jurnal 1 kedokteran

8/11/2019 jurnal 1 kedokteran

1/11

Review Article

Comparison of open preperitoneal and Lichtenstein repair for inguinal hernia repair: a meta-analysis of randomizedcontrolled trials Junsheng Li, M.D.*, Zhenling Ji, M.D., Tao Cheng, M.D.

Department of General Surgery, Afliated Zhong-Da Hospital, Southeast University, 210009 Nanjing, Jiangsu, China

AbstractBACKGROUND: The aim of this article was to compare the outcomes of the open preperito

approaches and the Lichtenstein technique in the repair of inguinal hernias.METHODS: A systematic literature review was undertaken to identify studies comparing the

comes of open preperitoneal and Lichtenstein techniques in the repair of inguinal hernias.RESULTS: The present meta-analysis pooled the effects of outcomes of a total of 2,860 pat

enrolled into 10 randomized controlled trials and 2 comparative studies. The preperitoneal technwas associated with a lesser incidence of recurrence (odds ratio .51; 95% condence interva.28.92). However, statistically there was no difference in the incidence of chronic pain, hematwound infection, testicular problem, urinary problem, numbness, inguinal parenthesis, and opertime.

CONCLUSIONS: The open preperitoneal approach is a feasible alternative for the standard Lichstein procedure with similar complication rates and potentially less postoperative recurrence. 2012 Elsevier Inc. All rights reserved.

KEYWORDS:Lichtenstein;Preperitoneal;Inguinal hernia;Repair;Randomizedcontrolled trials

Inguinal hernia repair is one of the most common surgi-cal procedures performed, and nearly 80 operative tech-niques have been described since Bassini reported hismethod in 1887. Surgeons continue to search for the idealrepair method with the best outcome. Because tension-freeinguinal hernia repair has a low recurrence rate, parametersother than recurrence are becoming increasingly importantto determine the effects of hernia repair (eg, postoperativeinguinal pain and discomfort). Although the laparoscopicapproach was reported to be associated with less pain,laparoscopic hernia repair is more expensive and has alonger learning curve and the need for general anesthesia;

hence, most surgeons reserve this approach for specindications and in specialized centers.1

One of the most frequently used open techniques isLichtenstein herniorraphy.2 Nowadays, chronic pain the main problem associated with the Lichtenstein produre with a reported rate of 15% to 40%.3,4 The reason o

the postoperative pain was complex, and the position ofmesh is probably 1 factor. Furthermore, this anterior metneeds extensive dissection of the inguinal wall and xation of the mesh.5 Despite skepticism about the anteriplacement of the mesh, Amid et al6 supported their claimthat Lichtenstein was a safe, easy, and effective inguihernia method, with a recurrence rate as low as .12% in thands.6

The open preperitoneal approach might benet from pting a mesh in the preferred preperitoneal space free ofdisadvantages of an endoscopic procedure. In the prep

* Corresponding author. Tel: 0086-25-13770927641; fax: 0086-25-83272064

E-mail address: [email protected] received September 27, 2011; revised manuscript February

5, 2012

0002-9610/$ - see front matter 2012 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.amjsurg.2012.02.010

The American Journal of Surgery (2012) 204, 769778
http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-mailto:[email protected]://dx.doi.org/10.1016/j.amjsurg.2012.02.010http://dx.doi.org/10.1016/j.amjsurg.2012.02.010mailto:[email protected]://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-


2/11

toneal approach, the mesh is held in place with intra-ab-dominal pressure and, thus, needs relatively less or noxation. The open preperitoneal approach has been in usefor more than 30 years.7,8 Several different methods havebeen designed and proved to be successful, such as thetransinguinal preperitoneal technique (TIPP) with a memoryring patch9 and lower abdominal incision with a Kugelpatch.10 In addition, a currently common used technique,the Prolene hernia system (PHS; Ethicon, South San Fran-cisco, CA) with a bilayer mesh, reinforcing both the pre-peritoneal space and inguinal oor, has the benet of lessxation and less dissection of the inguinal oor and pre-serves the advantages of open preperitoneal position of themesh.11

To date, there is no meta-analysis specially comparingthe effects of open preperitoneal mesh placement and thesubaponeurotic location. In the present article, we includedseveral different preperitoneal repair methods based on thepoint that, in these methods, the meshes were all placed inthe preperitoneal space, and which is the most importantaspect of these methods, and this is the truly clinical sig-nicance of the preperitoneal approach.

