Association of Mesh and Fixation Options with Reoperation Risk after Laparoscopic Groin Hernia Surgery: A Swedish Hernia Registry Study of 25,190 Totally Extraperitoneal and Transabdominal Preperitoneal Repairs

Bengt Novik, Gabriel Sandblom, Christoph Ansorge, Anders Thorell, Bengt Novik, Gabriel Sandblom, Christoph Ansorge, Anders Thorell

Abstract

Background: International guidelines concerning mesh and mesh fixation options in laparoscopic totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) groin hernia repair are based on studies focusing on either mesh or fixation. We hypothesized that the value of such recommendations is limited by lacking knowledge on how mesh and fixation interact. The current registry-based nationwide cohort study compared different mesh/fixation combinations for relative risks for reoperation after TEP and TAPP groin hernia repair.

Study design: All TEP and TAPP registered in the Swedish Hernia Registry 2005 to 2017 with standard polypropylene (StdPPM) or lightweight (LWM) flat mesh, having tack, fibrin glue, or no fixation, were included. The endpoint was reoperation due to recurrence as of December 31, 2018. Multivariable Cox regression rendered relative risk differences between the exposures, expressed as hazard ratios (HR) with 95% CIs.

Results: Of 25,190 repairs, 924 (3.7%) were later reoperated for recurrence. The lowest, mutually equivalent, reoperation risks were associated with StdPPM without fixation (HR 1), StdPPM with metal tacks (HR 0.8, CI 0.4 to 1.4), StdPPM with fibrin glue (HR 1.1, CI 0.7 to 1.6), and LWM with fibrin glue (HR 1.2, CI 0.97 to 1.6). Except for with fibrin glue, LWM correlated with increased risk, whether affixed with metal (HR 1.7, CI 1.1 to 2.7), or absorbable tacks (HR 2.4, CI 1.8 to 3.1), or deployed without fixation (HR 2.0, CI 1.6 to 2.6).

Conclusions: With StdPPM, neither mechanical nor glue fixation seemed to improve outcomes. Thus, for this mesh category, we recommend nonfixation. With LWM, we recommend fibrin glue fixation, which was the only LWM alternative on par with nonaffixed StdPPM.

Trial registration: ClinicalTrials.gov NCT03755219.

Conflict of interest statement

Disclaimer: All funders/supporters are public, tax-financed, non-profit Swedish institutions. They had no role in the design, analysis, or interpretation of the data; or writing of the manuscript. No commercial company or any other competing interest was affiliated with this study in any way. None of the authors has had any conflict of interest related to this study.

Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Surgeons.

Figures

Figure 1.
Figure 1.
Study flow chart. 3D, three-dimensional; IPOM intraperitoneal onlay mesh; TAPP, (laparoscopic) transabdominal preperitoneal mesh repair; TEP, (laparoscopic) totally extraperitoneal mesh repair.
Figure 2.
Figure 2.
Included vs excluded (laparoscopic) totally extraperitoneal mesh and (laparoscopic) transabdominal preperitoneal mesh repairs. Cumulative incidence of reoperations. postop, post operation; Reop, reoperation.
Figure 3.
Figure 3.
Mesh. (A) Cumulative incidence of reoperations. (B) Multivariable proportional hazards regression. Adjusted for (laparoscopic) totally extraperitoneal mesh repair vs (laparoscopic) transabdominal preperitoneal mesh repair, the patient’s sex and age, emergency vs elective procedures, recurrent vs primary hernia, bilateral vs unilateral repair, right vs left groin, hernia anatomy and size, surgical unit, and fixation type. Note that the LWPPM and Ultrapro curves are identical, reflecting equal hazard ratios (HRs). LWPPM, lightweight pure polypropylene mesh; postop, post operation; Reop, reoperation; StdPPM, standard pure polypropylene mesh.
Figure 4.
Figure 4.
Fixation. (A) Cumulative incidence of reoperations; (B) Multivariable proportional hazards regression. Adjusted for (laparoscopic) totally extraperitoneal mesh repair vs (laparoscopic) transabdominal preperitoneal mesh repair, the patient’s sex and age, emergency vs elective procedures, recurrent vs primary hernia, bilateral vs unilateral repair, right vs left groin, hernia anatomy and size, surgical unit, and mesh type. HR, hazard ratio; postop, post operation; Reop, reoperation.
Figure 5.
Figure 5.
Mesh/fixation combinations. (A) Cumulative incidence of reoperations. 0, no fixation; abs, absorbable. (B) Multivariable proportional hazards regression. Adjusted for (laparoscopic) totally extraperitoneal mesh repair vs (laparoscopic) transabdominal preperitoneal mesh repair, the patient’s sex and age, emergency vs elective procedures, recurrent vs primary hernia, bilateral vs unilateral repair, right vs left groin, hernia anatomy and size, and surgical unit. HR, hazard ratio; LWM, lightweight mesh; postop, post operation; Reop, reoperation; StdPPM, standard pure polypropylene mesh.

