Is mesh pore size in polypropylene meshes associated with the outcome in Lichtenstein inguinal hernia repair: a registry-based analysis of 22,141 patients.

INTRODUCTION: Experimental data show that large-pored meshes reduce foreign body reaction, inflammation and scar bridging and thus improve mesh integration. However, clinical data on the effect of mesh porosity on the outcome of hernioplasty are limited. This study investigated the relation of pore size in polypropylene meshes to the outcome of Lichtenstein inguinal hernioplasty using data from the Herniamed registry. METHODS: This analysis of data from the Herniamed registry evaluated perioperative and 1-year follow-up outcomes in patients undergoing elective, primary, unilateral Lichtenstein inguinal hernia repair using polypropylene meshes. Patients operated with a non-polypropylene mesh or a polypropylene mesh with absorbable components were excluded. Polypropylene meshes with a pore size of 1.0 × 1.0 mm or less were defined as small-pored meshes, while a pore size of more than 1.0 × 1.0 mm was considered large-pored. Unadjusted analyses and multivariable analyses were performed to investigate the relation of pore size of polypropylene meshes, patient and surgical characteristics to the outcome parameters. RESULTS: Data from 22,141 patients were analyzed, of which 6853 (31%) were operated on with a small-pore polypropylene mesh and 15,288 (69%) with a large-pore polypropylene mesh. No association of mesh pore size with intraoperative, general or postoperative complications, recurrence rate or pain requiring treatment was found at 1-year follow-up. A lower risk of complication-related reoperation tended to be associated with small-pore size (p = 0.086). Furthermore, small-pore mesh repair was associated with a lower risk of pain at rest and pain on exertion at 1-year follow-up. CONCLUSION: The present study could not demonstrate an advantage of large-pore polypropylene meshes for the outcome of Lichtenstein inguinal hernioplasty.

The comparative study of skin staples and polypropylene sutures for securing the mesh in Lichtenstein's tension-free inguinal hernia repair in HIV and hepatitis (B and C)-positive patients: a randomized controlled trial.

Introduction: The mesh fixation in the Lichtenstein's hernioplasty was traditionally performed with polypropylene sutures. A modification of this technique uses skin staples for securing the mesh. Using polypropylene sutures may increase the needle prick injuries (NPIs) in HIV and hepatitis-positive patients. This is the first study in India to compare the efficacy of anchoring the mesh with skin staplers and polypropylene sutures in hepatitis and HIV-positive patients. Methods: Fifty-two seropositive patients undergoing sixty repairs were randomized into two groups. In the control group polypropylene mesh was secured with polypropylene sutures and the skin was closed with ethilon. In the study group polypropylene mesh was secured with skin staples and the skin was closed with staples from the same stapler. Duration of surgery, postoperative complications, NPIs, recurrences and costs were compared. Results: The operation was significantly shorter when staples were used (median 46 vs. 57 min, P<0.00001). There was no significant difference in the incidence of postoperative complications. The NPIs was statistically significant in the suture group as compared to the stapler group (P<0.05). Conclusion: Using skin staples to secure the mesh in Lichtenstein inguinal hernioplasty significantly reduced the duration of surgery. It was as effective as conventional mesh fixation with polypropylene with added advantages to reduce the operating time, duration of exposure to infected blood, and the NPIs significantly in HIV, hepatitis B virus and hepatitis C virus-positive patients.

A Prospective Comparative Study of 3-Stitch Mesh Hernioplasty with Conventional Lichtenstein Repair.