Methods

By conducting an intensive search of the literature in themajor databases (ie, PubMed, EMBase, Springer, and Co-

chrane Library), we identied all trials published up to including May 2011 that compared the open preperitonand Lichtenstein procedures for the repair of inguinal hnias. The term inguinal hernia was used in combinatwith the following medical subject headings: preperneal, Lichtenstein, Kugel, PHS, tension-free, repair. The reference lists and relevant articles referenin these primary studies were downloaded from the dbases. The relevance function of the articles in the databwas used to widen the search results. All abstracts, compative studies, nonrandomized trials, and citations scanwere searched comprehensively. Ten randomized controltrials and 2 well-designed comparisons were identiedstudy. The 2 comparative studies had a large numbercases, long-term follow-up, and comparable baseline chacteristics. A total of 2,860 patients were summarized iformal meta-analysis. All the nonrelevant articles (eg, acles that did not compare these 2 procedures, trials treported on only 1 technique, and articles that reported psurgical experiences) were excluded from this study. A chart of the literature is shown in Figure 1.

To be included, studies had to be published as full-lenarticles or letters in peer-reviewed journals. For duplicpublications, the smaller dataset was excluded. These trreported at least 1 of the following outcomes: seromahematoma, infection, numbness, parenthesis, chronic ptesticular problems, operating time, urinary problem,recurrence (Table 1). Each article was critically reviewed

Potentially relevant trials identified andscreened for retrival

n=367

Trials retrieved for more detailed

evaluation

n=65

Trials included

n= 14

Potentially appropriate trials to be

included in the meta-analysisn=18

Trials with usuable information, by

outcome

n=12

Trials withdrawn n=2

Incomplete information n=1

Different outcome n=1

Trials excluded n=4

Femoral hernia trials n=1

Emergency cases studie n=1

Other techniques n=2

Trials excluded n=47

Non-comparative, case report, or review.

n=47

Trials excluded n=302

Trials not relevant n=302

Figure 1 A ow diagram of trial selection.

770 The American Journal of Surgery, Vol 204, No 5, November 201
http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-


3/11


4/11

The quality of trials was assessed with the Cochrane Handbook for Systematic Reviews of Interventions version5.0.112 (Table 2). Each included trial was assessed indepen-dently to ascertain the following methodologic qualities:sequence generation, allocation concealment, blinding of participants, personnel and outcome assessors, incompleteoutcome data, selective outcome reporting, and othersources of bias. No sponsors were involved in the studydesign, data collection, analysis, interpretation, and the writ-

ing and submitting of the report for publication. All authorshad access to the raw data.Pooled estimates of outcomes were calculated using a

xed-effects model, but a randomized-effects model wasused according to heterogeneity. Tests for heterogeneity andoverall effect were provided for each total or subtotal. Weused the chi-square statistic to assess the heterogeneitybetween trials and the I 2 statistic to assess the extent of inconsistency. For dichotomous data, results for each trialwere expressed as odds ratios (ORs) or risk differences(RDs) with 95% condence intervals (CIs).12

Forest plots were used for the graphic display of the

results from the meta-analysis. Statistical analysis was per-formed by Review Manager (RevMan version 5.0), theCochrane Collaborations software for preparing and main-taining Cohrane systematic reviews. Bias was studied usingsensitivity analysis by removing individual studies from thedataset and analyzing the overall effect size and theweighted regression test described by Egger et al.13 Publi-cation bias was tested using the Egger test.

Results

Figure 1 shows the owchart of studies from the initialresults of publication searches to the nal inclusion or

exclusion. Only randomized controlled trials and wellsigned comparative studies that were published in Engwere included in the present analysis. The electronic searcyielded 367 items from PubMed, EMBase, Springer, andCochrane Library. After reviewing these, we identiedoriginal studies.1425 The publication dates ranged fro2004 to 2011. A total of 2,860 patients were enrolledthese eligible trials.

