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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 64-69

Comparative evaluation of outcomes in different techniques of mesh fixation in totally extraperitoneal hernioplasty


Department of Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission09-Feb-2021
Date of Decision16-Mar-2021
Date of Acceptance22-Mar-2021
Date of Web Publication31-May-2021

Correspondence Address:
Dr. Awanish Kumar
Department of Surgery, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijawhs.ijawhs_11_21

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  Abstract 


PURPOSE: Inguinal hernia repair is the most commonly performed surgery worldwide with surgical approaches being open and endoscopic hernioplasty. Mesh fixation in endoscopic hernia repair still remains a topic of debate. Moreover, a paucity of literature is present with regard to the quality of life (QOL) outcomes after mesh fixation in endoscopic hernia repair.
MATERIALS AND METHODS: This prospective nonrandomized study was done on patients operated by totally extraperitoneal (TEP) hernioplasty. Primary outcome parameters included any complications, postoperative pain, and hernia-related QOL by Carolina's Comfort Scale among two different types of mesh fixation techniques (Group I - intracorporeal Suture fixation and Group II - tack fixation).
RESULTS: TEP repair was done on 74 patients with suture fixation of the mesh by intracorporeal knotting (Group I; n = 30) and tack fixation of mesh (Group II; n = 44). There was no significant difference in the time to return to routine work, sensation of mesh, and pain, but time to return to office work was significantly lower in the patients of Group I (4.29 ± 0.99) compared to Group II (4.75 ± 0.96) and there was a significant difference in movement limitation from postoperative to subsequent time period in all groups except for after 3 months to 6 months in Group II.
CONCLUSION: Intracorporeal suture fixation of mesh in TEP can be used as an alternate technique for mesh fixation with comparable perioperative and QOL outcomes.

Keywords: Endoscopy, inguinal hernia, mesh


How to cite this article:
Dandey A, Pal AK, Agrawal M, Kumar A, Anand A, Pahwa HS, Singh KK, Sonkar AA. Comparative evaluation of outcomes in different techniques of mesh fixation in totally extraperitoneal hernioplasty. Int J Abdom Wall Hernia Surg 2021;4:64-9

How to cite this URL:
Dandey A, Pal AK, Agrawal M, Kumar A, Anand A, Pahwa HS, Singh KK, Sonkar AA. Comparative evaluation of outcomes in different techniques of mesh fixation in totally extraperitoneal hernioplasty. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2021 Sep 19];4:64-9. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/2/64/317316




  Introduction Top


Inguinal hernia constitutes 75% of all abdominal wall hernias with its repair being the most commonly performed surgery worldwide.[1],[2],[3] Among surgical approaches, both open and endoscopic are widespread, but endoscopic hernioplasty (totally extraperitoneal [TEP] and transabdominal preperitoneal [TAPP]) provides benefit in terms of less postoperative pain, better cosmesis, and early return to work.[4] Among these, TEP repair has an additional advantage over TAPP as there is no peritoneal breach with consequent lesser risk of intraabdominal complications.[5]

While endoscopic hernioplasty has become commonplace among surgeons with expertise in the technique, controversy still remains over the ideal method of mesh fixation. Various mesh fixation techniques (tack, glue, suture, staples, etc.,) are being used in TEP hernioplasty[6],[7],[8] with studies still questioning the need of mesh fixation at all.[9] The early postoperative period is crucial in terms of increased chances of recurrence, discomfort and/or pain, and nonfixation of mesh may lead to folding or migration of mesh in the before tissue ingrowth.[10],[11],[12],[13] Although pain following endoscopic inguinal hernioplasty may represent an acute problem, the concern regarding hernia recurrence resulted in the recent surge in the literature pertaining to mesh fixation techniques.[14],[15],[16] Among various techniques of mesh fixation incorporation of principles of minimal trauma to local tissue as well as decreasing the chances of nerve entrapment is of paramount importance.

Studies addressing quality of life (QOL) issues in endoscopic hernia repair have cropped up recently with use of hernia specific QOL instruments such as Carolina's Comfort Scale (CCS)[17],[18],[19] suggesting contemporary relevance of QOL, but none of the studies have included mesh fixation technique in relation to QOL outcomes. Since various techniques (intracorporeal suture, tack, and trans fascial suture) of mesh fixation can have a bearing on the occurrence of perioperative complications, postoperative pain, movement limitation, and altered other QOL parameters,[20],[21],[22] we have performed a nonrandomized comparative study among two techniques (intracorporeal and tack) of mesh fixation to evaluate perioperative outcomes and QOL outcomes among patients undergoing TEP hernioplasty.