Background: Hernioplasty, in which a mesh is used to strengthen a weakness or defect in the inguinal wall, has replaced simple tissue repair. As it is associated with low recurrence, it is considered the gold standard and is one of the most common general surgical procedures. The ideal repair should be rapid, safe and simple to do, requires minimal dissection to create sufficient space, be cost-effective and be accompanied by a brief hospital stay, reduced pain, and fewer recurrences. The aim of the present study was to compare the efficacy of 3-stitch mesh fixation with that of traditional Lichtenstein mesh fixation of inguinal hernia repair. Materials and Methods: Between July 2018 and December 2019, 59 cases of primary, uncomplicated inguinal hernias were surgically treated. Both the classical Lichtenstein technique (group A, n = 30) and the Lichtenstein technique with the three-stitch fixation method (group B, n = 29) were used on patients with inguinal hernias. Between the two groups, the mean operative times, post-surgical pain scores, average hospital stays and postoperative complications including recurrence rates were compared. Results: With a P-value of 0.001, the 3-point fixation group (group B) took 3.41 ± 0.58 min less time to fix the mesh than the Lichtenstein group (group A, 5.52 ± 0.59 min). The pain after surgery was much less for participants who had 3-point mesh fixation than for those who had conventional mesh fixation in the early (1, 3, 7 and 15 days after surgery) and late (1 month and 3 months) postoperative periods, with a P-value of 0.0001. When compared to the classical mesh fixation group, the 3-point mesh fixation group had less urinary retention, seroma and swelling. Both groups had the same number of other complications. Conclusions: The three-point hernioplasty is a simple procedure that is easier to adopt, less time-consuming, causes less trauma and has a lower risk of postoperative discomfort including chronic groin pain.

[Four years of experience in plastic surgery of anterior abdominal wall hernias with mesh implants made of titanium thread]. / Chetyrekhletnii opyt plastiki gryzh perednei bryushnoi stenki setchatymi implantatami iz titanovoi niti.

OBJECTIVE: To evaluate the results of using titanium thread mesh implants in the treatment of anterior abdominal wall hernias. MATERIAL AND METHODS: This article evaluates the titanium thread mesh implant used by us in the treatment of 240 patients with anterior abdominal wall hernias; describes the features of this type of implants and the technical features of various types of operations using them. RESULTS: The overall rate of postoperative complications was 2.9%. Hernia recurrence was observed in 2.4% of patients after laparoscopic transabdominal preperitoneal hernioplasty. CONCLUSIONS: The use of a mesh implant made of titanium thread did not reveal any specific complications for this implant. At the stage of gaining experience with a mesh implant made of titanium thread, technical difficulties may occur when placing and fixing it, which increases the duration of surgery.

Randomized Controlled Trial Of Lichtenstein Repair Of Indirect Inguinal Hernias With Two Biologic Meshes From Porcine Small Intestine Submucosa.

BACKGROUND: Biologic mesh is a newly developed material for hernia repairs which has been successfully used in clinical practices. This study aims to evaluate the clinical efficacy between patients undergoing a Lichtenstein's hernioplasty with a new biologic mesh derived from porcine small intestine submucosal (SIS) extracellular matrix versus a standard SIS mesh. METHODS: A prospective, randomized, double-blinded, multi-center trial was conducted in a 6-month study. Lichtenstein hernioplasty was performed using the new SIS mesh (Beijing Biosis Healing Biotechnology) or the standard SIS mesh (Biodesign Surgisis, Cook Biotech). The postoperative follow-up examinations were carried out at during hospitalization, 1st week, 1st, 3rd, and 6th month after surgery. The primary outcome was the excellent and good rate of recovery. Secondary outcomes included recurrence rate, complications, and patient-centered outcomes. RESULTS: A total of 194 patients were randomized into experimental group receiving the new SIS mesh (n=97) and control group receiving the standard SIS mesh (n=97). The excellent and good rate of rehabilitation in the experimental group was 98.97%, while it was 100.00% in the control group (P>0.05). One patient had a recurrence in the experimental group, while there was no recurrence in the control group (P>0.05). Other clinical outcomes, including the length of operation or hospitalization, foreign body sensation in the inguinal area, incision healing, infection, postoperative chronic pain, postoperative allergy, hydrocele, and orchitis, were similar between the two groups. CONCLUSION: Lichtenstein hernioplasty using the SIS mesh was safe and effective, and the new SIS mesh tested in this study had comparable safety and efficacy to the wildly used SIS mesh.

