Description of the condition
Inguinal hernia repair is the most frequent operation in general surgery. Rutkow 2003 reports 800,000 groin hernia repairs in the US in 2003. The Lichtenstein technique, first described in 1986 (Lichtenstein 1986), is the standard open tension-free method of inguinal hernia repair and is used worldwide. In this method, a synthetic mesh is placed over the defect so that the hernia is repaired without the need to pull the tissues together under tension. The advantages of this procedure are that it is technically easy, is associated with lower recurrence rates, has shorter recovery times compared with tension repair (Grant 2002; Nordin 2002), and can be performed using local anaesthetic as a day procedure. However, postoperative chronic pain is frequently reported following mesh-based inguinal hernia repair, from 11.0% to as high as 40.5% (Eklund 2010; MRC Group 1999; Nienhuijs 2007; Nikkolo 2012; Paajanen 2002; Willaert 2012), and has a significant impact on quality of life (van Hanswijck 2008). It is difficult to overcome this problem, as surgery and the use of additional local analgesics haven't shown a clear benefit to the patients (Nienhuijs 2007).
Description of the intervention
Sutures are generally used to secure the prosthetic mesh but may contribute to chronic pain or other problems, such as numbness or groin discomfort, presumably through irritation or nerve compression (Heise 1998). This has prompted the development of less traumatic means of mesh fixation. The original technique for fixation of mesh in Lichtenstein hernioplasty used non-absorbable sutures. Since then, other surgeons have described using absorbable sutures (Paajanen 2002), various tissue glues (Canonico 2005), or novel self-fixing meshes (Kapischke 2010). These methods aim to reduce chronic neuropathic pain and simultaneously speed up the surgical procedure. Because the possibility of trapping nerves with suturing is eliminated, direct nerve irritation is reduced. Therefore, mesh fixation with glue (tissue adhesive) seems an optimal choice to reduce postoperative chronic pain.
How the intervention might work
Fibrin glue and N-butyl-2-cyanoacrylate are two of the most commonly used products for mesh fixation. Fibrin glue is a bio-degradable adhesive that combines human-derived fibrinogen and thrombin. In addition to its haemostatic action, the fibrinogen component gives the product tensile strength and adhesive properties (Katkhouda 2001), as well as promoting fibroblast proliferation (Zieren 1999). N-butyl-2-cyanoacrylate is a new generation of cyanoacrylate that has been used as a surgical tissue adhesive since the 1960s. It polymerises at room temperature and results in lower toxicity and fewer inflammatory reactions compared with cyanoacrylate (Levrier 2003; Montanaro 2001).
Why it is important to do this review
As inguinal hernia repair is performed so frequently and often associated with postoperative chronic pain, even relatively modest improvements in clinical outcomes would have a significant medical and economic impact. Comparison between mesh fixation with sutures and fixation with glue may support change in current surgical practice, if reduced postoperative chronic pain is demonstrated with fixation with glue.
However, there is concern of increased recurrence associated with glue fixation because fibrin glue is fully absorbed within 2 weeks of application (Petersen 2004). Several randomised trials and observational studies compare the two methods (Campanelli 2012; Helbling 2003; Negro 2011; Paajanen 2011), but consensus regarding which method is better has not been reached.
Thus, an evaluation of the use of mesh fixation with glue would be very useful.