  Materials and Methods Top


Our prospective nonrandomized study was done on 74 patients after due approval from the Institutional Ethical Committee. All of our patients were male aged between 18 and 65 years of age and operated after informed consent by TTEP (Triangular 3 - port TEP) [Figure 1] technique for inguinal hernia.[20],[21] Those having significant comorbidities, past surgical history, complicated inguinal hernias (irreducible/strangulated), and not fit for general anesthesia or not giving consent for endoscopic hernia repair were excluded from the study. The present study was undertaken from October 2016 to September 2018 with follow-up of 12 months for each patient. All TEP repairs were performed under general anesthesia by the same operating surgeon with previous experience of independently performed more than 100 TEP repairs. Mesh fixation in TEP repair was done with either tack fixation or sutures (intracorporeal). Procedures of sterilization of instruments were followed according to standards by our institutional protocol. All patients had received single intravenous dose of 1-g ceftriaxone at the time of induction of anesthesia.
Figure 1: External view of triangular 3-port technique for totally extraperitoneal in left inguinal hernia. (i) Left 5 mm port (ii) Midline 10 mm port (iii) Right 5 mm port

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Primary outcome parameters included any complications, postoperative pain, and hernia-related QOL by CCS. Data collection is done of baseline demographic characteristics, size of hernia defect, preoperative pain, peri-operative parameters such as length of operation (minutes), length of hospital stay (days), intraoperative complications (nerve or vascular injury), postoperative pain, postoperative complications (e.g., surgical site infections, seroma, hematoma, and recurrence), length of hospital stay (days), time taken for return to normal activity, and hernia related QOL by CCS. QOL was determined in terms of time to return to usual routine work and office work, sensation of mesh, sensation of pain and movement limitation (using, CCS), and tolerance to early oral feed were also noted. CCS was used to assess QOL post hernia repair and was administered in the preoperative, immediate postoperative period, and at the 1st, 3rd, and 6th month in the postoperative period. Visual analog scale (VAS) with the scores from 0 (no pain) to 10 (worst pain) was used to assess pain intensity at preoperative and postoperative (24 h, 1 week, 1 month, 6 months, and 12 months) periods.

In all the study patients, TTEP (triangular 3 - port TEP) technique for inguinal hernia repair was performed with a 15 cm × 10 cm polypropylene mesh (Prolene; Ethicon, Inc., Somerville, NJ, USA) as described elsewhere.[21] Accordingly, two groups of patients included in our study were made based on mesh fixation technique: Group I - intracorporeal suture fixation [Figure 2] done with two 2-0 polypropylene sutures placed at cooper's ligament and one was placed over lateral abdominal wall and Group II - tack fixation [Figure 3] done with application four spiral tacks (Protack; Covidien-Medtronic, Dublin, Republic of Ireland), out of which two were placed over cooper's ligament and two were placed over lateral abdominal wall avoiding triangle of pain.
Figure 2: Intracorporeal suture technique of mesh fixation. Arrow showing suture (Prolene 2-0) used for fixation of mesh at cooper's ligament in totally extraperitoneal of left inguinal hernia

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Figure 3: Tack fixation of mesh. Arrow showing nonabsorbable spiral tack being applied at cooper's ligament in totally extraperitoneal of left inguinal hernia

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Continuous data were summarized as mean ± standard deviation, whereas discrete (categorical) in number and percentage (%). Continuous groups were compared by independent Student's t-test. Categorical groups were compared by Chi-square test. A two-tailed P < 0.05 was considered statistically significant. Analyses were performed on SPSS Statistics for Windows, Version 17.0 (SPSS Inc., Chicago, IL, USA).


  Results Top


A total of 77 patients planned for TEP repair after clinic-radiological evaluation in the outpatient clinic were initially included in the study, but after exclusion of two patients with significant comorbidities (one had cardiac and one with chronic liver disease) and one patient with a history of prior exploratory laparotomy and reversal of ileostomy by ileo-ileal anastomosis, 74 patients operated by TEP repair were included in the study among patients presenting in the outpatient visit planned for TEP repair and suture fixation of mesh by intracorporeal knotting (Group I; n = 30) and tack fixation of mesh (Group II; n = 44) depending on the availability tack fixation device and surgeon's choice.