Recurrence

There was no signicant heterogeneity among thetrials1425 (P .94, I 2 0%); therefore, the xed-effecmodel was appropriate. Compared with the Lichtensgroup, the preperitoneal group showed less postoperatrecurrence (OR .51; 95% CI, .28.92; Fig. 2A). To testhe sensitivity of these results, we excluded 2 trials wsmall sample sizes20,22 and obtained similar results (OR.48; 95% CI, .25.91; Fig. 2B). We also excluded the triwith the shortest follow-up time14 and got the result did nchanged (OR .44; 95% CI, .22.87, Fig. 2C). Further

more, these results were recalculated with relative risk RD, and the same conclusion was obtained. Publication bwas also tested with the Egger test, and no publication was detected among the present included trials (Fig. 2D).

Pain

Seven14,16,17,19 21,23 of the 12 studies reported chronpain ( 6 months). The random-effects model was usbecause of the heterogeneity (P .0001, I 2 80%). Theresults showed that there was no signicant differencechronic pain between the preperitoneal and Lichtenstgroups (OR .55; 95% condence interval [CI], .221.3Fig. 3).

Table 2 Quality assessment of the randomized controlled trials

Study RandomizationAllocationconcealment Blinding

Incompleteoutcomedata

ITTanalysis

Selectingoutcomereporting

Othersourcesof bias

Nienhuijs et al, 2007 14 Computergenerated

Central allocation Single blind Yes No Unclear Unclear

Dogru et al, 200615

Admittanceorder

Central allocation Unclear Yes No Unclear Unclear

Muldoon et al 200416 Computergenerated

Sealed envelope Unclear Yes No Unclear Unclear

Mayagoitia et al 2006 19

Unclear Unclear Unclear Yes No Unclear Unclear

Sanjay et al 2006 20 Unclear Sealed envelope Unclear Yes No Unclear UnclearDalenback et al 200921 Unclear Central allocation Single blind Yes No Unclear UnclearAl Gun et al, 200722 Unclear Unclear Unclear Yes No Unclear UnclearVironen et al, 2006 23 Unclear Sealed envelope Double blind Yes No Unclear UnclearNienhuijs et al, 2005 24 Computer

generatedSealed envelope Single blind Yes No Unclear Unclear

Kingsnorth et al,2002 25

Unclear Unclear Double blind Yes No Unclear Unclear

http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-


5/11

Study or SubgroupBerrevoet F 2010Dalenback J 2009Dogru O 2006Gunal O 2007Kingsnorth 2002Koning GG 2011Mayagoitia JC 2006Muldoon RL 2004Nienhuijs 2005Nienhuijs S 2007Sanjay P 2006Vironen J 2006

Total (95% CI)Total eventsHeterogeneity: Chi = 4.84, df = 11 (P = 0.94); I = 0%Test for overall effect: Z = 2.23 (P = 0.03)

Events430101011210

14

Total1421556939

1032251361211118231

150

1364

Events721323253201

31

Total1361587042

1032712141261108433

149

1496

Weight21.7%6.1%4.6%8.8%7.8%8.5%6.0%

15.2%9.3%6.0%1.4%4.7%

100.0%

M-H, Fixed, 95% CI0.53 [0.15, 1.87]1.54 [0.25, 9.34]0.33 [0.01, 8.32]0.34 [0.03, 3.44]0.20 [0.01, 4.14]0.40 [0.04, 3.86]0.31 [0.01, 6.53]0.20 [0.02, 1.75]0.32 [0.03, 3.17]1.02 [0.14, 7.45]

3.30 [0.13, 83.97]0.33 [0.01, 8.14]

0.51 [0.28, 0.92]

oitaRsddOoitaRsddOnietsnethciLlaenotir eper PM-H, Fixed, 95% CI

0.01 0.1 1 10 100Favours preperitonal Favours Lichtenstein

Study or SubgroupBerrevoet F 2010Dalenback J 2009Dogru O 2006Kingsnorth 2002Koning GG 2011Mayagoitia JC 2006Muldoon RL 2004Nienhuijs 2005Nienhuijs S 2007Vironen J 2006

Total (95% CI)Total events

Heterogeneity: Chi = 3.47, df = 9 (P = 0.94); I = 0%Test for overall effect: Z = 2.24 (P = 0.02)

Events4300101120

12

Total14215569

10322513612111182

150

1294

Events7212325321

28

Total13615870

10327121412611084

149

1421

Weight24.1%6.7%5.1%8.6%9.4%6.7%

16.9%10.4%6.7%5.2%

100.0%

M-H, Fixed, 95% CI0.53 [0.15, 1.87]1.54 [0.25, 9.34]0.33 [0.01, 8.32]0.20 [0.01, 4.14]0.40 [0.04, 3.86]0.31 [0.01, 6.53]0.20 [0.02, 1.75]0.32 [0.03, 3.17]1.02 [0.14, 7.45]0.33 [0.01, 8.14]

