Randomized clinical trial comparing total extraperitoneal with Lichtenstein inguinal hernia repair (TEPLICH trial).

BACKGROUND: Chronic pain is reported after 10-35 per cent of inguinal hernia operations. The aim was to compare quality of life (QoL) after total extraperitoneal (TEP) and Lichtenstein hernia repairs in the setting of an RCT with operations performed by department-certified hernia surgeons. METHODS: Men aged 30-75 years with an ASA grade I-II primary inguinal hernia were randomized to TEP or Lichtenstein repair. Primary endpoint was pain at 1 year assessed with the Inguinal Pain Questionnaire (IPQ). Clinical examination, IPQ, SF-36® and study-specific questions were recorded before surgery, and at 1 and 3 years. RESULTS: Some 416 patients (202 TEP and 214 Lichtenstein) had surgery; 95·2 per cent completed 1-year and 89·9 per cent 3-year follow-up. At 1 year 'pain during last week' was reported by 6·9 per cent after TEP and by 9·8 per cent after Lichtenstein repair (P = 0·303), and 'pain right now' by 3·7 and 5·9 per cent respectively (P = 0·315). Favourable outcomes for TEP were duration of operation, 30-day complications, time to full recovery, foreign body sensation and sick leave. Groin sensory changes diminished after TEP but increased after Lichtenstein repair. Preoperative QoL was affected, especially in the physical subscales, but was restored to normal after surgery. At 1 and 3 years, 98·3 and 97·4 per cent respectively of the patients were satisfied; 1·6 per cent (6 of 374) suffered a recurrence at 3 years, four after TEP and two after Lichtenstein repair. CONCLUSION: In the medium term, both TEP and Lichtenstein hernia repair had similar outcomes after 1 year, with high rates of patient satisfaction and low rates of chronic pain and recurrence. There were short-term advantages for pain and recovery rate after TEP repair. Registration number: NCT00803985 ( www.clinicaltrials.gov).

Long-term retromuscular and intraperitoneal mesh size changes within a randomized controlled trial on incisional hernia repair, including a review of the literature.

Purpose Ingrowth of fibroblasts in a polypropylene mesh may cause contraction and a later recurrence. We assessed mesh contraction in intraabdominal and retromuscular implantation after incisional hernia repair. METHODS: A cohort of patients within an RCT on laparoscopic (LHR) versus open hernia repair (OHR) had their mesh borders marked with metal clips. X-ray was performed on postoperative day 1 and after 1 year. Total length, width, and dislocation were measured. A tacker fixated large-pore polypropylene mesh was used in LHR, and a retromuscular small-pore heavy-weight mesh was sutured to the midline in OHR. Patient's pain was assessed before surgery and after 1 year. RESULTS: For analysis 37/47 patients remained: 20 LHR and 17 OHR. Hernia defect area was median 41 cm2 in LHR and 25 cm2 in OHR (p < 0.140). Implanted mesh size was 300 cm2 for LHR and 240 cm2 for OHR (p < 0.341). After 1 year the mesh area decreased by 4.4% and 0.5% in LHR and OHR, respectively (p < 0.063). Longitudinal distance decreased by 2.8% in LHR and by 2.6% in OHR (p < 0.269). Transverse distance decreased by 1.6% in LHR but increased by 3.1% in OHR (p < 0.005). Dislocation was seen in four LHR and one OHR. Two recurrent and one port-site hernia were diagnosed after LHR. Measurements between observers were identical in 58% and consensus was made in the remainder. Pain was not correlated to mesh area change. CONCLUSIONS: Mesh contraction after 1 year is not a clinical issue for an intraperitoneal large-pore mesh or a retromuscular small-pore mesh. It is not correlated to postoperative pain.

Negative Pressure Wound Therapy for Treatment of Mesh Infection After Abdominal Surgery: Long-Term Results and Patient-Reported Outcome.

BACKGROUND AND AIMS: Treatment of synthetic mesh infections has previously often resulted in mesh explantation. Negative pressure wound therapy has been used in these situations with encouraging results. The aims of this study were to evaluate wound healing, mesh preservation, and patient-reported outcome after negative pressure wound therapy of mesh infections. MATERIAL AND METHODS: Medical records of patients treated with negative pressure wound therapy for mesh infection and age-matched mesh-operated controls without postoperative complications were scrutinized in a retrospective study. An abdominal wall complaints questionnaire was used to evaluate patient-reported outcome. RESULTS: Of 722 mesh operations performed 2005-2012, negative pressure wound therapy was used for treating postoperative mesh infections in 48 patients. A total of 48 age-matched controls were recruited from patients without wound complications. No differences were found between groups regarding preoperative characteristics. The following peroperative characteristics were significantly more frequent in the negative pressure wound therapy group: emergency operation, dirty/infected surgical field, surgical techniques other than laparoscopic intraperitoneal onlay mesh repair, implantation of more than one mesh, larger mesh size, longer duration of surgery, and mesh not completely covered with anterior rectus fascia. The entire mesh was salvaged in 92%, while four meshes were partly excised. Wounds healed in 88% after a median of 110 (range 3-649) days. In total, 85% in the negative pressure wound therapy group and 75% in the control group answered the questionnaire. There were no significant differences regarding pain, other abdominal wall symptoms, and satisfaction with the final result in favor of the controls. CONCLUSION: No mesh had to be explanted and wound healing was achieved in the majority of patients when negative pressure wound therapy was used for treatment of mesh infections. However, time to healing was long, and numerous procedures were sometimes needed. Positive long-term outcome was more frequently reported among controls.

Quality of life and hernia development 5 years after open abdomen treatment with vacuum-assisted wound closure and mesh-mediated fascial traction.

PURPOSE: To report incisional hernia (IH) incidence, abdominal wall (AW) discomfort and quality of life (QoL) 5 years after open abdomen treatment with vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). METHODS: Five-year follow-up of patients included in a prospective study 2006-2009. The protocol included physical examination, patient interview, chart review, questionnaires on abdominal wall and stoma complaints and the SF-36 questionnaire. RESULTS: Fifty-five (12 women, 43 men; median age 70 years) of 111 included patients were alive. Follow-up rate was 91 %. Cumulative IH incidence during the whole study was 62 %. One-third of the IHs was repaired. At 5-year follow-up 59 % of IHs were clinically detectable. AW symptoms were equivalent in patients with (15/23) and without (11/21) IH (p = 0.541). SF-36 scores were lower than population mean for component scores and all subscales except bodily pain. Patients with major co-morbidity had lower physical component score [31.6 (95 %, CI 25.6-37.4)] compared to those without [48.9 (95 %, CI 46.2-51.4)]. Major co-morbidity was not associated with IH (p = 0.56), AW symptoms (p = 0.54) or stoma (p = 0.10). Patients with IH or other AW symptoms had similar SF-36 results compared to those without, whereas patients with a stoma had >5 point lower mean scores for general health, social function and physical component score compared to those without. CONCLUSIONS: VAWCM treatment results in high incidence of IH. However, at five years, there was no detectable difference in abdominal wall complaints and QoL in patients with IH compared to those without. Lower QoL appeared mainly to be associated with the presence of major co-morbidity.