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KEYWORDS: Abstract
Meta-analysis; BACKGROUND: The objective of this study was to examine the outcomes of comparisons between
Evidence based; laparoscopic and open mesh repairs in the setting of recurrent inguinal hernia.
Publication bias; METHODS: The electronic databases MEDLINE, Embase, Pubmed, and the Cochrane Library were
Recurrent inguinal used to search for articles from 1990 to 2008. The present meta-analysis pooled the effects of outcomes
hernia; of a total of 1,542 patients enrolled into 5 randomized controlled trials and 7 comparative studies, using
Totally classic and modern meta-analytic methods.
extraperitoneal; RESULTS: Significantly fewer cases of hematoma/seroma formation were observed in the laparo-
Transabdominal scopic group in comparison with the Lichtenstein group (odds ratio, .38; .15.96; P .04). A matter
preperitoneal; of great importance is the higher relative risk of overall recurrence in the transabdominal preperitoneal
OPM; group compared with the totally extraperitoneal group (relative risk, 3.25; 1.327.9; P .01).
Open preperitoneal CONCLUSIONS: Laparoscopic versus open mesh repair for recurrent inguinal hernia was equivalent
mesh; in most of the analyzed outcomes.
Stoppa; 2010 Elsevier Inc. All rights reserved.
Giant prosthetic
reinforcement of the
visceral sac;
Lichtenstein procedure
The repair of recurrent inguinal hernia is a demanding inal wall has been established during the past decades.2 The
procedure accounting for 10% to 15% of inguinal hernia mesh can be placed either anteriorly under the external
repairs.1 The use of mesh for reinforcement of the abdom- aponeurosis (interparietal) or posteriorly (preperitoneal).3,4
Georgia Dedemadi designed the study, analyzed data, and was Anagnostou designed the study and was responsible for critical revision.
responsible for acquisition of data; George Sgourakis designed the All authors have read and approved the final version of the manuscript
study, analyzed data, and was responsible for acquisition of data; to be published. Georgia Dedemadi and George Sgourakis take respon-
Arnold Radtke analyzed data and was responsible for acquisition of sibility for the integrity of the data and the accuracy of the data analysis.
data; Alexandros Dounavis designed study and was responsible for * Corresponding author. Tel.: 30-210-6033361; fax: 30-210-
acquisition of data; Ines Gockel drafted the manuscript and was respon- 7514179.
sible for substantial review; Ioannis Fouzas was responsible for critical E-mail address: gdedemadi@yahoo.gr
review and drafting the manuscript; Constantine Karaliotas designed Manuscript received June 9, 2009; revised manuscript December 1,
the study and was responsible for critical revision; and Evangelos 2009
0002-9610/$ - see front matter 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjsurg.2009.12.009
292 The American Journal of Surgery, Vol 200, No 2, August 2010
Issues concerning the most appropriate treatment are still keyword lists: randomized controlled trials, double-blind, re-
under consideration.57 The Lichtenstein technique com- current inguinal hernia, totally extraperitoneal, transabdominal
monly is used for the repair of primary inguinal hernia and preperitoneal,OPM, open preperitoneal mesh, Stoppa, giant
may be suitable for repairing recurrent inguinal hernia if the prosthetic reinforcement of the visceral sac, and Lichtenstein
defect is larger than 4 cm.8 However, the technical ease and procedure. Where it was applicable the earlier-mentioned
low recurrence rate of this technique has lead to its wide- terms were used in [MESH] (PubMed and the Cochrane
spread use to repair recurrent inguinal hernias of any Library), otherwise the terms were combined with AND/
size.9,10 Laparoscopic repairs are based on the same princi- OR and asterisks. In addition, the abstracts from na-
ples as preperitoneal mesh repair and therefore combine the tional and international conferences were searched using
advantages of open preperitoneal repair with those of min- online search engines corresponding to the particular
imal access surgery.11,12 There is a major body of criticism conference.
concerning laparoscopic hernia repair.1315 The main argu- The scheme for this repetitive search is shown in Figure 1.
ments address the potential long-term recurrence rate, in- After the initial screen additional criteria were imposed as
traoperative complications, and the need for general anes- follows: (1) adult population undergoing recurrent hernia
thesia.1,16 Conversely, laparoscopic procedures may be repair, (2) elective surgeries, (3) Nyhus class II to III her-
associated with less postoperative pain, simultaneous repair nias, and (4) analysis on an intention-to-treat basis.