The mean age of the patient between Group I (Intracorporeal) and Group II (Tack fixation) were 42.75 ± 12.03 and 42.66 ± 15.05 years, respectively. Comparison of demographic characteristics and body mass index between two groups did not reveal any significant findings [Table 1]. The mean size (width in cm) of hernia defect was comparable in two groups (1.57 ± 0.40 in Group I and 1.60 cm ± 0.43 cm in Group II). Although the mean duration of surgery was significantly higher in Group I (89.77 ± 12.05) compared to Group II (84.17 ± 9.74), there was no significant difference in the duration of the hospital stay between the groups. Preoperative pain VAS scores were comparable in both groups. Postoperative pain VAS scores were relatively higher in Group II but without statistical significance. None of the patients in two groups had intra-operative complications (nerve or vessel injury). No significant difference was found in postoperative bleeding and surgical site infection as no patient in each of the three groups had this postoperative complication. Only one patient in Group II (Tack group) had seroma formation [Table 1]. There was no significant difference in the time to return to routine work between the groups. But the time to return to office work was significantly lower in the patients of Group I (4.29 ± 0.99) in comparison to Group II (4.75 ± 0.96) [Table 2].
Table 1: Demographic and peri-operative characteristics

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Table 2: Quality of life characteristics (Carolina's Comfort scale and Tolerance to oral feeds)

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With regard to the sensation of mesh and sensation of pain, no significant difference could be found between the groups at all time periods, but there was a significant difference in movement limitation from postoperative to subsequent time period in both groups. Oral feed was tolerated in all the patients (100%) of Group I and 95.5% in Group II on 1st postoperative day, however the association was insignificant [Table 2].


  Discussion Top


TEP repair since its first description by McKernon and Laws[23] has undergone various procedural modifications, one of which is use of triangular-three port technique or two hand technique.[20],[21] Aspects of perioperative outcomes, QOL outcomes, and comparison of various mesh fixation techniques in TEP hernioplasty have already been studied.[14],[15],[16],[17],[18],[19]

In our study, no significant findings were found in demographic characteristics, body mass index, and duration of the hospital stay (minutes), but the duration of surgery was significantly higher in Group I (Intracorporeal suture) compared to Group II (Tack) technique of mesh fixation. The higher duration of surgery in the intracorporeal suture group signifies the time spent during suturing in a limited extraperitoneal space. With regard to the mean hospital stay (in days) for different types of mesh fixation, there was no significant difference in our groups but comparable to other studies (median in each case 2.0 days; range 1–6.3 days after TEP and 1–6.4 days after TAPP).[23],[24]

The mean pain score measured on VAS for postoperative pain for two groups was insignificantly higher in Group II (Tack - 2.86 ± 0.76). Our pain scores were comparable to other studies as quoted in a meta-analysis by Sajid et al.[13],[14],[25],[26],[27],[28] With regard to return to routine work and office work, the time taken to return to office work was significantly lower in Group I (intracorporeal) suggested the probability of least discomfort in intracorporeal suture as compared to tack fixation. Using CCS for procedure-specific QOL in Hernia, there was no significant difference in the mean change of sensation of pain and mesh in the postoperative period in our study groups, but there was a significant difference in movement limitation from postoperative to subsequent time period. This suggested the comparable QOL outcomes in various techniques of mesh fixation used in our study. Although CCS is being utilized as a QOL tool in the hernia repair,[18],[19],[21] in this current study, CCS scores are evaluated for mesh placement with different fixation techniques.

Evaluating various techniques (intracorporeal and tack) of mesh fixation and perioperative outcomes along with QOL outcomes among patients undergoing TEP hernioplasty by triangular-three port technique or two hand technique. Our results suggest that suture fixation (intracorporeal) of mesh may be a cost-effective alternative with comparable QOL outcomes with regard to tack fixation of mesh in TEP, especially in developing countries where other techniques (tack, staplers, or glue) can add to the cost of the procedure. The main limitation of our study is its nonrandomized nature and lack of long-term follow-up (1 year) in our study. These limitations can be overcome by future well-designed prospective randomized studies.


  Conclusion Top


This study re-emphasizes upon the importance of assessing QOL in endoscopic hernioplasty and intracorporeal suture fixation of mesh has comparable peri-operative and QOL outcomes against tack fixation and can be utilized as an acceptable alternative technique for mesh fixation in a cost constraint setting. However further studies are still needed to validate these results.

Acknowledgment

The authors have no conflicts of interest to declare with regard to this manuscript. This study was approved by the Institutional Ethical Committee.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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