Randomized clinical trial comparing 5-year recurrence rate after laparoscopic versus Shouldice repair of primary inguinal hernia.

BACKGROUND: The Shouldice technique is the 'gold standard' of open non-mesh hernia repair. The aim of this study was to compare 5-year recurrence rates after Shouldice and laparoscopic transabdominal preperitoneal patch (TAPP) repair for primary inguinal hernia. METHOD: Men with a primary unilateral inguinal hernia were randomized to either Shouldice or TAPP operation. An independent observer scored the surgeons' performance. Follow-up comprised clinical examination after 1 year, a questionnaire after 2 and 3 years, and a clinical examination after 5 years. RESULTS: Between February 1993 and March 1996, 1183 patients were included. Nine hundred and twenty patients were followed for 5 years, 454 in the TAPP group and 466 in the Shouldice group. Recurrences were evenly distributed between groups throughout the follow-up period. The cumulative recurrence rate after 5 years was 6.6 per cent in the TAPP group and 6.7 per cent in the Shouldice group. Postoperative pain was a risk factor for recurrence after Shouldice operation but not after TAPP repair. There was a correlation between a low surgeon's performance score and recurrence. CONCLUSION: The 5-year recurrence rate is acceptable, with no difference between TAPP and Shouldice repair. Poor operative performance resulted in a higher recurrence rate. The TAPP operation represents an excellent alternative for primary inguinal hernia repair.

Does mesh implantation affect the spermatic cord structures after inguinal hernia surgery? An experimental study in rats.

BACKGROUND: Inguinal hernia repair is the most common operation in general surgery. Prosthetic reinforcement of the inguinal area with polypropylene mesh has increased dramatically in the last decade. The aim of this study was to evaluate how different types of mesh affect the spermatic cord structures. METHODS: Thirty rats were divided into three groups. The spermatic cord was dissected free and a conventional suture repair was performed in group I, an operation mimicking the Lichtenstein operation with a heavyweight polypropylene mesh in group II and the same operation using large pore, lightweighted polypropylene/polyglactin composite mesh in group III. A vasography was performed after 90 days. The cross-sectional area of the vas deferens and s-testosterone from the spermatic vein were measured using the contralateral side as control. Light microscopy of the inguinal canal was performed and inflammation and fibrosis were graded. RESULTS: Vasography revealed patent vas deferens in all animals. In group III, there was a lower s-testosterone in the spermatic vein and a reduced cross-sectional area of the vas deferens on the operated compared to the control side. However, there was no difference in the other groups and there was no significant difference in s-testosterone levels between the groups. There was significantly more inflammation and fibrosis after mesh repair compared to suture repair, but there was no difference between the two mesh groups. Unexpectedly, polyglactin fibres were still seen in specimens in group III after 90 days. CONCLUSION: In conclusion, the only effect on the spermatic cord structures in a rat model is seen as an impaired s-testosterone production and a reduced cross-sectional area of the vas deferens after use of a low-weight composite mesh compared to the control side. No difference in inflammation or fibrosis was found between heavyweight polypropylene mesh and low-weight composite mesh.