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Open versus laparoscopic mesh repair of primary unilateral uncomplicated inguinal hernia: a systematic review with meta-analysis and trial sequential analysis

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Abstract

Background

One standard repair technique for groin hernias does not exist. The objective of this study is to perform an update meta-analysis and trial sequential analysis to investigate if there is a difference in terms of recurrence between laparoscopic and open primary unilateral uncomplicated inguinal hernia repair.

Methods

The reporting methodology conforms to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Randomised controlled trials only were included. The intervention was laparoscopic mesh repair (transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP)). The control group was Lichtenstein repair. The primary outcome was recurrence rate and secondary outcomes were acute and chronic post-operative pain, morbidity and quality of life.

Results

This study included 12 randomised controlled trials with 3966 patients randomised to Lichtenstein repair (n = 1926) or laparoscopic repair (n = 2040). There were no significant differences in recurrence rates between the laparoscopic and open groups (odds ratio (OR) 1.14, 95% CI 0.51–2.55, p = 0.76). Laparoscopic repair was associated with reduced rate of acute pain compared to open repair (mean difference 1.19, CI − 1.86, − 0.51, p ≤ 0.0006) and reduced odds of chronic pain compared to open (OR 0.41, CI 0.30–0.56, p ≤ 0.00001). The included trials were, however, of variable methodological quality. Trial sequential analysis reported that further studies are unlikely to demonstrate a statistically significant difference between the two techniques.

Conclusion

This meta-analysis and trial sequential analysis report no difference in recurrence rates between laparoscopic and open primary unilateral inguinal hernia repairs. Rates of acute and chronic pain are significantly less in the laparoscopic group.

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References

  1. Kingsnorth A, LeBlanc K (2003) Hernias: inguinal and incisional. Lancet 362(9395):1561–1571

    Article  PubMed  Google Scholar 

  2. The HerniaSurge Group (2018) International guidelines for groin hernia management. Hernia 22(1):1–65

    Article  Google Scholar 

  3. Simons MP, Aufenacker TJ, Berrevoet F, Bingener J, Bisgaard T, Bittner R, Bonjer HJ, Bury K, Campanelli G, Chen DC, Chowbey PK (2017) World guidelines for groin hernia management. http://news.europeanherniasociety.eu/sites/www.europeanherniasociety.eu/files/medias/PDF/HerniaSurgeGuidelinesPART1TREATMENT.pdf. Accessed 1 Apr 2019

  4. Nordin P, Bartelmess P, Jansson C, Svensson C, Edlund G (2002) Randomized trial of Lichtenstein versus Shouldice hernia repair in general surgical practice. Br J Surg 89(1):45–49

    Article  CAS  PubMed  Google Scholar 

  5. Lange JFM, Kaufmann R, Wijsmuller AR, Pierie JPEN, Ploeg RJ, Chen DC, Amid PK (2015) An international consensus algorithm for management of chronic postoperative inguinal pain. Hernia 19(1):33–43

    Article  CAS  PubMed  Google Scholar 

  6. O’reilly EA, Burke JP, O’connell PR (2012) A meta-analysis of surgical morbidity and recurrence after laparoscopic and open repair of primary unilateral inguinal hernia. Ann Surg 255(5):846–853

    Article  PubMed  Google Scholar 

  7. Bobo Z, Nan W, Qin Q, Tao W, Jianguo L, Xianli H (2014) Meta-analysis of randomized controlled trials comparing Lichtenstein and totally extraperitoneal laparoscopic hernioplasty in treatment of inguinal hernias. J Surg Res 192(2):409–420

    Article  PubMed  Google Scholar 

  8. Scheuermann U, Niebisch S, Lyros O, Jansen-Winkeln B, Gockel I (2017) Transabdominal Preperitoneal (TAPP) versus Lichtenstein operation for primary inguinal hernia repair: a systematic review and meta-analysis of randomized controlled trials. BMC Surg 17(1):55

