesh is an acceptable form of treatment for primary IHs,
(staple/tack vs glue) in TAPP repair although only medium-term data are available and no
specific information on the outcome in larger (direct) her-
Recurrence nias. It has no benefits over the Lichtenstein technique other
One meta-analysis of moderate quality that included only than a somewhat shorter operative time. The device’s addi-
RCTs 574, 576–578 specifically addressed glue versus staple tional cost must be considered (Chapter 6c). Glue fixation in
fixation in TAPP repair. 550 and reported no significant inter- the Lichtenstein technique can be performed in hernias
group difference. The results of six RCTs 569, 571, 574, 576–578 limited to MII or LII types (EHS classification) according to
586, 588, 589
and three case control trials confirmed this finding. HerniaSurge Group consensus.
In addition to the meta-analyses and RCTs, a recently pub- In TEP and TAPP inguinal/femoral hernia repair non-
lished study from the Danish Hernia Database included 1535 fixation of mesh is recommended in almost all hernia types
patients and detected no significant difference using Cox except large medial defects (M3 EHS classification) where
regression analysis [hazard ratio 0.8; 95% CI (0.5–1.2)] 599 in mesh fixation is recommended. The fixation of large medial
long-term reoperation rates and clinical recurrences (median defects in TEP/TAPP is expert opinion and consensus
follow-up time of 31 months) in patients undergoing TAPP within the HerniaSurge Group. A crucial precondition in
IH repair with mesh fixation by fibrin sealant compared to large medial defects is the use of an adequate size and
tacks. overlap of mesh and the reduction of the dead space caused
Acute and chronic pain by the dilated transverse facia. To minimize the risk of
One systematic review 550 that included four acute postoperative pain atraumatic fixation techniques
574, 576–578
RCTs found no significant difference in acute (fibrin glue, cyanoacrylate) should be considered.
postoperative pain between glue- and staple-fixation

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