References

    1. EU Hernia Trialists Collaboration. Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials. Ann Surg. 2002;235:322–332.
    1. Bisgaard T, Bay-Nielsen M, Christensen IJ, et al. . Risk of recurrence 5 years or more after primary Lichtenstein mesh and sutured inguinal hernia repair. Br J Surg. 2007;94:1038–1040.
    1. HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018;22:1–165.
    1. Murphy BL, Ubl DS, Zhang J, et al. . Trends of inguinal hernia repairs performed for recurrence in the United States. Surgery. 2018;163:343–350.
    1. Murphy BL, Zhang J, Ubl DS, et al. . Surgical trends of groin hernia repairs performed for recurrence in Medicare patients. Hernia. 2019;23:677–683.
    1. Swedish Hernia Registry. Annual report 2019 [in Swedish] 2020. Available at: . Accessed December 25, 2021.
    1. Palser TR, Swift S, Williams RN, et al. . Variation in outcomes and use of laparoscopy in elective inguinal hernia repair. BJS Open. 2019;3:466–475.
    1. Dulucq J. Traitement des hernies de l’aine par mise en place d’un patch prothétique sous-péritonéal en rétro-péritonéoscopie. Cahiers de Chirurgie. 1991;79:15–16.
    1. Arregui ME, Davis CJ, Yucel O, et al. . Laparoscopic mesh repair of inguinal hernia using a preperitoneal approach: a preliminary report. Surg Laparosc Endosc. 1992;2:53–58.
    1. Köckerling F, Bittner R, Kuthe A, et al. . TEP or TAPP for recurrent inguinal hernia repair-register-based comparison of the outcome. Surg Endosc. 2017;31:3872–3882.
    1. Aiolfi A, Cavalli M, Ferraro SD, et al. . Treatment of inguinal hernia: systematic review and updated network meta-analysis of randomized controlled trials. Ann Surg. 2021;274:954–961.
    1. Lowham AS, Filipi CJ, Fitzgibbons RJ, Jr, et al. . Mechanisms of hernia recurrence after preperitoneal mesh repair. Traditional and laparoscopic. Ann Surg. 1997;225:422–431.
    1. Ferzli GS, Frezza EE, Pecoraro AM, Jr, et al. . Prospective randomized study of stapled versus unstapled mesh in a laparoscopic preperitoneal inguinal hernia repair. J Am Coll Surg. 1999;188:461–465.
    1. Wantz GE. Laparoscopic hernioplasty without staples. J Am Coll Surg. 1999;188:531.
    1. Moreno-Egea A, Torralba Martínez JA, Morales Cuenca G, et al. . Randomized clinical trial of fixation vs nonfixation of mesh in total extraperitoneal inguinal hernioplasty. Arch Surg. 2004;139:1376–1379.
    1. Novik B. Randomized trial of fixation vs nonfixation of mesh in total extraperitoneal inguinal hernioplasty. Arch Surg. 2005;140:811–812; author reply 812.
    1. Sahebally SM, Horan J, Rogers AC, et al. . Fixation versus no fixation in laparoscopic totally extraperitoneal repair of primary inguinal hernia-a systematic review and meta-analysis of randomized controlled trials. Langenbecks Arch Surg. 2020;405:435–443.
    1. Habib Bedwani NAR, Kelada M, Smart N, et al. . Glue versus mechanical mesh fixation in laparoscopic inguinal hernia repair: meta-analysis and trial sequential analysis of randomized clinical trials. Br J Surg. 2021;108:14–23.
    1. Klinge U, Klosterhalfen B, Conze J, et al. . Modified mesh for hernia repair that is adapted to the physiology of the abdominal wall. Eur J Surg. 1998;164:951–960.
    1. Novik B, Hagedorn S, Mörk UB, et al. . Fibrin glue for securing the mesh in laparoscopic totally extraperitoneal inguinal hernia repair: a study with a 40-month prospective follow-up period. Surg Endosc. 2006;20:462–467.
    1. van Veenendaal N, Simons M, Hope W, et al. ; HerniaSurge Group. Consensus on international guidelines for management of groin hernias. Surg Endosc. 2020;34:2359–2377.
    1. Roos MM, Bakker WJ, Schouten N, et al. . Higher recurrence rate after endoscopic totally extraperitoneal (TEP) inguinal hernia repair with Ultrapro lightweight mesh: 5-year results of a randomized controlled trial (TULP-trial). Ann Surg. 2018;268:241–246.