    Article  PubMed  PubMed Central  Google Scholar 

  9. Patterson TJ, Beck J, Currie PJ, Spence RA, Spence G (2019) Meta-analysis of patient-reported outcomes after laparoscopic versus open inguinal hernia repair. Br J Surg. https://doi.org/10.1002/bjs.11139

    Article  PubMed  Google Scholar 

  10. Köckerling F, Stechemesser B, Hukauf M, Kuthe A, Schug-Pass C (2016) TEP versus Lichtenstein: which technique is better for the repair of primary unilateral inguinal hernias in men? Surg Endosc 30(8):3304–3313

    Article  PubMed  Google Scholar 

  11. University of York, Centre for Reviews and Dissemination. PROSPERO; International prospective register of systematic reviews. http://www.crd.york.ac.uk/PROSPERO. Accessed 1 Apr 2019

  12. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 6(7):e1000100

    Article  PubMed  PubMed Central  Google Scholar 

  13. Robinson KA, Dickersin K (2002) Development of a highly sensitive search strategy for the retrieval of reports of controlled trials using PubMed. Int J Epidemiol 31(1):150–153

    Article  PubMed  Google Scholar 

  14. Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, Cohen M, Evers S, Finnerup NB, First MB, Giamberardino MA (2015) A classification of chronic pain for ICD-11. Pain 156(6):1003

    PubMed  PubMed Central  Google Scholar 

  15. Alfieri S, Amid PK, Campanelli G, Izard G, Kehlet H, Wijsmuller AR, Di Miceli D, Doglietto GB (2011) International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia 15:239. https://doi.org/10.1007/s10029-011-0798-9

    Article  CAS  PubMed  Google Scholar 

  16. Higgins JPT, Deeks JJ (2011) Obtaining standard deviations from standard errors, confidence intervals, t values and p values for differences in means. Cochrane handbook for systematic reviews of interventions. Version 5.1.0. https://handbook-5-1.cochrane.org/. Accessed 1 Apr 2019

  17. DeMets D, Lan KK (1994) Interim analysis: the alpha spending function approach. Stat Med 12:1341–1352

    Article  Google Scholar 

  18. O’Brien PC, Fleming TR (1979) A multiple testing procedure for clinical trials. Biometrics 35:549–556

    Article  PubMed  Google Scholar 

  19. Higgins JP, Altman DG (2009) Assessing risk of bias in included studies. In: Higgins JP, Green S (eds) Cochrane handbook for systematic reviews of interventions. Wiley, West Sussex, pp 187–235

    Google Scholar 

  20. Sevi̇nç B, Damburaci N, Güner M, Karahan Ö (2019) Comparison of early and long term outcomes of open Lichtenstein repair and totally extraperitoneal herniorrhaphy for primary inguinal hernias. Turk J Med Sci 49(1):38–41

    Article  PubMed  PubMed Central  Google Scholar 

  21. Koju R, Koju RB, Malla B, Dongol Y, Thapa LB (2017) Transabdominal pre-peritoneal mesh repair versus Lichtenstein’ s hernioplasty. J Nepal Health Res Counc 15(2):135–140

    Article  PubMed  Google Scholar 

  22. Westin L, Wollert S, Ljungdahl M, Sandblom G, Gunnarsson U, Dahlstrand U (2016) Less pain 1 year after total extra-peritoneal repair compared with Lichtenstein using local anesthesia: data from a randomized controlled clinical trial. Ann Surg 263(2):240–243

    Article  PubMed  Google Scholar 

  23. Dahlstrand U, Sandblom G, Ljungdahl M, Wollert S, Gunnarsson U (2013) TEP under general anesthesia is superior to Lichtenstein under local anesthesia in terms of pain 6 weeks after surgery: results from a randomized clinical trial. Surg Endosc 27(10):3632–3638

