MESH VS SUTURE FIXATION IN LAPAROSCOPIC HERNIA REPAIR: RECURRENCE, CHRONIC PAIN, AND COMPLICATIONS; A SYSTEMATIC REVIEW AND META-ANALYSIS.

Abstract

Background: Mesh fixation technique in laparoscopic hernia repair remains a topic of surgical controversy, especially the impact of tacks, sutures, glue and non-fixation on recurrence, chronic postoperative groin pain and early surgical complications. Previous studies have shown variable results and most of the comparative trials have differences in the fixation method and duration. This systematic review and meta-analysis is a synthesis of evidence from seven high-quality clinical studies to offer evidence on whether suture-based fixation is superior to tacker fixation and other fixation strategies in achieving good postoperative outcomes.

Objectives: The goal of this review is to compare suture-based mesh fixation and tacker fixation in laparoscopic hernia repair with a primary focus on differences in recurrence of hernia. Secondary aims involve evaluating differences in chronic postoperative groin pain, early postoperative pain and early complications, such as seroma, hematoma and wound infection. Overall, the purpose of the review is to establish the answer to the following question: Do atraumatic fixation methods promote a better postoperative outcome without higher recurrence risk?

Methodology: A systematic search was conducted to identify eligible studies within the final reference set verified, including RCT's and a single quality registry-based cohort. 7 studies were finally eligible for the inclusion criteria. Outcomes extracted were recurrence, chronic postoperative pain, early postoperative pain and early complications. Data were obtained from full articles if available or from published abstracts when full text articles were not available. Chronic pain was measured as either binary results or as VAS scores where measured. Recurrence and complication rates were noted as number of events/arm of the study. Respondents that applied different fixation procedures (e.g., glue, non-fixation) became comparator subgroups. Due to heterogeneity in reporting, the synthesis of outcomes was done narratively in the abstract, with quantitative comparison done in the results section of the full manuscript.

Results: In the seven studies selected, they all had a total sample of about 2,700 patients with laparoscopic TAPP repairs employing different techniques of mesh fixation. In studies testing sutures versus tacks directly (Abdalgaleil & Shaat, Hassan et al, Bansal et al, Kleidari et al, Oguz et al) recurrence is either absent in both groups or occurs in 1 patient in 1 study arm, and is clinically equivalent. Chronic postoperative pain exhibited greater significant variation: There were consistent demonstrations that chronic discomfort was more frequent in cases where tacker fixation was implemented. The large randomized study by Habeeb et al. reported chronic pain in 19.9% of the patients in the tacker group than 1.9% with non-fixation and 7.1% with glue fixation. Lovisetto et al. also found that there was less long-term discomfort with fibrin glue when compared to staples. Registry based data from Andresen et al. also supported moderately less chronic pain with fibrin fixation than with tacks (18 vs. 20%). Early postoperative pain was also tended to be higher with tacks than with sutures or glue across a number of trials. Early complication rates, such as seroma, hematoma, wound infection, and swelling of the structures surrounding the hernia (edema) were low, yet consistent across all of the studies and there was no consistent pattern of superiority for any one fixation method.

Conclusion: The available evidence suggests that although the recurrence rates are similar with either method of fixation, tacker fixation appears consistently to be associated with increased early postoperative pain and risk of chronic groin pain than sutures, glue, or non-fixation. Suture based or atraumatic fixation techniques seem to have some benefit in postoperative comfort and no recurrence detriment. These results are indicative of a preference for suture fixation or atraumatic options for routine laparoscopic hernia repair. There should be more superior quality randomization trials involving pain measurement and extensive follow up to further hone clinical recommendations.