Factors predicting chronic pain after open inguinal hernia repair: a regression analysis of randomized trial comparing three different meshes with three fixation methods (FinnMesh Study).

BACKGROUND: Chronic pain after inguinal hernioplasty is the foremost side-effect up to 10-30% of patients. Mesh fixation may influence on the incidence of chronic pain after open anterior mesh repairs. METHODS: Some 625 patients who underwent open anterior mesh repairs were randomized to receive one of the three meshes and fixations: cyanoacrylate glue with low-weight polypropylene mesh (n = 216), non-absorbable sutures with partially absorbable mesh (n = 207) or self-gripping polyesther mesh (n = 202). Factors related to chronic pain (visual analogue scores; VAS ≥ 30, range 0-100) at 1 year postoperatively were analyzed using logistic regression method. A second analysis using telephone interview and patient records was performed 2 years after the index surgery. RESULTS: At index operation, all patient characteristics were similar in the three study groups. After 1 year, chronic inguinal pain was found in 52 patients and after 2 years in only 16 patients with no difference between the study groups. During 2 years' follow-up, three (0.48%) patients with recurrences and five (0.8%) patients with chronic pain were re-operated. Multivariate regression analysis indicated that only new recurrent hernias and high pain scores at day 7 were predictive factors for longstanding groin pain (p = 0.001). Type of mesh or fixation, gender, pre-operative VAS, age, body mass index or duration of operation did not predict chronic pain. CONCLUSION: Only the presence of recurrent hernia and early severe pain after index operation seemed to predict longstanding inguinal pain.

Centralized, capacity-building training of Lichtenstein hernioplasty in Brazil.

BACKGROUND: In Brazil, access to healthcare varies widely by community. Options for repair of surgically correctable conditions, such as inguinal hernias, are limited. A training program was instituted to expand access to Lichtenstein hernioplasty. METHODS: Between September, 2014 and September, 2015, 3 orders of training series took place in São Paulo, Brazil. Participating surgeons received training and assessments from expert trainers using the Operative Performance Rating Scale (OPRS). Those who completed training successfully were invited to become trainers. OPRS scores were compared between training series. Outcomes were documented up to 6 months post-training. RESULTS: The 3 orders of training series resulted in 45 surgeons trained and 213 hernias repaired. Eleven trainees subsequently became trainers. Mean post-training OPRS scores were 4.4 (scale of 5) and did not vary significantly between training series. The overall complication rate was 4.7%, with no hernia recurrences or reoperations at 6 months. CONCLUSIONS: Competency-based training generates a regional network of surgeons proficient in Lichtenstein hernioplasty. Each training session progressively expands patient access to high quality operations in underserved communities in Brazil.

Prospective study evaluating the impact of severity of chronic pain on quality of life after inguinal hernioplasty.

PURPOSE: The definition of chronic pain after inguinal hernioplasty and the methods of its assessment vary a great deal, which make it complicated to conduct meta-analyses. The primary aim of the present prospective study was to evaluate at which pain severity degree the quality-of-life scores will be reduced. METHOD: A prospective study of patients operated for inguinal hernia was conducted. A pain questionnaire and a quality-of-life (QoL) questionnaire were completed. RESULTS: Altogether, 370 patients were investigated and included in analysis. Of them, 33.8% experienced pain during different activities. Compared to the non-pain response group, significantly lower QoL scores for the Bodily pain domain were reported by patients who gave 1, 2, or 3 positive responses to the pain questionnaire. Patients with no pain as well as patients who gave 1 positive response to the pain questionnaire and whose VAS score was ≤20 had similar QoL scores for all domains. Patients who gave 1 positive response to the pain questionnaire and whose VAS score was >20, and patients who gave two or more positive responses to the pain questionnaire, showed significantly lower QoL scores in most of the domains compared with the non-pain group. When the patients who gave 1 positive response to the pain questionnaire and whose VAS score was ≤20 were excluded from the group of patients with pain, the rate of chronic pain was 19.7%. Considering the above result, the reduction in the rate of chronic pain from 33.8 to 19.7% was statistically significant. CONCLUSION: Pain scores 20 mm or less on the VAS (0 to 100 mm) have no impact on the patients' quality of life. Uniform assessment methods of chronic pain should be developed to improve the quality of research.