of bilateral and other concurrent less-frequent types of in-
guinal hernia, short hospital stay, and early return to normal Data extraction
activities.13,17,18 To date, the effectiveness of the treatment
modalities, concerning short- and long-term results for re- Two authors (G.D., G.S.) independently selected stud-
current inguinal hernia, has not been compared by meta- ies for inclusion and exclusion, and reached consensus
analysis of published reports. when they did not agree on the initial assignment. The
following variables concerning studies addressing pa-
tients with recurrent hernia repair were recorded: authors,
journal and year of publication, country of origin, trial
Methods duration, participant demographics, and data concerning
complications and follow-up evaluation. Where neces-
Literature search sary, the corresponding authors were contacted to obtain
supplementary information.
All randomized control trials and comparative studies
concerning recurrent hernia repair were identified.1,19 29 Interventions and outcome definition. Definitions were
The electronic databases MEDLINE, Embase, Pubmed, and as follows: early recurrence was defined as hernia recur-
the Cochrane Library were used to search for relevant arti- rence during the first 2 months of follow-up evaluation;
cles published in English from 1990 to 2008 using the totally extraperitoneal (TEP) was defined as laparoscopic
following terms and/or combinations in their titles, abstracts, or hernia repair with extraperitoneal mesh placement; transab-
G. Dedemadi et al. Laparoscopic versus open mesh repair 293
NR not reported.
*RCTs with 3 treatment arms and subsequently 2 comparisons.
When comparing the laparoscopic and the OPM groups, threshold effect was examined by calculating the Spearman
results in terms of hematoma/seroma formation were similar correlation coefficient. No inverse correlation was observed
(Table 4). Sensitivity analysis disclosed that the study by (.000; P 1.000), putting the presence of heterogeneity in
Alani et al26 contributed to the noncombinability of the question. The study by Richards et al24 showed a marginal
studies (P .009, I2 74%). By omitting this study the sensitivity by using resampling tests and bootstrapping to
OPM treatment arm presented fewer cases of hematoma/ generate CIs around the overall cumulative mean effect size
seroma formation (pooled OR, 2.6; 1.49 4.51; P .001). (OR, .4507; bootstrap CI, 1.2274 to .4889).
Funnel plots did not detect any obvious publication bias.
There was no significant difference in terms of urinary Laparoscopic versus Lichtenstein (hematoma/seroma). Het-
infection between the laparoscopic and open treatment arms erogeneity among studies was observed (P .001/I2
(Table 4). Neither heterogeneity nor publication bias was 64.4%), and the threshold effect was examined by calculat-
present. ing the Spearman correlation coefficient. No inverse corre-
The RR of overall recurrence was less in the TEP treat- lation was observed (.754; P .084), putting the presence
ment arm when compared with that of TAPP. Heterogeneity of heterogeneity in question. Resampling tests derived from
and publication bias were absent. 999 iterations and bootstrapping were used to generate CIs
around the overall cumulative mean effect size (OR, .6546;
Analyzing heterogeneity. bootstrap CI, 1.1005 to .0266).
TEP versus Lichtenstein (hematoma/seroma). Heterogeneity Laparoscopic versus OPM (hematoma/seroma). Significant
among studies was observed (P .007/I2 75.1%) and the heterogeneity among studies was observed (P .009/I2
Test for
overall Publication bias Study Favors
Outcome/subgroup Studies N Effect estimate (95% CI) Heterogeneity effect (indicator/P value) quality group
Wound infection 3 294 FE, OR .49 (.122.0) P .379 2 .48 Harbold-Egger: 2A None
bias .84
I2 0% P .489 P .786 1C
Hematoma/seroma 4 344 RE, OR .43 (.091.91) P .007 2 1.24 Egger: 2A None
bias 3.3
I2 75.1% P .264 P .427 2 C
Urinary retention 3 248 FE, OR .47 (.092.42) P .733 2 .3 Egger: bias .3 1 A None
I2 0% P .580 P .923 2 C
Overall recurrence 4 344 FE, RR .48 (.181.33) P .531 2 1.97 Egger: bias .16 2 A None
I2 0% P .160 P .943 2 C
The P values of comparisons are given in the column labeled Test for overall effect and the group favored is depicted in the column labeled Favors
group.
FE fixed-effects model; RE random-effects model; A high-quality studies; C comparative studies.
