Introduction

UpToDate, the international guidelines for inguinal hernioplasty are still considering Liechtenstein technique as the reference standard of inguinal hernioplasty [1], yet about 1—3% of patients suffer from postoperative chronic pain and foreign body sensation which is suspected to be caused by sutured mesh fixation [2, 3], therefore numerous advances have been introduced in the field of inguinal hernioplasty aiming at decreasing these burdens [4, 5]; among them is using of self-gripping mesh implants [6, 7].

Self-gripping mesh implants have been introduced since the beginning of the new millennium inclined to overcome such causes of postoperative pain through avoiding the use of a non-locking mesh implants which had to be reapproximated with sutures after encircling the cord structures during laparoscopic inguinal hernioplasty [8] and even during open inguinal hernioplasty by Liechtenstein, which dramatically reduced operative-time [3].

Furthermore, advances have extended to involve methods of spreading self- gripping mesh implants rather than the conventional method of mesh placement around the spermatic cord by tailoring mesh around the cord which results in mesh fixation to undesired surrounding tissues and upon separation from these tissues leads to hematoma and oozing due to tissue micro-trauma. The four-fold and rolling techniques during open inguinal hernioplasty [9], mesh deployment technique during Totally Extraperitoneal (TEP) inguinal hernia repair [10, 11] and Swiss-roll folding during Transabdominal Pre-peritoneal (TAPP) repair [12], not only bypassed such drawbacks but in addition significantly reduced mesh implantation time, incidence of post-operative pain and the duration of postoperative analgesic intake [13].

Alternative mesh fixation methods such as absorbable elastic tacks are associated with less incidence of postoperative pain and neuralgia [14]. Furthermore, non-absorbable tacks were found to results in no chronic discharging sinuses nor causing mesh failure [15].

Objectives: assessing the results of using two kinds of mesh implants: self-gripping mesh implants and polypropylene mesh fixed by tacks in open inguinal hernioplasty by Liechtenstein upon the way of mesh fixation in both groups.

Materials and methods

Our study was done upon 100 patients (n=100) with inguinal hernia which had anterior inguinal hernioplasty at the clinical bases of the department of operative surgery and clinical anatomy named after I.D. Kirpatovsky of medical institute of People’s Friendship university of Russia named after Patrice Lumumba (RUDN university) in 5 years.

Our patients were divided into two equal groups (n=50); Group A; we used Adhesix ^TM self-gripping mesh implants (fig. 1), and Group B; we used polypropylene mesh implants fixed by elastic absorb tack fixing device (fig. 2).

Fig. 1. Self-gripping mesh implant intraoperatively.

Fig. 2. Fixation of a polypropylene mesh with elastic tacks intraoperatively.

In group A, the mean age was 54.6 years (Me=54.6) for 46 (92%) male patients and 4 (8%) female patients. From them, 34 (68%) patients were diagnosed with a left-sided inguinal hernia and 16 (32%) patients were diagnosed with a right-sided inguinal hernia. In group B — the average age was 50.1 years (Me=50.1) for 48 (96%) male patients and 2 (4%) female patients. Of these, 36 (72%) patients were diagnosed with a left-sided inguinal hernia and 14 (28%) patients were diagnosed with a right-sided inguinal hernia (Table 1).

Table 1. Distribution of sex, side of inguinal hernia and average age in both groups

Our exclusion Criteria included Patients with bilateral inguinal hernia, patients over 71 years of age and under 21 years of age, pregnant patients, emergency patients and patients with recurrent inguinal hernia.

The comparison criteria for our study included; The duration of the operation, postoperative complications, hospital stays (beds/day) and Complications in six months follow-up.

We used for statistical analysis:

The Mann—Whitney test was used for independent samples [(P-value (p<0.0001). Mean (M), Median (Me), standard deviation (Sd)], for statical processing of operative-time (by minutes) and the duration of hospital stays (by beds/day).

The Kruskal—Wallis test for independent samples [(P-value (p<0.0001). Odds Ratio (OR), Confidence Interval (CI)], for statical processing of complications during both the post-operative and the short-term follow-up periods.

Results

1. Time of operation: When we compared the 2 groups by using the Kruskal—Wallis test for independent samples. The analysis showed significant differences in the duration of the operation (p<0.0001).

The results were distributed as the next report:

Group A; using self- gripping mesh implants — Mean=28.14, Me=28.5, Sd=7.23 (by minutes).

Group B; using polypropylene mesh fixed by elastic tacks — Mean=36.34, Me=35.0, Sd=8.64 (by minutes).

So, we found that using self-gripping mesh implants have decreased the time of operation by more than 8 minutes in average less than the time of operation when we used polypropylene mesh fixed by elastic tacks (fig. 3).

Fig. 3. Operative-time (in minutes) for both groups.

2. Duration of hospital stays:

When we compared the two groups by using the Kruskal—Wallis test for independent samples.

