Comparative Study of Different types of Mesh Fixation during Laparoscopic Repair of Inguinal Hernia

INTRODUCTION

Inguinal hernia is a peritoneal sac protrusion through a weak point within the groin area which often contains abdominal content and is traditionally treated with surgery (Mizrahi et al., 2012). Inguinal hernia is the most common abdominal wall hernia. However about 50 % of patients with inguinal hernia is unaware of this, repair of inguinal hernia is one of the most commonly performed surgical procedures worldwide.¹ Inguinal hernia repair is the commonest operation in general surgical practice as hernias occur in about 1–5% of the general population.² The prevelance of inguinal hernia ranges from about 110 per 10 thousands-male patients aged between 16 to -24 years-old to 2 thousands per 10 thousands male-patients with 75-years old or older in males. ⁵

Males are more commonly affected by inguinal hernia than females. The male to female ratio is approximately 9 to 1.⁶ There are many risk factors that may contribute to the occurrence of inguinal hernia like pregnancy, history of hernia or prior hernia repair, obesity, male gender, older age.⁷ Surgery is the first-line treatment option for patients with inguinal hernia which is usually reserved for patients with either large bulges through a small hole, painful hernia, high risk for complication such as strangulation and incarceration.⁸

Current repair techniques for inguinal hernias are Tissue-suture repairs and Tension-free prosthetic repairs which include Anterior repairs (lichenstein repair and its modification, Patch and plug repairs and Double-layer devices) and Posterior repairs.⁹ Laparoscopic repair of inguinal hernias has been around for more than two decades. ¹⁰ Inguinal hernias can be repaired laparoscopically using a variety of techniques, including trans-abdominal-ligation, laparoscopy, total extra-peritoneal-ligation, and intra-peritoneal-ligation.¹¹

Also as reported by Aiolfi et al.; ¹² Minimally invasive laparoscopic transabdominal preperitoneal repair and totally extraperitoneal repair techniques were associated with reduced early postoperative pain, return to work/activities, chronic pain, hematoma, and wound infection compared to the Lichtenstein tension-free repair technique.¹² Presently, inguinal-protrousion mesh repair is the most-commonly used surgical method. There are different types of mesh-fixation included; sutures, staples, staples, self-fixing gauze, fibrin or other adhesives.¹³

This study purposes to assess and compare efficacy of mesh fixation using fibrin glue, stapels and sutures during laparoscopic repair of inguinal hernia.

PATIENTS AND METHODS

This study is prospective-observational study assumed from May 2021 to November 2021 in 15 adult male patients with inguinal hernia. These patients were admitted from outpatient surgical clinics to Al-Azhar University Hospitals. Patients aged 15-70 with inguinal hernia, patients with inguinal swelling only, and cases undergoing laparoscopic repair of inguinal hernia were included. Patients with recurrent hernia, patients with inguinoscrotal hernia, patients with obstructed and strangulated hernia, patients with types of hernia other than inguinal, significant breast involvement, not suitable for general anesthesia and patients taking anticoagulants were excluded. Included patient were divided intro three groups: Group 1: Net fixation with fibrin glue, Group 2: Net fixation with staple and Group 3: Net fixation with sutures. Clinical history: a detailed history was obtained, including name, age, occupation, residence, and particular habits of clinical significance.

Current context: including complaints analysis; starts evaluates body systems, sinus problems, bowel problems like constipation, and urinary problems. Family history: the presence of hernias and other family diseases. Local examination of the thigh and scrotum to confirm the diagnosis of the hernia, its nature, and the presence of complications. Laboratory tests: complete blood tests, blood tests, liver and kidney function tests, fasting blood sugar. X-ray examination: ultrasound of the pelvis and abdomen. Specific studies: Electrocardiograms have been ordered in patients over forty-years of age.

