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Mesh fixation in endoscopic inguinal hernia repair: evaluation of methodology based on a systematic review of randomised clinical trials

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Abstract

Background

The issue of mesh fixation in endoscopic inguinal hernia repair is frequently debated and still no conclusive data exist on differences between methods regarding long-term outcome and postoperative complications. The quantity of trials and the simultaneous lack of high-quality evidence raise the question how future trials should be planned.

Methods

PubMed, EMBASE and the Cochrane Library were searched, using the filters “randomised clinical trials” and “humans”. Trials that compared one method of mesh fixation with another fixation method or with non-fixation in endoscopic inguinal hernia repair were eligible. To be included, the trial was required to have assessed at least one of the following primary outcome parameters: recurrence; surgical site infection; chronic pain; or quality-of-life.

Results

Fourteen trials assessing 2161 patients and 2562 hernia repairs were included. Only two trials were rated as low risk for bias. Eight trials evaluated recurrence or surgical site infection; none of these could show significant differences between methods of fixation. Two of 11 trials assessing chronic pain described significant differences between methods of fixation. One of two trials evaluating quality-of-life showed significant differences between fixation methods in certain functions.

Conclusion

High-quality evidence for differences between the assessed mesh fixation techniques is still lacking. From a socioeconomic and ethical point of view, it is necessary that future trials will be properly designed. As small- and medium-sized single-centre trials have proven unable to find answers, register studies or multi-centre studies with an evident focus on methodology and study design are needed in order to answer questions about mesh fixation in inguinal hernia repair.

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Acknowledgements

The authors would like to thank Thomas Hallgren MD, PhD and Simon Agerskov MD for proofreading the article and providing language corrections.

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Authors and Affiliations

  1. Department of General Surgery, Torsby Hospital, Värmland County Council, Box 502, 68529, Torsby, Sweden

    Hans Lederhuber, Franziska Stiede & Stephan Axer

  2. Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, and Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden

    Ursula Dahlstrand

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  1. Hans Lederhuber
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Correspondence to Hans Lederhuber.

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Hans Lederhuber holds a grant from the Swedish Society for Surgical Innovation (SIKT), founded by BARD Norden. The grant has no connection to the submitted work. Franziska Stiede, Stephan Axer and Ursula Dahlstrand have no conflict of interest or financial ties to disclose.

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Lederhuber, H., Stiede, F., Axer, S. et al. Mesh fixation in endoscopic inguinal hernia repair: evaluation of methodology based on a systematic review of randomised clinical trials. Surg Endosc 31, 4370–4381 (2017). https://doi.org/10.1007/s00464-017-5509-x

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