    1. Wu F, Zhang X, Liu Y, et al. . Lightweight mesh versus heavyweight mesh for laparo-endoscopic inguinal hernia repair: a systematic review and meta-analysis. Hernia. 2020;24:31–39.
    1. Bakker WJ, Aufenacker TJ, Boschman JS, et al. . Heavyweight mesh is superior to lightweight mesh in laparo-endoscopic inguinal hernia repair: a meta-analysis and trial sequential analysis of randomized controlled trials. Ann Surg. 2021;273:890–899.
    1. von Elm E, Altman DG, Egger M, et al. ; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370:1453–1457.
    1. Benchimol EI, Smeeth L, Guttmann A, et al. ; RECORD Working Committee. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med. 2015;12:e1001885.
    1. Novik B, Nordin P, Skullman S, et al. . More recurrences after hernia mesh fixation with short-term absorbable sutures: a registry study of 82 015 Lichtenstein repairs. Arch Surg. 2011;146:12–17.
    1. Ludvigsson JF, Otterblad-Olausson P, Pettersson BU, et al. . The Swedish personal identity number: possibilities and pitfalls in healthcare and medical research. Eur J Epidemiol. 2009;24:659–667.
    1. Claus C, Furtado M, Malcher F, et al. . Ten golden rules for a safe MIS inguinal hernia repair using a new anatomical concept as a guide. Surg Endosc. 2020;34:1458–1464.
    1. Novik B. Defining recurrence from the patient’s point of view (reply to comment) [JAMA Network web site]; c2011. Available at: . Accessed October 24, 2021.
    1. Weyhe D, Schmitz I, Belyaev O, et al. . Experimental comparison of monofile light and heavy polypropylene meshes: less weight does not mean less biological response. World J Surg. 2006;30:1586–1591.
    1. Chastan P. Tension free open inguinal hernia repair using an innovative self gripping semi-resorbable mesh. J Minim Access Surg. 2006;2:139–143.
    1. Kibbe MR. Reporting of sex as a variable in research published in surgical journals. JAMA Surg. 2018;153:983.
    1. Flanagin A, Frey T, Christiansen SL; AMA Manual of Style Committee. Updated guidance on the reporting of race and ethnicity in medical and science journals. JAMA. 2021;326:621–627.
    1. Miserez M, Alexandre JH, Campanelli G, et al. . The European hernia society groin hernia classification: simple and easy to remember. Hernia. 2007;11:113–116.
    1. Aquina CT, Fleming FJ, Becerra AZ, et al. . Explaining variation in ventral and inguinal hernia repair outcomes: a population-based analysis. Surgery. 2017;162:628–639.
    1. Stulberg JJ, Huang R, Kreutzer L, et al. . Association between surgeon technical skills and patient outcomes. JAMA Surg. 2020;155:960–968.
    1. Andresen K, Friis-Andersen H, Rosenberg J. Laparoscopic repair of primary inguinal hernia performed in public hospitals or low-volume centers have increased risk of reoperation for recurrence. Surg Innov. 2016;23:142–147.
    1. Maneck M, Köckerling F, Fahlenbrach C, et al. . Hospital volume and outcome in inguinal hernia repair: analysis of routine data of 133,449 patients. Hernia. 2020;24:747–757.
    1. IBM. Test of Proportional Hazards [IBM SPSS Statistics V23.0 documentation web site]. Available at: . Accessed August 16, 2021.
    1. Lillemoe KD. Joint statement by the Surgery Journal Editors Group 2018. Ann Surg. 2018;267:991.
    1. Mayer F, Niebuhr H, Lechner M, et al. . When is mesh fixation in TAPP-repair of primary inguinal hernia repair necessary? The register-based analysis of 11,230 cases. Surg Endosc. 2016;30:4363–4371.
    1. Köckerling F, Hantel E, Adolf D, et al. . Differences in the outcomes of scrotal vs. lateral vs. medial inguinal hernias: a multivariable analysis of registry data. Hernia. 2021;25:1169–1181.