G. Dedemadi et al. Laparoscopic versus open mesh repair 295
74%), and this threshold effect was evaluated by calculating term laparoscopic (TAPP/TEP) or open repair (Lich-
the Spearman correlation coefficient. An inverse correlation tenstein/OPM)). Probability between studies was .287 and
was observed (.400; P .6) confirming the stated heter- within studies was .076. The total model probability was
ogeneity. A sensitivity analysis disclosed that the study by .088, justifying our comparisons.
Alani et al26 contributed to the noncombinability of the
studies. By omitting this study, the OPM treatment arm
presented fewer cases of hematoma/seroma formation.
Comments
Validating our model of comparisons. Randomization
tests were used to test the significance of our model struct- A meta-analysis of RCTs and comparative studies con-
ure (pooling the effects of different procedures under the cerning patients treated for recurrent inguinal hernia with
Table 4 Comparisons of outcomes between laparoscopic and open procedures and TAPP versus TEP
tions, and recurrence, although this review was based 17. Sayad P, Abdo Z, Cacchione R, et al. Incidence of incipient contralat-
mainly on nonrandomized studies of primary inguinal her- eral hernia during laparoscopic hernia repair. Surg Endosc 2000;14:
5435.
nia repair. 18. Geis WP, Crafton WB, Novak MJ, et al. Laparoscopic herniorrhaphy:
In summary, laparoscopic versus open mesh repairs for results and technical aspects in 450 consecutive procedures. Surgery
recurrent inguinal hernia were equivalent in most of the 1993;114:76572.
analyzed outcomes and particularly for overall recurrence. 19. Mok KT, Wang BW, Chang HT, et al. Laparoscopic versus open
A matter of major importance is the higher RR of overall preperitoneal prosthetic herniorrhaphy for recurrent inguinal hernia.
Int Surg 1998;83:174 6.
recurrence in the TAPP compared with the TEP group. 20. Memon MA, Feliu X, Sallent EF, et al. Laparoscopic repair of recur-
Reports of the long-term follow-up period (up to 10 years) rent hernias. Surg Endosc 1999;13:80710.
of the existing studies or new sufficiently powered random- 21. Jarhult J, Hakanson C, Akerud L. Laparoscopic treatment of recurrent
ized controlled trials are most welcome. inguinal hernias: experience from 281 operations. Surg Laparosc En-
dosc Percutan Tech 1999;9:115 8.
22. Kumar S, Nixon SJ, MacIntyre IM. Laparoscopic or Lichtenstein
repair for recurrent inguinal hernia: one units experience. J R Coll
Surg Edinb 1999;44:3012.
References 23. Beets GL, Dirksen CD, Go PM, et al. Open or laparoscopic preperi-
toneal mesh repair for recurrent inguinal hernia? A randomized con-
1. Neumayer I, Giobbie-Hurder A, Jonasson O, et al. Open mesh versus trolled trial. Surg Endosc 1999;13:3237.
laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004;350: 24. Richards SK, Vipond MN, Earnshaw JJ. Review of the management of
1819 27. recurrent inguinal hernia. Hernia 2004;8:144 8.
2. Collaboration EH. Mesh compared with non-mesh methods of open 25. Feliu X, Torres G, Vinas X, et al. Preperitoneal repair for recurrent
groin hernia repair: systemic review of randomized controlled trials. inguinal hernia: laparoscopic and open approach. Hernia 2004;
Br J Surg 2000;87:854 9. 8:113 6.
3. Lichenstein IL, Shulman AG, Amid PK, et al. The tension-free hemio- 26. Alani A, Duffy F, ODwyer PJ. Laparoscopic or open preperitoneal
plasty. Am J Surg 1989;157:188 93. repair in the management of recurrent groin hernias. Hernia 2006;10:
4. Stoppa RE. The treatment of complicated groin and incisional hernias. 156 8.
World J Surg 1989;13:54554. 27. Dedemadi G, Sgourakis G, Karaliotas C, et al. Comparison of laparo-
5. Jonasson O. Introduction: inguinal hernia management-testing man- scopic and open tension-free repair of recurrent inguinal hernias: a
agement strategies in two clinical trials. J Am Coll Surg 2003;196: prospective randomized study. Surg Endosc 2006;20:1099 104.