0.48 [0.25, 0.91]


0.01 0.1 1 10 100Favours preperitoneal Favours Lichtenstein

A

Study or SubgroupBerrevoet F 2010Dalenback J 2009Dogru O 2006Kingsnorth 2002Koning GG 2011Mayagoitia JC 2006Muldoon RL 2004Nienhuijs 2005Vironen J 2006


Events430010110

10

Total14215569

103225136121111150

1212

Events721232531

26

Total13615870

103271214126110149

1337

Weight25.9%7.2%5.5%9.3%

10.1%7.2%

18.1%11.1%5.6%

100.0%

M-H, Fixed, 95% CI0.53 [0.15, 1.87]1.54 [0.25, 9.34]0.33 [0.01, 8.32]0.20 [0.01, 4.14]0.40 [0.04, 3.86]0.31 [0.01, 6.53]0.20 [0.02, 1.75]0.32 [0.03, 3.17]0.33 [0.01, 8.14]

0.44 [0.22, 0.87]



B

C

Figure 2 (A) Postoperative inguinal hernia recurrence. (B) Postoperative inguinal hernia recurrence; 2 trials with small sampleexcluded from analysis (Sanjay [2006] and Gunal [2007]). (C) Postoperative inguinal hernia recurrence; 1 trial with the shortest folwas excluded from analysis (Nienhuijs [2007] was excluded). (D) The Egger test publication bias plot for postoperative recurrence apreperitoneal and Lichtenstein procedures. Using the Egger test, t .06; P .523; and 95% CI, 1.905346 to 1.033382 [includes 0]no obvious publication bias was detected.

773J. Li et al. Preperitoneal and Lichtenstein techniques in inguinal hernias


6/11

Hematomas and seromas

Ten studies1524 reported the incidence of hematomas.The xed-effects model was used because of the heteroge-neity (P .24, I 2 22%). The results showed that therewas no signicant difference in the incidence of hematomasbetween the preperitoneal and Lichtenstein repair groups(OR 1.04; 95% CI, .661.64; Fig.4).

Wound infection

Seven studies15,16,1921,23,24 reported wound infection af-

ter surgery. The main meta-analysis with the xed-effectsmodel showed no statistically signicant difference betweenthe 2 groups (RD .01; 95% CI, .00 to .03). The heter-ogeneity was not signicant (P .27, I 2 21%, Fig. 5).

Testicular problems

Figure 6 shows the testicular problems. Seven studieswere included,1416,19,2123 and the xed-effects model wasused because of the heterogeneity (P .18, I 2 34%). The

results showed no signicant difference in testicular prlems between the 2 groups (OR .67; 95% CI, .321.42

Urinary problems

Five studies14,16,17,21,22 reported urinary problems (iurinary retention/infection). The xed-effects model wused because of the heterogeneity (P .71, I 2 0%). Theresults showed that there was no signicant differenceurinary problems between the 2 groups (OR.83; 95% CI.461.53; Fig. 7).

Numbness

The meta-analysis showed that there was no statisticasignicant difference in postoperative numbness (OR .50; 95% CI, .181.43). The heterogeneity of the sties14,16,18,23 was signicant (P .01, I 2 74%), and thrandom-effects model was used.

Inguinal parenthesis

The results of the studies that included information abinguinal parenthesis14,19,21 indicated that there was no diference in the incidence of inguinal parenthesis betweenpreperitoneal and Lichtenstein groups (OR .82; 95% CI.145.02).

Operative time

The analysis results of the operative time between the pperitoneal and Lichtenstein groups showed that there wasstatistically signicant difference (mean difference

1.94%; 95% CI, 5.41 to 1.53).