    Article  PubMed  Google Scholar 

  24. Wang WJ, Chen JZ, Fang Q, Li JF, Jin PF, Li ZT (2013) Comparison of the effects of laparoscopic hernia repair and Lichtenstein tension-free hernia repair. J Laparoendosc Adv Surg Tech 23(4):301–305

    Article  Google Scholar 

  25. Eker HH, Langeveld HR, Klitsie PJ, van’t Riet M, Stassen LP, Weidema WF, Steyerberg EW, Lange JF, Bonjer HJ, Jeekel J (2012) Randomized clinical trial of total extraperitoneal inguinal hernioplasty vs Lichtenstein repair: a long-term follow-up study. Arch Surg 147(3):256–260

    Article  PubMed  Google Scholar 

  26. Langeveld HR, van’t Riet M, Weidema WF, Stassen LP, Steyerberg EW, Lange J, Bonjer HJ, Jeekel J (2010) Total extraperitoneal inguinal hernia repair compared with Lichtenstein (the LEVEL-Trial): a randomized controlled trial. Ann Surg 251(5):819–824

    Article  PubMed  Google Scholar 

  27. Eklund A, Montgomery A, Bergkvist L, Rudberg C (2010) Chronic pain 5 years after randomized comparison of laparoscopic and Lichtenstein inguinal hernia repair. Br J Surg 97(4):600–608

    Article  CAS  PubMed  Google Scholar 

  28. Eklund AS, Montgomery AK, Rasmussen IC, Sandbue RP, Bergkvist LÅ, Rudberg CR (2009) Low recurrence rate after laparoscopic (TEP) and open (Lichtenstein) inguinal hernia repair: a randomized, multicenter trial with 5-year follow-up. Ann Surg 249(1):33–38

    Article  PubMed  Google Scholar 

  29. Eklund A, Rudberg C, Smedberg S, Enander LK, Leijonmarck CE, Österberg J, Montgomery A (2006) Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair. Br J Surg: Inc Eur J Surg Swiss Surg 93(9):1060–1068

    Article  CAS  Google Scholar 

  30. Pokorny H, Klingler A, Schmid T, Fortelny R, Hollinsky C, Kawji R, Steiner E, Pernthaler H, Függer R, Scheyer M (2008) Recurrence and complications after laparoscopic versus open inguinal hernia repair: results of a prospective randomized multicenter trial. Hernia 12(4):385–389

    Article  CAS  PubMed  Google Scholar 

  31. Butters M, Redecke J, Köninger J (2007) Long-term results of a randomized clinical trial of Shouldice, Lichtenstein and transabdominal preperitoneal hernia repairs. Br J Surg: Inc Eur J Surg Swiss Surg 94(5):562–565

    Article  CAS  Google Scholar 

  32. Köninger J, Redecke J, Butters M (2004) Chronic pain after hernia repair: a randomized trial comparing Shouldice, Lichtenstein and TAPP. Langenbeck’s Arch Surg 389(5):361–365

    Article  Google Scholar 

  33. Lau H, Patil NG, Yuen WK (2006) Day-case endoscopic totally extraperitoneal inguinal hernioplasty versus open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males. Surg Endosc Other Interv Tech 20(1):76–81

    Article  CAS  Google Scholar 

  34. Heikkinen T, Bringman S, Ohtonen P, Kunelius P, Haukipuro K, Hulkko A (2004) Five-year outcome of laparoscopic and Lichtenstein hernioplasties. Surg Endosc Other Interv Tech 18(3):518–522

    Article  CAS  Google Scholar 

  35. Heikkinen TJ, Haukipuro K, Hulkko A (1998) A cost and outcome comparison between laparoscopic and Lichtenstein hernia operations in a day-case unit. Surg Endosc 12(10):1199–1203