Three-year results of a randomized study comparing self-gripping mesh with sutured mesh in open inguinal hernia repair.

BACKGROUND: The primary aim of the present study was to evaluate whether usage of self-gripping mesh in open inguinal hernia repair, compared with standard Lichtenstein repair with sutured mesh, could result in a decreased rate of chronic pain. The secondary aim was to evaluate the rate of foreign body feeling, hernia recurrence, and risk factors for chronic pain development. METHODS: The patients were randomized into two study groups: the OLP group received Optilene LP mesh and the PPG group received self-gripping Parietex ProGrip mesh. Pain scores were measured on a visual analog scale. Foreign body feeling was registered as a yes-no question. RESULTS: A total of 75 patients in the OLP group and 70 patients in the PPG group were analyzed at 3-y follow-up. According to the primary endpoint, of the patients, 41.3% in the OLP group and 28.6% in the PPG group experienced pain during different activities at 3-y follow-up (P = 0.108). The risk ratio for the primary endpoint was 1.45, 95% confidence interval (CI): 0.91, 2.29 (P = 0.114). Analysis demonstrated an increased rate of chronic pain in patients with severe preoperative pain (odds ratio: 2.47; 95% CI: 1.08, 5.65; P = 0.032) and severe early postoperative pain (odds ratio: 4.29; 95% CI: 1.82, 10.10; P = 0.001). Overall, of the patients, 28% in the OLP group and 21.4% in the PPG group reported foreign body feeling at the operation site at 3-y follow-up (P = 0.360). There were two hernia recurrences in the OLP group and none in the PPG group (P = 0.168). CONCLUSIONS: We failed to demonstrate the advantages of self-gripping mesh in terms of chronic pain and foreign body feeling. However, usage of self-gripping mesh does not increase hernia recurrence rate. Considering the higher price of self-gripping mesh, analysis of cost-effectiveness is needed to prove its advantage and to justify its usage. As severe early postoperative pain is a risk factor for chronic pain development, a very effective postoperative pain control strategy is important after inguinal hernioplasty to reduce the rate of chronic pain.

Three-Year Results of a Single-Centre Single-Blinded Randomised Study Evaluating the Impact of Mesh Pore Size on Chronic Pain after Lichtenstein Hernioplasty.

BACKGROUND AND AIMS: The aim of the present study was to determine whether usage of mesh with larger pores, compared with mesh with smaller pores, would result in a decreased rate of chronic pain at 3-year follow-up. According to earlier published short-term results, differences in mesh pore size do not influence the rate of chronic pain. MATERIAL AND METHODS: The patients were randomized into two study groups for which meshes with similar weight but different pore size were used: the UM group received Ultrapro mesh (pore size 3-4 mm) and the OM group received Optilene LP mesh (pore size 1 mm). Pain scores were measured on a visual analog scale. The feeling of a foreign body was a yes-or-no question. RESULTS: A total of 65 patients in the UM group and 63 patients in the OM group were included in analysis. Of the patients, 33.9% in the UM group and 15.9% in the OM group reported having experienced pain during different activities at 3-year follow-up (P = 0.025). Comparison with the results of 6-month follow-up (46.3% in the UM group, 34.3% in the OM group) showed that the rate of chronic pain had decreased significantly in the OM group (P = 0.009) but not in the UM group (P = 0.113). The feeling of a foreign body in the inguinal region was experienced by 23.1% of the patients in the UM group and by 15.9% in the OM group (P = 0.375). There was one hernia recurrence in the OM group. Severe preoperative pain and younger age were identified as risk factors for development of chronic pain. CONCLUSIONS: Mesh with larger pores, compared with mesh with smaller pores, has no advantages in reducing the rate of chronic pain. We speculate that the reason for the higher rate of chronic pain in the study group where the mesh with larger pores was used might have been the different composition of the meshes at implantation. Also, it is possible as development of chronic pain after inguinal hernia repair is multifactorial, we failed to find a plausible explanation for this difference. Low recurrence rates were achieved with both meshes used in our study.