Comments

Tension-free hernia repair has reduced the incidencerecurrence. Although the recurrence rate after tension-f

Egger's publication bias plot

s t a

n d

a r

d i z

e d

e f f

e c

t

precision0 .5 1 1.5

-2

-1

0

1

D

Figure 2 Continued

Study or SubgroupBerrevoet F 2010Dalenback J 2009Mayagoitia JC 2006Muldoon RL 2004Nienhuijs S 2007Sanjay P 2006Vironen J 2006

Total (95% CI)Total eventsHeterogeneity: Tau = 1.17; Chi = 30.77, df = 6 (P < 0.0001); I = 80%Test for overall effect: Z = 1.26 (P = 0.21)

Events441

10174

18

58

Total1421551361218231

150

817

Events43467

345

12

111

Total1361582141268433

149

900

Weight15.1%13.1%

9.4%15.5%17.1%13.1%16.7%

100.0%

M-H, Random, 95% CI0.06 [0.02, 0.18]1.02 [0.25, 4.15]0.26 [0.03, 2.16]1.53 [0.56, 4.16]0.38 [0.19, 0.77]0.83 [0.20, 3.42]1.56 [0.72, 3.36]

0.55 [0.22, 1.39]

oitaRsddOoitaRsddOnietsnethciLlaenotir eper PM-H, Random, 95% CI


Figure 3 Chronic pain after inguinal hernia repair.

http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-


7/11

repair was as low as 2% to 5% recently,26 other variablessuch as postoperative pain and discomfort gained moreattention considering the patients quality of life after sur-gery. There is still an ongoing debate on what the preferredtechnique is in the treatment of inguinal hernia. Commonlyused tension-free repair techniques include the Stoppa pro-cedure, the Kugel technique, the PHS procedure, Gilbertprocedure, mesh plug repairs, and laparoscopic hernia re-pairs.14,19,20 Among these inguinal hernia repair techniques,the meshes were placed in 2 different positions: either theanterior or posterior (preperitoneal space) layer.

Some surgeons prefer the anterior subaponeurotic tech-nique because it is technically easier and, when performedcorrectly, is associated with very low recurrence rates,6,27whereas others state that all the anterior approaches involvean extensive dissection (especially in the Lichtenstein po-cedure) of the inguinal canal; however, an open preperito-neal dissection approach might have the benet of a mesh inthe preferred preperitoneal space, with limited inguinal ca-nal dissection, but without the disadvantages of an endo-scopic procedure.

Until now, no consensus has been reached regardingthe best surgical approach to inguinal hernia repair,28,29

and there has been no meta-analysis comparing thestechniques published in the English literature. In present study, we combined several preperitoneal teniques in 1 group including the Kugel, Read-Rives, Nhus, and Tipp procedures and PHS because all thtechniques involve the preperitoneal placement of mesh and have the same clinical signicance. In Prepair, the upper part of the mesh is placed in the ingucanal; however, the anterior inguinal canal dissectionlimited. Furthermore, the large and lower important pis placed in the preperitoneal place, with the main aimpreventing any form of hernia recurrence through myopectineal orice.17,20 Therefore, there are no clincally relevant differences in these preperitoneal produres. Further subgroup analysis would only hinder statistical evaluation. The Lichtenstein operation is most widely accepted anterior tension-free approach,we used the Lichtenstein procedure as the control groin the present meta-analysis.

In this meta-analysis, more recurrence was found in Lichtenstein group compared with the preperitoneal groThe recurrence after inguinal hernia repair may be situanear the pubic tubercle, through the internal ring, or lat

Study or SubgroupBerrevoet F 2010Dalenback J 2009Dogru O 2006Gunal O 2007Koning GG 2011Mayagoitia JC 2006Muldoon RL 2004Nienhuijs 2005Sanjay P 2006Vironen J 2006


Events2

1521419112

38

Total1421556939

22513612111131

150

1179

Events480131730

11

38

Total1361587042

27121412611033

149

1309

Weight11.0%19.5%1.3%2.6%7.3%2.1%

17.3%8.1%1.3%

29.6%

100.0%

M-H, Fixed, 95% CI0.47 [0.08, 2.62]2.01 [0.83, 4.88]

5.22 [0.25, 110.78]1.08 [0.07, 17.86]

1.62 [0.36, 7.30]1.58 [0.10, 25.44]

1.37 [0.49, 3.79]0.32 [0.03, 3.17]

3.30 [0.13, 83.97]0.17 [0.04, 0.78]

1.04 [0.66, 1.64]



Figure 4 Hematoma after hernia repair.