    Article  CAS  PubMed  Google Scholar 

  36. Heikkinen TJ, Haukipuro K, Koivukangas P, Hulkko A (1998) A prospective randomized outcome and cost comparison of totally extraperitoneal endoscopic hernioplasty versus Lichtenstein hernia operation among employed patients. Surg Laparosc Endosc 8(5):338–344

    Article  CAS  PubMed  Google Scholar 

  37. Heikkinen T, Haukipuro K, Leppälä J, Hulkko A (1997) Total costs of laparoscopic and Lichtenstein inguinal hernia repairs: a randomized prospective study. Surg Laparosc Endosc 7(1):1–5

    Article  CAS  PubMed  Google Scholar 

  38. Anadol ZA, Ersoy E, Taneri F, Tekin E (2004) Outcome and cost comparison of laparoscopic transabdominal preperitoneal hernia repair versus open Lichtenstein technique. J Laparoendosc Adv Surg Tech 14(3):159–163

    Article  Google Scholar 

  39. Gokalp A, Inal M, Maralcan G, Baskonus I (2003) A prospective randomized study of Lichtenstein open tension-free versus laparoscopic totally extraperitoneal techniques for inguinal hernia repair. Acta Chir Belg 103(5):502–506

    Article  CAS  PubMed  Google Scholar 

  40. http://www.rcseng.ac.uk/commisioning/groin-hernia-commissioning-guide. Accessed 1 May 2019

  41. https://www.precis-2.org/. Accessed 1 May 2019

  42. Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R Jr, Dunlop D, Gibbs J, Reda D, Henderson W (2004) Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 350(18):1819–1827

    Article  CAS  PubMed  Google Scholar 

  43. Blencowe NS, Skilton A, Gaunt D, Brierley R, Hollowood A, Dwerryhouse S, Higgs S, Robb W, Boddy A, Hanna G, Barham CP (2019) Protocol for developing quality assurance measures to use in surgical trials: an example from the ROMIO study. BMJ Open 9(3):e026209

    Article  PubMed  PubMed Central  Google Scholar 

  44. Daes J, Felix E (2017) Critical view of the myopectineal orifice. Ann Surg 266(1):e1–e2

    Article  PubMed  Google Scholar 

  45. Clavien PA, Barkun J, De Oliveira ML, Vauthey JN, Dindo D, Schulick RD, De Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187–196

    Article  PubMed  Google Scholar 

  46. Bhangu A, Singh P, Pinkney T, Blazeby JM (2015) A detailed analysis of outcome reporting from randomised controlled trials and meta-analyses of inguinal hernia repair. Hernia 19(1):65–75

    Article  CAS  PubMed  Google Scholar 

  47. Gohel MS, Chetter I. Are clinical trials units essential for a successful trial?. Bmj. 2015 May 27;350:h2823

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Funding

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Authors and Affiliations

  1. Department of Colorectal Surgery, Royal Devon and Exeter NHS Foundation Trust, Royal Devon and Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK

    N. L. Bullen, L. H. Massey & N. J. Smart

  2. Surgical Department, St Loukas Hospital, Thessaloniki, Greece

    S. A. Antoniou

  3. European University Cyprus, Nicosia, Cyprus

    S. A. Antoniou

  4. Department of General, Visceral and Oncological Surgery, Wilhelminenspital, 1160, Vienna, Austria

    R. H. Fortelny

  5. Medical Faculty, Sigmund Freud University, Freudplatz 3, 1020, Vienna, Austria

    R. H. Fortelny

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Correspondence to N. L. Bullen.

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NLB, LHM, SAA, NJS and RHF declare no conflict of interest.

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The article is part of the Topical Collection “Forum on primary monolateral uncomplicated inguinal hernia”.

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Bullen, N.L., Massey, L.H., Antoniou, S.A. et al. Open versus laparoscopic mesh repair of primary unilateral uncomplicated inguinal hernia: a systematic review with meta-analysis and trial sequential analysis. Hernia 23, 461–472 (2019). https://doi.org/10.1007/s10029-019-01989-7

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