Fifteen-patients underwent laparoscopic inguinal-hernio-plasty for pre-peritoneal repair. Patient lying-down on the operating-table and a urinary-catheter were applied. Cover the patient and rub the entire abdomen, thighs, penis and scrotum. The camera port is inserted below the navel using an open technique and five-mm ports are inserted flush with the navel on either side of the rectal sheath. The stomach swells with carbon dioxide at a pressure of fourteen-mmHg. First, exploratory laparoscopy is performed to identify the groin and important anatomical landmarks such as the epigastria-vessels, umbilical-cord, lesion-triangle, and pain. Dissection of the peritoneal lobe begins near the ASIS and extends medially to the midline, after which the lumen is created by dissection of the peritoneum from the transverse fascia. A polypropylene mesh sheet measuring 11 x 6 cm is rolled into a tubular shape and passed through the umbilical cord holes with a diameter of ten-mm. The grid is placed in three different ways, one for each group of patients; Fibrin glue, pins and threads.

In the fibrin glue group, two-ml of fibrin reinforcers are used to secure the mesh, in the staple group, the mesh is stapled, while in the 2/0 suture group, polyproline suture is used. The peritoneal flap is closed with 2/0 Vicryl sutures. Remove the door and close the skin.

Antibiotics and analgesia was maintained with an oral non-steroidal anti-inflammatory drug at discharge. Postoperative pain was assessed using a visual analogue scale and patients were asked to rate their pain at various intervals. Early postoperative complications such as scrotal edema, hematoma, wound infection, seroma and urinary retention. Hospital stay after surgery (in hours). All patients were followed up as an outpatient at 1 week and then 1, 4 and 6 months later using a standardized telephone script.

Data were calculated and analyzed using IBM SPSS Version 20.0 (Armonk, NY: IBM Corp). Qualitative data were described in numbers and percentages. Quantitative data were described by time interval (minimum and maximum), mean and standard deviation. The significance of the obtained results was evaluated at the 5% level. Chi-square test for categorical variables to compare between different groups. ANOVA test: for quantitative variables, usually used to compare two study groups. Kruskal-Wallis H-Test: Compare two study groups for anomalous quantitative variables.

RESULTS

Table 1: socio-demographic data distribution among studied group

Operative time in Group (I) was ranged between 50-65 min with mean±S.D. 57.80±6.512 min while in Group (II) was ranged between 58-72 min with mean±S.D. 64.00±5.292 min and in Group (III) was ranged between 65-84 min with mean±S.D. 73.80±6.680 min. There were highly statistically significant differences between groups (Table 1).

Table 2: Comparison between groups as regard to patient’s Operative time

P: p value for comparing between the studied groups

P1: p value for comparing between group (I) and other groupP2: p value for comparing between group (II) and each of group (III)  *: Statistically significant at P <0.05

Fig. 1: Comparison between groups as regard to patient’s Operative time

Post-operative pain score (VAS score) show highly statistically significant differences between groups with high score in group (III) and the lowest score was in group (I) in all follow up time except after 6 months there were no statistically significant differences between groups.(Table 3; Figure 2)

Table 3: Comparison between groups as regard to patient’s post-operative pain score (VAS score)

Fig. 2: Comparison between groups as regard to patient’s Post-operative pain score (VAS score)

Table 4: Comparison between groups as regard to patient’s Post-operative pain score severity

Fig. 3: Comparison between groups as regard to patient’s post-operative pain score severity

Table 5: Comparison between groups as regard to patient’s Early post operative complications

Fig. 4: Comparison between groups as regard to patient’s early post operative complications.

Hospital stay (hrs) in Group (I) was ranged between 4-7 hrs with mean±S.D. 5.60±1.075 hrs while in Group (II) was ranged between 4-7.5 hrs with mean±S.D. 5.90±1.350 hrs and in Group (III) was ranged between 4-10 hrs with mean±S.D. 6.60±2.271 hrs.

Table 6: Comparison between groups as regard to patient’s Hospital stay (hrs)

Fig. 5: Comparison between groups as regard to patient’s Hospital stay (hrs)

Table 7: Comparison between groups as regard to patient’s Economic Cost

Table 8: Comparison between groups as regard to patient’s Return to normal activity

Fig. 9: Comparison between groups as regard to patient’s Return to normal activity