Study or SubgroupDalenback J 2009Dogru O 2006Mayagoitia JC 2006Muldoon RL 2004Nienhuijs 2005Sanjay P 2006Vironen J 2006


Events6100

1223

24

Total15569

13612111131

150

773

Events3020812

16

Total158

70214126110

33149

860

Weight19.4%8.6%

20.6%15.3%13.7%4.0%

18.5%

100.0%

M-H, Fixed, 95% CI0.02 [-0.02, 0.06]0.01 [-0.02, 0.05]

-0.01 [-0.03, 0.01]0.00 [-0.02, 0.02]0.04 [-0.04, 0.11]0.03 [-0.07, 0.14]0.01 [-0.02, 0.04]

0.01 [-0.00, 0.03]

Preperitoneal Lichtenstein Risk Difference Risk DifferenceM-H, Fixed, 95% CI

-0.1 -0.05 0 0.05 0.1Favours preperitoneal Favours Lichtenstein

Figure 5 Wound infection.

http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-


8/11

to the mesh. Recently, evidence was published suggestingthat recurrent femoral hernias are 15 times more frequentthan primary femoral hernias,30 and these recurrences occurearlier than inguinal recurrences, suggesting the femoralhernia is overlooked at the primary operation. Furthermore,it has been reported that the incidence of femoral herniasafter preperitoneal repair is half that observed after Lich-tenstein repair, which also proves the advantage of thepreperitoneal approach in this situation.30 The myopetinealorice is a large potential area of weakness in the lowerabdominal wall that is closed by the fascia transversalis withthe inguinal above and femoral canal below and transversedby the inguinal ligament and permits inguinal and femoralhernias. All the listed preperitoneal repair approaches in thismeta-analysis (eg, Kugel, Tipp, PHS, and so on), closeweakness at the myopectineal orice completely rather thanpartly in its anterior inguinal portion (as in the Lichtensteinapproach). In the present meta-analysis, femoral hernia re-currence was clearly identied in only 1 trial.21 Most of therecurrences in the Lichtenstein group were inguinal herniasrather than additional femoral hernias. This result is consis-tent with the observation of Muldoon et al,16 who pointedout that the early failure in the Lichtenstein series waspresumed to be secondary to surgical error. Shulman et al,27from the Lichtenstein Clinic states that it is not an onlaybut an inlay technique because the prosthesis lies beneath

the external oblique aponeurosis, and Kux31 also believethis is the right layer for the patch.

Although postoperative recurrence was a failure of guinal hernia repair, some authors regarded chronic paina more severe complication than recurrence because ofincapacitating character.14 Chronic pain has signicant efects on all daily activities, including walking, workisleep, mood, relationships with other people, and the geral enjoyment of life.32 The exact incidence of chronic pais unknown. Well-conducted, large, and unselected epimiologic studies suggest that about 20% of patients ainguinal hernia repair are affected with chronic pain.30,3234Five issues have been addressed to minimize the postopative pain including using a small incision, minimal disstion around the inguinal nerves, a better location of the min the preperitoneal space, minimal xation of the mesh, a lesser amount of material to prevent severe local inmation and brosis around the nerves and the cord strtures during tissue ingrowth.17 Researchers also imply thearly postoperative pain intensity can reliably predict likelihood of postoperative chronic pain, and the pain scoduring the rst 14 days correlated well with the pain scoat the long-term follow-up.24

The Lichtenstein procedure was reported with an indence of chronic pain more than 15%,32 and in this metaanalysis no difference in chronic pain was detected betw

Study or SubgroupDalenback J 2009Dogru O 2006Gunal O 2007Mayagoitia JC 2006Muldoon RL 2004Nienhuijs S 2007Vironen J 2006


Events0100216

10

Total155

6939

136121

82150

752

Events1170502

16

Total1587042

21412684

149

843

Weight8.8%5.8%

42.4%

28.6%2.9%

11.4%

100.0%

M-H, Fixed, 95% CI0.34 [0.01, 8.35]

1.01 [0.06, 16.55]0.06 [0.00, 1.09]

Not estimable0.41 [0.08, 2.14]

3.11 [0.12, 77.46]3.06 [0.61, 15.42]

0.67 [0.32, 1.42]



Figure 6 Testicular problems after inguinal hernia repair.

