|Year : 2023 | Volume
| Issue : 1 | Page : 37-43
Evaluation of light weight large pore mesh versus heavy weight small pore mesh in total extraperitoneal repair of inguinal hernia: A prospective randomized study
Sarabjit Singh1, Kiranjot Rana1, Bhupinder S Walia2, Vivek Pahuja3, Pankaj Dugg2
1 Department of General Surgery, Punjab Institute of Medical Sciences, Jalandhar, India
2 Department of General Surgery, Government Medical College, Amritsar, Punjab, India
3 Department of General Surgery, Adesh Medical College and Hospital, Vill Mohri, The Shahbad, Haryana, India
|Date of Submission||06-Jan-2023|
|Date of Decision||24-Feb-2023|
|Date of Acceptance||27-Feb-2023|
|Date of Web Publication||30-Mar-2023|
Department of General Surgery, Government Medical College, Amritsar, Punjab
Source of Support: None, Conflict of Interest: None
BACKGROUND: The type of mesh to be used in laparoscopic groin hernia repair has always been debatable whether to use lightweight (LW) or heavyweight (HW) mesh. The study compares the lightweight large pore mesh with HW small pore mesh in total extraperitoneal groin (TEP) hernia repair and its outcome. MATERIALS AND METHODS: A total of 50 patients, who met the inclusion criteria, were randomized in the two groups. In group I (n = 25) LW large pore mesh (pore size 1 mm) was used whereas in group II (n = 25) HW small pore mesh (pore size < 0.65 mm) was used. Outcomes were observed with respect to complications, recurrence, and patient satisfaction. Statistical analysis was performed using χ2 test and student t test. RESULTS: Mean age of the patients group I was 45 ± 18.52 while in group II it was 48.88 ± 20.529 years. The complication rates were comparable between the two groups. However, seroma formation was higher in group II. The occurrence of groin pain and foreign body sensation between the two groups was comparable after 6-month follow-up. No recurrence was reported in either of the groups. CONCLUSION: Although there was no significant difference between the two groups, but the present study showed some advantage of LW mesh over HW weight mesh in TEP with respect to complications and patient satisfaction.
Keywords: Inguinal hernia, pain, recurrence, surgical mesh
|How to cite this article:|
Singh S, Rana K, Walia BS, Pahuja V, Dugg P. Evaluation of light weight large pore mesh versus heavy weight small pore mesh in total extraperitoneal repair of inguinal hernia: A prospective randomized study. Int J Abdom Wall Hernia Surg 2023;6:37-43
|How to cite this URL:|
Singh S, Rana K, Walia BS, Pahuja V, Dugg P. Evaluation of light weight large pore mesh versus heavy weight small pore mesh in total extraperitoneal repair of inguinal hernia: A prospective randomized study. Int J Abdom Wall Hernia Surg [serial online] 2023 [cited 2023 Jun 9];6:37-43. Available from: http://www.herniasurgeryjournal.org/text.asp?2023/6/1/37/372933
| Introduction|| |
Inguinal hernia most probably has been a disease ever since mankind existed. Traditionally the concept of tissue-to-tissue approximation has been followed as a mainstay for hernia repair. However, it leads to undue tension on the suture line. For this reason, the recurrence rate is reported as high as 10%–15% at follow-up period of 5 years. On the other hand, tension-free methods have low recurrence rates and have become the most acceptable methods internationally. The use of synthetic material to repair hernia has further resolved the tension problem. The recurrence rate of these methods was 0.1% for the original hernia and 2% for the recurrent hernia. The tension-free method presently used is either the Lichtenstein’s repair or using synthetic material via laparoscopy.
The introduction of mesh in hernia repair has reduced recurrence and has revolutionized hernia surgery. However, the search for an ideal mesh still continues as meshes are associated with various adverse events. These adverse events include infection, mechanical failure, pain, reaction, intestinal complications, adhesions, seroma, erosion/migration, no in-growth, sterility, shrinkage of mesh, bleeding, and hematoma. Major factor determining complications depends upon the material used to construct the prosthesis and its structure.