735 6. 28. Eklund A, Rudberg C, Leijonmarck CE, et al. Recurrent inguinal
6. Macintyre IM. Best practice in groin hernia repair. Br J Surg 2003; hernia: randomized multicenter trial comparing laparoscopic and Lich-
90:1312. tenstein repair. Surg Endosc 2007;21:634 40.
7. Gianetta E, Cuneo S, Vitale B, et al. Anterior tension-free repair of 29. Kouhia ST, Huttunen R, Silvasti SO, et al. Lichtenstein hernioplasty
recurrent hernia under local anesthesia: a 7-year experience in a teach- versus totally extraperitoneal laparoscopic hernioplasty in treatment of
ing hospital. Ann Surg 2000;231:132 6. recurrent inguinal herniaa prospective randomized trial. Ann Surg
8. Lichtenstein IL, Shulman AG, Amid PK. The cause, prevention, and 2009;249:384 7.
treatment of recurrent groin hernia. Surg Clin North Am 1993;73:529 44. 30. Moher D, Cook DJ, Eastwood S, et al. Improving the quality of reports
9. Wilson MS, Deans GT, Brough WA. Prospective trial comparing of meta-analyses of randomized controlled trials: the QUOROM state-
Lichtenstein with laparoscopic tension-free mesh repair of inguinal ment. Quality of reporting of meta-analyses. Lancet 1999;354:1896
hernia. Br J Surg 1995;82:274 7. 900.
10. Kark AE, Kurzer M, Waters KJ. Tension-free mesh hernia repair: 31. Mahid SS, Hornung CA, Minor KS, et al. Systematic reviews and
review of 1098 cases using local anaesthesia in a day unit. Ann R Coll meta-analysis for the surgeon scientist. Br J Surg 2006;93:131524.
Surg Engl 1995;77:299 304. 32. Egger M, Smith GD, Altman DG. Systematic Reviews in Health Care:
11. McKernan JB, Laws HL. Laparoscopic repair of inguinal hernias using Meta-analysis in Context. 2nd ed. London: BMJ Books; 2001.
a totally extraperitoneal prosthetic approach. Surg Endosc 1993;7: 33. Review Manager (RevMan) [COMPUTER PROGRAM]. Version 4.2
26 8. for Windows. Copenhagen: The Nordic Cochrane Centre, The Co-
12. Liem MS, van der Graaf Y, van Steensel CJ, et al. Comparison of chrane Collaboration; 2003.
conventional anterior surgery and laparoscopic surgery for inguinal- 34. Higgins JPT, Green S, eds. Cochrane Handbook For Systematic Re-
hernia repair. N Engl J Med 1997;336:15417. views of Interventions 4.2.6 (Updated September 2006). The Cochrane
13. Johansson B, Hallerbck B, Glise H, et al. Laparoscopic mesh versus Library. Chichester, UK: John Wiley & Sons, Ltd.; 2006.
open preperitoneal mesh versus conventional technique for inguinal 35. Zamora J, Abraira V, Muriel A, et al. Meta-DiSc: a software for
hernia repair: a randomized multicenter trial (SCUR Hernia Repair meta-analysis of test accuracy data. BMC Med Res Methodol 2006;
Study). Ann Surg 1999;230:22531. 6:31.
14. Stoker DL, Spiegelhalter DJ, Singh R, et al. Laparoscopic versus open 36. Rosenberg MS, Adams DC, Gurevitch J. MetaWin. Statistical Soft-
inguinal hernia repair: randomized prospective trial. Lancet 1994;21: ware for Meta-Analysis, Version 2. Sunderland, MA: Sinauer Asso-
12435. ciates; 2000.
15. Heikkinen TJ, Haukipuro K, Hulkko A. A cost and outcome compar- 37. McCormack K, Scott NW, Go PM, et al. Hernia Trialists Collabora-
ison between laparoscopic and Lichtenstein hernia operations in a tion. Laparoscopic techniques versus open techniques for inguinal
day-case unit: a randomized prospective study. Surg Endosc 1998;12: hernia repair. Cochrane Database Syst Rev 2003;1:CD001785.
1199 203. 38. Wake BL, McCormack K, Fraser C, et al. Transabdominal pre-peri-
16. Memon MA, Cooper NJ, Memon B, et al. Meta-analysis of random- toneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic tech-
ized clinical trials comparing open and laparoscopic inguinal hernia niques for inguinal hernia repair. Cochrane Database Syst Rev 2005;
repair. Br J Surg 2003;90:1479 92. 1:CD004703.