Study or SubgroupBerrevoet F 2010Dalenback J 2009Gunal O 2007Muldoon RL 2004Nienhuijs S 2007


Events91181

20

Total14215539

12182

539

Events841

110

24

Total13615842

12684

546

Weight33.2%17.1%4.1%

43.6%2.1%

100.0%

M-H, Fixed, 95% CI1.08 [0.41, 2.89]0.25 [0.03, 2.26]

1.08 [0.07, 17.86]0.74 [0.29, 1.91]

3.11 [0.12, 77.46]

0.83 [0.46, 1.53]



Figure 7 Urinary retention/infection after inguinal hernia repair.

http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-


9/11

the Lichtenstein and preperitoneal approaches. As Berre-voet et al suggested,7 chronic pain was affected not only bythe position of the mesh but also by the length of theincision, the extent of the dissection, and the need for meshxation.

Hematomas and seromas are potential complications of placing the mesh in the preperitoneal layer, which wereaddressed by laparoscopic repair. However, in our meta-analysis, the incidence of hematomas and seromas whenusing the preperitoneal approach was not signicantly dif-ferent from that when using the Lichtenstein repair. Simi-larly, in this meta-analysis, no differences in urinary prob-lems (ie, urinary retention), numbness, wound infection,testicular problems, or parenthesis were found between thepreperitoneal and Lichtenstein groups.

The evaluation of long-term complications in the meta-analysis of randomized controlled trials is still difcultalthough the overall follow-up rates were indeed high,reaching above 95% in this meta-analysis. However, mostof the follow-up periods were of a short duration (Table 1).Moreover, the mode of examination (eg, questionnaire, tele-phone interview, clinical examination, or ultrasound or sur-gical exploration) and the blinding status of the investiga-tors tend to be unclear. These problems might affect therecurrence rate after hernia repair.

This study also had other limitations including the factthat there was heterogeneity among the trials in this meta-analysis (Table 1). The rst possible cause of heterogeneityin the included trials would be the different repair method inthe preperitoneal group. The second possible cause of het-erogeneity would be the different anesthesia type becauselocal epidural anesthesia and general anesthesia were allused in these trials. Third, all these trials were performed bydifferent surgeons. Also, the follow-up time of several out-comes in these trials was not consistent, which could lead tohigh performance bias and measuring bias.

Based on the present meta-analysis, we concluded thatfor surgeons who prefer an open procedure, the preperito-neal approach is a feasible alternative for the standard Lich-tenstein procedure, with similar postoperative complicationrates and potentially less postoperative recurrence. How-ever, more trials with longer follow-up evaluations are re-quired to strengthen this evidence.

References

1. Heikkinen TJ, Haukipuro K, Hulkko A. A cost and outcome compar-ison between laparoscopic and Lichtenstein hernia operations in aday-case unit. Surg Endosc 1998;12:1199203.

2. Herniorrhaphy LI. A personal experience with 6,321 cases. Am J Surg1987;153:5538.

3. Frnneby U, Sandblom G, Nordin P, et al. Risk factors for long-termpain after hernia surgery. Ann Surg 2006;244:2129.

4. Bay-Nielsen M, Perkins FM, Kehlet H, et al. Pain and functionalimpairment 1 year after inguinal herniorrhaphy: a nationwide ques-tionnaire study. Ann Surg 2001;233:17.

5. Frnneby U, Sandblom G, Nordin P, et al. Risk factors for long-pain after hernia surgery. Ann Surg 2006;244:2129.

6. Amid PK, Shulman AG, Lichtenstein IL. A critical evaluation oLichtenstein tension-free hernioplasty. Int Surg 1994;79:769.

7. Rignault DP. Preperitoneal prosthetic inguinal hernioplasty throuPfannenstiel approach. Surg Gynecol Obstet 1986;163:4658.

8. Stoppa R, Wantz GE. Henri Fruchaud WGE (18941960): a mabravery, an anatomist, a surgeon. Hernia 1988;2:457.

9. Champault G, Bernard C, Rizk N, et al. Inguinal hernia repairchoice of prosthesis outweighs that of technique. Hernia 20071258.

10. Kugel RD. Minimally invasive, non-laparoscopic, preperitonand sutureless, inguinal herniorrhaphy. Am J Surg 1999;178:2302.

11. Gilbert AI, Young J, Graham MF, et al. Combined anterior posterior inguinal hernia repair: intermediate recurrence rates three groups of surgeons. Hernia 2004;8:2037.