Presently no single product has all the properties of the ideal mesh. Meshes are broadly classified according to the structure of filament (monofilament versus multifilament), weight of mesh, and pore size. The advantages of monofilament meshes are high tensile strength and resistance to bacterial attachment, but at the same time it has decreased pliability and low conformity to the abdominal wall. Multifilament meshes are relatively more pliable, but their susceptibility to bacterial infections is high. Presently, there is no single classification exists that covers all the complications and risks.
The present study compares the light weight (LW) large pore mesh with high weight (HW) small pore mesh in total extra peritoneal (TEP) repair of groin hernia with respect to outcome, patient satisfaction, recurrence, and complications.
| Materials and Methods|| |
The present study was conducted for 3 years after taking permission from the institutional ethic committee. A total of 50 diagnosed cases of inguinal hernia were included in the study. All the cases underwent TEP repair under general anesthesia. Single-blinded randomization of patients by the chit method was performed, where patients were asked to pick a chit and hence were divided into two groups. In group I (n = 25) LW (44 g/m2) large pore mesh (pore size > 1 mm) was used, whereas in group II (n = 25) HW (90 g/m2) small pore mesh (pore size < 0.65 mm) was used.
Patients were evaluated with detailed history and complete biodata. Routine investigations were performed. Patients were assigned to the two different groups randomly.
Inclusion criteria were (1) unilateral inguinal hernia, (2) bilateral inguinal hernia, and (3) recurrent inguinal hernia.
Exclusion criteria were (1) incarcerated nonreducible hernia, (2) recurrence after laparoscopic repair, (3) massive scrotal hernia, (4) previous history of pelvic lymph node resection, and (5) previous history of pelvic or groin irradiation.
A detailed history was taken and clinical examination was performed. The following investigations were carried out:
- bleeding time, clotting time
- total leucocyte count, differential leucocyte count
- complete urine examination
- blood urea, serum creatinine
- serum Na+, K +
- fasting blood sugar
- other investigations, if any.
After explaining the detailed procedure and risks of anesthesia and surgery, a written consent was obtained from the patient. The patient was kept fasting overnight. The parts were shaved and prepared overnight. 1.5 g of ceftriaxone was given intravenously preoperatively.
The procedure was performed with the patients under general anesthesia. Foley’s catheter was inserted for bladder decompression.
Position of the surgical team
The surgeon stood toward the opposite side of the hernia. The camera assistant stood on the side opposite to the surgeon.
Approach to pre peritoneal space
A 1 cm transverse skin incision was made just below the umbilicus 1 cm lateral to the midline on the side of hernia. The incision was deepened down to reach the anterior rectus sheath which is opened under direct vision. Preperitoneal space was insufflated with CO2 by direct suprapubic needle puncture (Dulucq technique). A blunt trocar of 10 mm was inserted from the umbilical incision toward the space of Retzius. Two 5 mm ports were inserted under vision, first at halfway between the symphysis pubis and the umbilicus and another in the supra pubic space in the midline.
Dissection of preperitoneal space
Stopa’s parietalization technique was used for separating the elements of the spermatic cord from the peritoneum and peritoneal sac. Inferior epigastric vessels were traced toward the deep ring. Indirect hernias lie lateral to the inferior epigastric vessels and direct hernia lies medial to the vessels. The dissection in the inguinal region was continued all around the sac to encircle the neck. The iliac vessels lie under neck of sac so extreme caution was taken during the dissection. The dissection in the case of direct inguinal hernia was carried out from the medial side and directed above downward. The direct sac was freed from the transversalis fascia and continued until the peritoneum reached the iliac vessels inferiorly. Care was taken to avoid any hole formation in the peritoneum to maintain a good working space. If any hole was formed it was identified and enlarged which equalized the pressure on both sides of the peritoneum. A 5 mm port or Veress needle was inserted at Palmer’s point to decompress the abdominal cavity.
Introduction of mesh in total extraperitoneal groin
Mesh of appropriate size (15 cm × 12 cm) was rolled and inserted via an umbilical port. The mesh was then unrolled on the peritoneal floor and placed at the hernial orifice. Mesh was fixed by two tacks to Cooper’s ligament.
Follow-up was clinical where each patient was called for reexamination after 1 week, 1 month, and 6 months after operation for recording any short-term and long-term complications. Results were analyzed in terms of disability days, pain, cosmetic acceptance, and recurrence. Postoperative pain was measured on a visual analog scale (VAS) with values from 1 to 10 measuring no pain at 1 and severe at 10.
Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) software version 21 manufactured by IBM Corp., Chicago, IL, USA. Analysis was done using χ2 and student t test. P value of <0.05 was considered significant.
| Results|| |
Mean age in the group I was 45 ± 18.52 years whereas in group II it was 48.88 ± 20.52 years. The minimum age recorded was 13 years while maximum was 82 years and all were male patients. The maximum number of patients were of 51–60 years and 21–30 years age groups, comprising 18% each [Table 1]. The findings were statistically insignificant (P > 0.05).
[Table 2] depicts the distribution of patients in two groups according to the side and type of hernia. Ratio of left–right inguinal hernia was 1:1.8. Ratio of direct to indirect hernia was 1:1.6. The difference between the two groups was insignificant (P > 0.05).
Mean operating time between two groups was comparable (P > 0.05). [Figure 1] depicts the t-variation of subjects among LW large pore mesh and HW small pore mesh. Thus, the use of different type of mesh does not affect the operating time of the surgery.
[Table 3] compares pain on VAS on immediate postoperative and at 1 week. There was no significant difference (P > 0.05).
The intraoperative and postoperative general complications in both groups were not very significant [Table 4]. Intraoperatively one (4%) patient in the group I had pneumoperitoneum due to the opening of peritoneum and one (4%) patient in the group I had hemorrhage due to injury to the inferior epigastric artery but no other intraoperative complication was observed. Postoperatively one (4%) patient in group I and one (4%) patient in group II had fever. One (4%) patient in group I and one (4%) patient in group II had urinary retention. Two (8%) patients in group I and five (20%) patients in group II had seroma formation. Chronic inguinal pain was observed in one (4%) case in each group.
No recurrence was observed in any of the groups [Table 4].
Foreign body sensation between the two groups immediately postoperative, at 1 week, 1 month, 3 months, and at 6 months was comparable [Table 5]. It is found that foreign body sensation decreases with a passage of time and is found in 20% of the patients in group I (LW large pore mesh) and 36% of the patients in group II (HW small pore mesh), at 6 months interval (P = 0.208).
[Figure 2] presents patient satisfaction levels in the two groups. The difference in the level of satisfaction between the two groups was not statistically significant (P value > 0.05).
| Discussion|| |
The evolution of inguinal hernia treatment over the past 150 years is observed from truss support to surgical treatment reserved for life-threatening situations to elective outpatient repair. Various techniques using different approaches were used to repair the hernia but none had yielded a satisfactory result.
Primary cause of indirect hernia in infants and children is patent processus vaginalis. In adults’ enormous high intra-abdominal pressure due to coughing or straining and strenuous physical activity may lead to the development of hernia. In old age, weakening of muscles and fascia of the abdominal wall with or without chronic cough, constipation, or urinary obstruction led to the formation of hernia.
Maximum number of patients in the present study were in 3rd and 6th decades of life [Table 1]. Gilbert also reported similar findings with a maximum number of patients in the age group of 51–60 years.
All patients in the present study were men with no female patients presented to us with groin hernia during the study period. The studies in the past had shown similar results with male-to-female ratio of 12:1, 24:1, 25:1, and 112:15.
In our study, right inguinal hernias were more than the left inguinal hernias. Indirect hernias were slightly higher in our study (n = 31). The incidence of indirect hernias is much higher than direct hernias as shown by other studies. The difference in the percentage from other studies could be due to the small size of our study.
The mean operating time of the TEP is equal to and often shorter than that of open repair. But Takeuchi et al., in their study found that TEP has a significantly longer operating time than open mesh repair. However, there was significantly less blood loss. There are many factors that play a role in determining the operating time, that is, experience of surgeon, type of hernia, and ease of handling the mesh. The mean operating time decreases to less than 40 min and reaches a plateau after 51–81 cases.
The operating time was also influenced by the ease of handling of the mesh and time to unroll the mesh. It was found that the LW large pore mesh was easy to handle and load in the reducer than HW small pore mesh. However, HW small pore mesh was easy to unroll in comparison to LW large pore mesh. This could be explained on the basis of mesh memory. HW small pore mesh containing more mesh material has more mesh memory.