Chronic pain after open inguinal hernia repair.

Following the widespread use of mesh repairs, recurrence rates after inguinal hernia surgery have become acceptable and focus has shifted from recurrence to chronic pain. Although pain can be controlled with analgesics, chronic postsurgical pain is a major clinical problem, which can significantly influence the patient's quality of life. The rate of chronic pain after inguinal hernia mesh repair can reach 51.6%. The reasons for posthernioplasty chronic pain are often unclear. It has been linked to nerve injury and nerve entrapment, but there is also association between the rate of chronic pain and the type of mesh used for hernia repair. As there are >160 meshes available in the market, it is difficult to choose a mesh whose usage would result in the best outcome. Different mesh characteristics have been studied, among them weight of mesh has probably gained the most attention. The choice of adequate therapy for chronic groin pain after inguinal hernia repair is controversial. The European Hernia Society recommends that a multidisciplinary approach at a pain clinic should be considered for the treatment of chronic postoperative pain. Although surgical treatment of chronic posthernioplasty pain is limited because of the lack of relevant research data, resection of entrapped nerves, mesh removal in the case of mesh related pain or removal of fixation sutures can be beneficial for the patient with severe pain after inguinal hernia surgery. One drawback of published studies is the lack of consensus over definition of chronic pain, which makes it complicated to compare the results of different studies and to conduct meta-analyses and systematic reviews. Therefore, a uniform definition of chronic pain and its best assessment methods should be developed in order to conduct top quality multicenter randomized trials. Further research to develop meshes with optimal parameters is of vital importance and should be encouraged.

Single-center, single-blinded, randomized study of self-gripping versus sutured mesh in open inguinal hernia repair.

BACKGROUND: The primary aim of the present study was to evaluate whether usage of self-gripping mesh in open inguinal hernia repair, compared with standard Lichtenstein repair with sutured mesh, could result in a decreased rate of chronic pain at 6-mo follow-up. The secondary outcome was to evaluate foreign body feeling and the quality of life after inguinal hernia repair. METHODS: The patients were randomized into two study groups as follows: the OLP group received Optilene LP mesh and the PPG group received self-gripping Parietex ProGrip mesh. Pain scores were measured on a visual analog scale. Foreign body feeling was registered as a yes or no question. Quality of life was evaluated using the Medical Outcome Study Short-Form 36 questionnaire. RESULTS: A total of 75 patients in the OLP group and 70 patients in the PPG group were included in the analysis. According to the primary end point, 45.3% and 31.4% of the patients in the OLP group and PPG group experienced pain during different activities at 6-mo follow-up, respectively (P = 0.092). Per secondary end point, 22.7% in the OLP group and 40% in the PPG group reported foreign body feeling at the operation site at 6-mo follow-up (P = 0.031, risk ratio 0.57, 95% confidence interval 0.29-1.07). There were no significant differences in any domain of quality of life according to the Short-Form 36 questionnaire between the two study groups at 6-mo follow-up, except for the social functioning domain (P = 0.035). In the OLP group, the quality of life scores improved significantly after operation in all domains except for general health and mental health. In the PPG group, the quality of life scores improved significantly after operation in the domains of bodily pain, physical functioning, and physical role. CONCLUSIONS: Self-gripping mesh compared with standard Lichtenstein operation has no advantages in reducing chronic pain 6-mo after surgery. The rate of foreign body feeling was higher in the self-gripping mesh group. Scores of bodily pain, physical functioning, and physical role improved significantly in both study groups after hernia surgery.