    1. Burcharth J, Pommergaard HC, Bisgaard T, et al. . Patient-related risk factors for recurrence after inguinal hernia repair: a systematic review and meta-analysis of observational studies. Surg Innov. 2015;22:303–317.
    1. Zinther NB, Wara P, Friis-Andersen H. Intraperitoneal onlay mesh: an experimental study of adhesion formation in a sheep model. Hernia. 2010;14:283–289.
    1. Harsløf S, Zinther N, Harsløf T, et al. . Mesh shrinkage depends on mesh properties and anchoring device: an experimental long-term study in sheep. Hernia. 2017;21:107–113.
    1. Klinge U, Koch A, Weyhe D, et al. . Bias-variation dilemma challenges clinical trials: inherent limitations of randomized controlled trials and meta-analyses comparing hernia therapies. Int J Clin Pract. 2014; 5:778–789.
    1. Nolsøe A, Andresen K, Rosenberg J. Repair of recurrent hernia is often performed at a different clinic. Hernia. 2016;20:783–787.
    1. Schwab R, Dietz UA, Menzel S, et al. . Pitfalls in interpretation of large registry data on hernia repair. Hernia. 2018;22:947–950.
    1. Haapaniemi S, Nilsson E. Recurrence and pain three years after groin hernia repair. Validation of postal questionnaire and selective physical examination as a method of follow-up. Eur J Surg. 2002;168:22–28.
    1. LeBlanc KA. Tack hernia: a new entity. JSLS. 2003;7:383–387.
    1. Lerdsirisopon S, Frisella MM, Matthews BD, et al. . Biomechanical evaluation of potential damage to hernia repair materials due to fixation with helical titanium tacks. Surg Endosc. 2011;25:3890–3897.
    1. Poobalan AS, Bruce J, Smith WC, et al. . A review of chronic pain after inguinal herniorrhaphy. Clin J Pain. 2003;19:48–54.
    1. Vigneswaran Y, Linn JG, Gitelis M, et al. . Educating surgeons may allow for reduced intraoperative costs for inguinal herniorrhaphy. J Am Coll Surg. 2015;220:1107–1112.
    1. Staarink M, van Veen RN, Hop WC, et al. . A 10-year follow-up study on endoscopic total extraperitoneal repair of primary and recurrent inguinal hernia. Surg Endosc. 2008;22:1803–1806.
    1. Brandt-Kerkhof A, van Mierlo M, Schep N, et al. . Follow-up period of 13 years after endoscopic total extraperitoneal repair of inguinal hernias: a cohort study. Surg Endosc. 2011;25:1624–1629.
    1. Peitsch WK. A modified laparoscopic hernioplasty (TAPP) is the standard procedure for inguinal and femoral hernias: a retrospective 17-year analysis with 1,123 hernia repairs. Surg Endosc. 2014;28:671–682.
    1. Barbaro A, Kanhere H, Bessell J, et al. . Laparoscopic extraperitoneal repair versus open inguinal hernia repair: 20-year follow-up of a randomized controlled trial. Hernia. 2017;21:723–727.
    1. Roos MM, van Hessen CV, Verleisdonk EJMM, et al. . An 11-year analysis of reoperated groins after endoscopic totally extraperitoneal (TEP) inguinal hernia repair in a high volume hernia center. Hernia. 2019;23:655–662.
    1. Köckerling F, Koch A, Lorenz R, et al. . How long do we need to follow-up our hernia patients to find the real recurrence rate? Front Surg. 2015;2:24.
    1. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet. 2007;370:1508–1519.
    1. Helgstrand F, Rosenberg J, Kehlet H, et al. . Reoperation versus clinical recurrence rate after ventral hernia repair. Ann Surg. 2012;256:955–958.
    1. Sadava EE, Krpata DM, Gao Y, et al. . Laparoscopic mechanical fixation devices: does firing angle matter? Surg Endosc. 2013;27:2076–2081.
    1. Zihni AM, Cavallo JA, Thompson DM, Jr, et al. . Evaluation of absorbable mesh fixation devices at various deployment angles. Surg Endosc. 2015;29:1605–1613.
    1. Christoffersen MW, Brandt E, Helgstrand F, et al. . Recurrence rate after absorbable tack fixation of mesh in laparoscopic incisional hernia repair. Br J Surg. 2015;102:541–547.
    1. Daes J, Felix E. Critical view of the myopectineal orifice. Ann Surg. 2017;266:e1–e2.

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