12. Higgins JPT, Green S, eds. Cochrane Handbook for Systematicviews of Interventions, version 5.0.1 Chichester, United Kingdom:Cochrane collaboration; 2008.

13. Egger M, Smith GD, Altman DG. Systematic Reviews in Health Meta-Analysis in Context. 2nd edn. London: BMJ; 2001.

14. Nienhuijs S, Staal E, Keemers-Gels M, et al. Pain after open pretoneal repair versus Lichtenstein repair: a randomized trial. WJ Surg 2007;31:17517.

15. Dogru O, Girgin M, Bulbuller N, et al. Comparison of KugelLichtenstein operations for inguinal hernia repair: Results of a spective randomized study. World J Surg 2006;30:34650.

16. Muldoon RL, Marchant K, Johnson DD, et al. Lichtenstein vs anpreperitoneal prosthetic mesh placement in open inguinal herniapair: a prospective, randomized trial. Hernia 2004;8:98103.

17. Berrevoet F, Maes L, Reyntjens K, et al. Transinguinal preperitomemory ring patch versus Lichtenstein repair for unilateral inguhernias. Langenbecks Arch Surg 2010;395:55762.

18. Koole D, de Jongh MA, de Schipper JP, et al. The transingupreperitoneal hernia correction vs Lichtensteins technique; is Ttop? Hernia 2011;15:1922.

19. Prieto-Daz JC, Chvez E, Surez D, Cisneros HA, et al. Predicfactors comparison of complications and recurrences in three tensfree herniorraphy techniques. Hernia 2006;10:14751.

20. Sanjay P, Harris D, Jones P, et al. randomized controlled trial cparing prolene hernia system and Lichtenstein method for inguhernia repair. ANZ J Surg 2006;76:54852.

21. Dalenbck J, Andersson C, Anesten B, et al. Prolene hernia sysLichtenstein mesh and plug-and-patch for primary inguinal herepair: 3-year outcome of a prospective randomized controlled tHernia 2009;13:1219.

22. Gnal , zer S, Grleyik Bahebas T. Does the approach togroin make a difference in hernia repair? Hernia 2007;11:429

23. Vironen J, Nieminen J, Eklund A, et al. Randomized clinical triLichtenstein patch or prolene hernia system for inguinal hernia re

Br J Surg 2006;93:339.24. Nienhuijs SW, Van Oort I, Keemers-Gels ME, et al. Randomiclinical trial comparing prolene hernia system, mesh plug repairLichtenstein method for open inguinal hernia repair. Br J Surg 292:338.

25. Kingsnorth AN, Wright D, Porter CS, et al. Prolene hernia syscompared to Lichtenstein patch: a randomised double blind studshort term and medium term outcomes in primary inguinal herepair. Hernia 2002;6:1139.

26. Amid PK, Shulman AG, Open LIL. Tensionfree repair of innal hernias: the Lichtenstein technique. Eur J Surg 1996;44753.

27. Shulman AG, Amid PK, Lichtenstein IL. Mesh between the obmuscles is simple and effective in open hernioplasty. Am Surg 161:3267.

28. Mokete M, Earnshaw JJ. Evolution of an inguinal hernia surpractice. Postgrad Med J 2001;77:18890.

http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-


10/11

29. Read RC. Milestones in the history of hernia surgery: prosthetic repair.Hernia 2004;8:814.

30. Bay-Nielsen M, Kehlet H, Mikkelsen T. Femoral hernia after inguinalherniorrhaphy. Br J Surg 2002;89:4868.

31. Kux M. Anatomy of the groin: a view from the surgeon. In: Fitzgib-bons RJ, Greenberg AG (eds): Nyhus and Condons Hernia. 5th edn.Philadelphia, PA: J B Lippincott, 2002:4553.

32. Hair A, Duffy K, Mclean J, et al. Groin hernia repair in ScotlandSurg 2000;87:17226.

33. Poobalan AS, Bruce J, Smith WC, et al. Chronic pain and qualilife following open inguinal hernia repair. Br J Surg 2001;88:112

34. Bay-Nielsen M, Perkins FM, Kehlet H, et al. Pain and functiimpairment 1 year after inguinal herniorrhaphy: a nationwide qtionnaire study. Ann Surg 2001;233:17.



11/11

2012 Elsevier

jurnal 1 kedokteran

Documents