Randomized clinical study evaluating the impact of mesh pore size on chronic pain after Lichtenstein hernioplasty.

BACKGROUND: The primary aim of this study was to determine whether mesh pore size influences the rate of chronic pain at 6-mo follow-up. Another aim was to evaluate the rate of foreign body feeling and quality of life after inguinal hernia repair. METHODS: The patients were randomized into two study groups: the UM group received Ultrapro mesh (pore size 3-4 mm) and the OM group received Optilene LP mesh (pore size 1 mm). Pain scores were measured on a visual analog scale. The feeling of a foreign body was a yes-or-no question. Quality of life was evaluated using the Medical Outcome Study Short-Form-36 questionnaire. RESULTS: A total of 67 patients in the UM group and 67 patients in the OM group were investigated 6 mo after operation. There were no significant differences in the results of the pain questionnaire between the study groups. Of the patients, 46.3% in the UM group reported pain during different activities at 6-mo follow-up versus 34.3% in the OM group (P = 0.165). The feeling of a foreign body in the inguinal region was experienced by 47.8% of the patients in the UM group and by 31.3% of the patients in the OM group at 6-mo follow-up (P = 0.052; risk ratio 1.52, 95% confidence interval: 1.00-2.37). There were no significant differences in the quality of life according to the Short-Form 36 questionnaire between the two study groups at 6-mo follow-up. In both study groups, the quality of life scores improved after operation by most dimensions. CONCLUSIONS: Differences in mesh pore size did not influence the rate of chronic pain. Although there was a trend for higher rate of foreign body feeling in the study group where a mesh with larger pores was used, we failed to find an explanation for this. The pore size of meshes investigated in this study did not affect the quality of life after inguinal hernia repair. Considering the fact that the quality of life improved significantly after operation, elective repair of symptomatic inguinal hernias should be undertaken as promptly as possible.

Tratamiento quirúrgico de una hernia inguinal gigante reproducida después de una plastia de Lichtenstein: presentación de un caso / Surgical treatment of a giant inguinal hernia, reproduced after a Lichtenstein hernioplasty: presentation of a case

La hernia inguinal es la enfermedad quirúrgica más tratada de forma electiva en muchos centros de salud, la complejidad de su tratamiento varía en dependencia de varios factores, dentro de estos el tamaño de la hernia y la anatomía local deformada son de los más influyentes. El uso de las prótesis simplificó su tratamiento, pero se deben cumplir principios quirúrgicos establecidos pues la recurrencia luego de la colocación de una prótesis distorsiona aun más la anatomía. Se presenta el caso de un paciente masculino de 78 años de edad, de raza blanca, intervenido de urgencia por hernia inguinal primaria atascada, donde se le realizó una plastia tipo Lichtenstein. Dos años después acude a consulta portando una hernia inguinal reproducida que rebasa el tercio distal del muslo, se prepara para la operación y se le realiza una plastia por vía posterior tipo Stoppa, la evolución postoperatoria fue favorable y a los seis años de operado se encuentra libre de la enfermedad.

The inguinal hernia is the surgical disease most treated in an elective way in many health care institutions. Its treatment difficulty changes in dependence on several factors; the hernia size and the deformed local anatomy are the most important of them. The usage of prosthesis simplified its treatment, but there are established surgical principles that have to be fulfilled, because the recurrence after placing prosthesis distorts the anatomy even more. We present the case of a white male patient aged 78 years old, surgically treated in emergency by an obstructed primary inguinal hernia. It was used the Lichtenstein technique. Two years later he assisted to the consultation presenting a reproduced inguinal hernia exceeding the distal third of the thigh. He was prepared for the surgery and was operated by the posterior port using the Stoppa type surgery. The post surgery evolution was favorable, and after six year of the surgery he is free of the disease.