ReviewOpen preperitoneal groin hernia repair with mesh: A qualitative systematic review
Introduction
Optimal repair of inguinal hernia is still a discussion among surgeons. Important issues are recurrences and especially chronic pain, and in order to find the best way to repair inguinal hernias, new randomized clinical studies are still being conducted.1, 2, 3 Placement of the mesh in relation to nerves is a possible contributing factor to chronic postoperative pain.4 Laparoscopic repair of inguinal hernia reduces the risk of early and chronic pain compared to open anterior techniques.5 The major difference between the open anterior repairs and the laparoscopic repairs is the plane of dissection and placement of the mesh. In the open anterior repair, the surgeon dissects through the inguinal canal and places the mesh close to the nerves and structures in this area. On the contrary, when placing the mesh behind the muscles of the abdominal wall in the preperitoneal plane posteriorly to the transversalis fascia, the dissection of the inguinal canal as well as the placing of mesh in close proximity to the nerves can be avoided. Thus, preperitoneal mesh placement might be beneficial regarding chronic pain compared to an anterior approach. When operating on the posterior side of the fascia transversalis the ilioinguinal and the hypogastric nerves are only present in the most lateral part of the field. Furthermore, there is often fatty tissue protecting the nerves in this area, unless the patient is very skinny.
Preperitoneal mesh placement can be performed by a laparoscopic approach or by an open preperitoneal technique. When choosing the optimal open procedure, open preperitoneal techniques needs therefor to be considered. Several open surgical methods have been described where the purpose is to place the mesh in the preperitoneal plane through an open access.6, 7, 8, 9 The authors of a Cochrane review chose to only include three methods,10 but since that review, additional methods have been presented. The aim of this study was to describe open preperitoneal repairs with emphasis on the techniques and the published clinical evidence.
Section snippets
Material and methods
This systematic review was conducted in accordance with the PRISMA statement,11 and the PRISMA-P was used to guide the protocol.12 The study was registered on PROSPERO (ID no. CRD42016017325). The following criteria were used to select studies: Patients had to have an inguinal hernia and receive surgical treatment with an open procedure where the mesh was placed in the preperitoneal space. The follow-up of the patients had to be at least one month and the language had to be either English or
Results
The systematic search identified 2296 records, 647 records were removed for being duplicates (Fig. 1). Reports were screened on title and abstract. Hereby, 162 reports were found potentially relevant, and full texts were retrieved. A total of 67 reports were included for this review, describing nine different methods of preperitoneal repair of inguinal hernias, see Table 1.
The number of patients operated preperitoneally varied from 1914 to 956.15 Several different meshes and fixation methods
Discussion
This systematic review identified nine methods of placing a mesh in the preperitoneal space through an open approach. In general, the results regarding pain, complications and recurrence rates are promising. However, some of the reports were from specialized centers, especially regarding the newest techniques. The available evidence is generally from cohorts and only few randomized clinical trials. Furthermore, there is a lack of head-to-head comparisons of different open preperitoneal
Conclusion
In general, the benefit of these preperitoneal techniques is the avoidance of the anterior plane where the nerves are vulnerable to surgical trauma during the operation and afterwards are vulnerable to compression and fibrosis from the mesh in the healing process. There are concerns when operating in the preperitoneal space because delicate structures are located here such as large vessels and the bladder. Bladder injuries were reported by several authors and with several techniques. Therefore,
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