The mean operating time was almost the same in group I and group II. The operative time ranged from 60 to 140 min in group I and 60 to 150 min in group II. The mean duration of surgery in group I is 81.28 ± 22.63 and in group II is 88.60 ± 24.77, and hence no significant difference was observed (P < 0.281). Thus, using different types of mesh does not alter the duration of operation.
The studies conducted by Lal et al. and Hamza et al. showed a mean operating time of 75.72 ± 31.10 and 77.40 ± 43.21 min, respectively, whereas Vidovic et al. showed less than hour as mean operating time (58.60 ± 18.10 min). The increase in time in comparison to other studies could be due to the unfamiliarity of assistants to the laparoscopic anatomy of the inguinal region. The surgeon was the sole person accustomed to laparoscopic TEP.
Complications are known to occur in TEP. Hemorrhage can occur at inferior epigastric vessels, obturator artery, and at the triangle of doom as reported by many studies.,,, Bladder injury has been reported to occur during port placement, which can be prevented by urinary bladder catheterization.
Postoperative complications include urinary retention, seroma formation, infection, chronic groin pain, testicular pain, and recurrence. Chowbey et al., in their study of comparison between ultrapro mesh and polypropylene mesh found a significant difference in VAS score. However, in the present study, no significant complications were observed. VAS score between the two groups was comparable and there was no significant difference [Table 3] and [Table 4]. VAS score was <2 in both groups after 1 week. But there is slightly less pain in LW mesh group than HW mesh group.
There was no recurrence on follow-up in any of the groups. Chowbey et al. reported a recurrence of 0.2% in LW (ultrapro) and 1.3% in HW (prolene) mesh (P = 0.078). However Wu et al. reported that HW mesh had an advantage for recurrence over LW mesh (P = 0.01) but was comparable with respect to foreign body sensation, seroma formation, and infection. Xu et al. also observed a high incidence of recurrence with LW mesh (P = 0.03). Hematoma mesh lifting and inadequate lateral inferior and medial inferior mesh fixation represent the most common causes of recurrence for surgeons experienced in traditional or laparoscopic preperitoneal hernia repair. Novik et al. recommended fixation of LW mesh with fibrin glue while nonfixation for other meshes. Current guidelines recommend that in TEP/TAPP mesh fixation is required in large hernial defects (M3 EHS classification) only.
Groin pain after hernia repair occurring due to neuralgia is one of the most vexing complications. The incidence of groin pain varies from 9.9% to 29% in TEP., Groin pain is seen more commonly with HW mesh. Nikkolo et al. reported pain at rest in a greater number of patients with the HW mesh group than in the LW mesh group at 6 months follow-up (6.3% vs. 0%, P = 0.038). The incidence of groin pain reported by Chowbey et al. was 1.6% and 4.7% (P = 0.178) with ultrapro and prolene group, respectively. However in the present study, one patient from each group reported groin pain in the follow-up period. Wu et al. and Xu et al. showed similar results where there is no significant difference in groin pain and foreign body sensation.
Foreign body sensation with LW mesh was less compared to HW mesh as reported in the study conducted by Nikkolo et al. where it was 20.9% and 32.8% (P = 0.123), respectively. Bakker et al. also reported no significant difference in groin pain and foreign body sensation between the use of HW and LW mesh. Similar findings were observed in the present study (P = 0.208).
Patient satisfaction was seen more in group I (88%) than in group II (76%). This was due to the less incidence of postoperative complications such as seroma formation and foreign body sensation. A study reported that early postoperative convalescence was better with LW mesh in terms of early return to walking and driving; however, the incidence of groin pain, postoperative pain, QOL, and recurrences were comparable with both LW and HW mesh groups. Similarly, no difference was observed in terms postoperative complications and quality of life on long-term follow-up study conducted by Arnold et al.
Although there was no significant difference between the two groups but LW large pore mesh carries some advantage over HW small pore mesh in terms of postoperative seroma formation, pain, and foreign body sensation.
It is difficult to make statement regarding recurrence and chronic groin pain due to the short duration of the study, lack of measurement of pre operative pain, and small sample size. The study was underpowered (post hoc power of study was 20%). Another limitation of the study was defect size could not be measured.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]