The report was distributed as follows:

Group A; patients using self-gripping mesh implants — Mean=4.64, Me=5.0, Sd=1.495 (by beds/day).

The analysis showed no significant differences in the duration of hospital stays among both groups; 4.6 beds/days for using self-gripping mesh implants and 4.5 beds/days for using polypropylene mesh fixed by elastic tacks (fig. 4).

Fig. 4. Duration of hospital stays (beds/day) for both groups.

3. Postoperative complications:

For group A; We found in the postoperative period 4 (8%) of the 50 patients with postoperative pain relieved by analgesics, the pain gradually decreased with the help of NSAIDs.

Using self-gripping mesh implants was not associated with postoperative pain (OR=0.067; 95%CI 0.024—0.185; p=0.0001), nor with surgical site infection (OR=1.04; 95%CI 0.98—1.10; p=0.47)

For group B; We found that in the postoperative period in 18 (36%) of the 50 patients with postoperative pain, which gradually decreased with the help of NSAIDs.

Using polypropylene mesh fixed by elastic tacks is not associated with the risk of postoperative pain (OR= 26.00; 95%CI 9.803—68.958; p=0.163), nor with surgical site infection (OR=0.980; 95%CI 0.953—1.008; p=0.314)

Therefore, using self-gripping mesh implants have significantly reduced the incidence of post-operative pain in-comparison to using polypropylene mesh fixed by elastic tacks. No other complications like surgical site infection had been recorded in both groups (Table 2).

Table 2. Number of patients with postoperative complications in both groups

4. Complication within 6 months:

For Group A; All patients were satisfactory without any complications, moreover without any recurrences.

Using self-gripping mesh implants is not associated with chronic pain in the short-term follow-up (OR=0.475; 95%CI 0.052—4.364; p=0.501), nor with foreign body sensation (OR=0.828; 95%CI 0.757—0.906; p=0.002), nor with the formation of seroma (OR=0.980; 95%CI 0.953—1.008; p=0.307)

For group B — we found 17 (34%) patients of the 50 patients with foreign body sensation, without any recurrence.

Using polypropylene mesh fixed by elastic tacks was neither associated with short-term chronic pain (OR=0.95; 95%CI 0.908—0.994; p=0.108), nor with foreign body sensation (OR=1.515; 95%CI 1.242—1.849; p=0.0001), or with the formation of seroma (OR=0.980; 95%CI 0.953—1.008; p=0.314)

That’s why using self-gripping mesh implants was significantly superior to using polypropylene mesh fixed by elastic tacks regarding the incidence of foreign body sensation. No cases of chronic pain or any other complications e.g., seroma formation, or recurrence had been recorded among both groups (Table 3).

Table 3. Number of patients with complications during the six-months follow-up

Discussion

Upon using both self-gripping mesh implants and polypropylene mesh fixed by tacks during inguinal hernioplasty;

Operative-time was significantly reduced with using self-gripping mesh in relation to polypropylene mesh fixed by tacks during both open anterior hernioplasty (p<0.0001) and Trans-Abdominal Preperitoneal laparoscopic inguinal hernioplasty (TAPP) (p<0.0001) [16].

Not a worthy of attention differences was recorded about the duration hospital stays among both groups upon operation by Liechtenstein technique (p=0.777) or even by Trans-Abdominal Preperitoneal laparoscopic inguinal hernioplasty (TAPP) (p=0.651) [17].

Using self-gripping mesh implants have significantly reduced the incidence of post-operative pain in-comparison to using polypropylene mesh fixed by elastic tacks, also didn’t result in any other complications like surgical site infection during open anterior hernioplasty. Indeed, the same results are obtained also during laparoscopic inguinal hernia repair [18].

The incidence of complications during the short-term follow-up; chronic post-operative pain, seroma formation and hernia recurrence upon using self-gripping mesh implants and polypropylene mesh fixed by tacks during both open and laparoscopic hernioplasty are significantly reduced. However, the incidence of foreign body sensation during both techniques was significantly reduced upon using self-gripping mesh implants incomparison to using tacks in both techniques [3, 19].

Conclusion

Self-gripping mesh implants have shown higher efficiency compared with polypropylene mesh fixed by elastic tacks in terms of duration of surgery, acute postoperative pain, and foreign body sensation so we can recommend using self-gripping mesh in practice when the choice of surgeon well be between self-gripping mesh and polypropylene mesh fixed by tacks.

Participation of authors:

Concept and design of the study — Protasov A.V., Mekhaeel M.Sh.F.

Data collection and processing — Mekhaeel M.Sh.F., Salem S.M.A.

Statistical processing of the data — Mekhaeel M.Sh.F.

Text writing — Salem S.M.A., Mekhaeel M.Sh.F.

Editing — Mekhaeel M.Sh.F.

Consent for publication.

Patient were informed verbally and in writing about the study and gave written informed consent.