A group of researchers from Surgery Clinic of University in Napoli have examined frequency of occurrence and escalation of postoperative pain and other complications in patients who underwent operation on inguinal hernia with the use of lightweight mesh with larger pores and heavyweight one with small pores which were fixed with fibrin glue.
Operative treatment is recommended in patients with any recognized inguinal hernia and its aim is to avoid dangerous complications. On the basis of long-lasting observations it may be concluded that tension free techniques, which use meshes made of plastic, are more effective than traditional reconstructions.
The most common way to operate inguinal hernias is plasticity with method of Lichtenstein. During the procedure mesh is sewed into the back wall of inguinal canal (thus strengthening it) and its sides embrace spermatic cord and reconstruct the deep inguinal ring. This technique results in small number or recurrences and complications. Topical ailments such as discomfort or decreased mobility of abdominal wall are very often but they are well tolerated by the patients since they subside fast and completely. Postoperative pain is present in 30% of cases and 12% of patients report limitations of everyday activities because of it. Observations show that more than ¼ of the patients complain of average or strong postoperative pain within a period up to 3 months after the procedure and almost 1/3 of the patients feel limitations of everyday activity.
There are two types of mesh. One is older, heavyweight mesh with small pores and the other is modern lightweight with larger pores. Heavyweight are more stiff, they have tendency to shrink and due to larger surface they adhere to tissues and they may cause inflammatory reactions more often. Contrary to them, the lightweight mesh does not only cause less complications, but it also contributes to less frequency of pain occurrence because of its lightness and elasticity.
What is more, the use of the new technique of mesh fixation contributes to decrease of pain complications. The use of Human Fibrin Glue (HFG) made of human fibrinogen, aprotinin, thrombin and calcium chloride is a perfect alternative for sewing in the mesh.
Double-blind, randomized research involved 80 patients. 40 of them got lightweight mesh and the remaining 40 standard heavyweight mesh. In all of the cases meshes were fixed with HFG glue. Criteria adopted by the researchers involved age (over 18), BMI (less than 35), and diagnosed non-operated and non complicated one sided inguinal hernia. Excluded were patients with two-sided inguinal hernia, advanced hernia (M3 or L3 according to European Hernia Society Classification) diabetes, immunological and psychiatric disorders and hypersensitivity to glue’s ingredient (aprotinin). Preoperative intake of NSAIDs also disqualified patients from the research.
The course of all procedures was without complications. In postoperative period hematoma in groin appeared only in 1 patient and ecchymoses were present in 7 patients who were given lightweight mesh and in 4 patients with heavyweight mesh. Patients with lightweight mesh reported less pain. After one month from the procedure there were no recurrences nor inflammatory complications in operated area. In terms of pain tendency was in favour of patients with lightweight mesh. After 6 months from the procedure there were no complications in any patient and differences in postoperative pain were not observed in any group.
The research confirmed assumptions of the scientists that the type of mesh and way of its implementation influence frequency of postoperative pain occurrence. The perfect mesh should not only be chemically and biologically compatible with tissues, but also it should not cause long-lasting complications, recurrences, infections and chronic pain. Lightweight mesh with large pores seems to give satisfactory results because of its physical properties (lightness, elasticity), size of pores and small surface of adherence (reduced reaction caused by adherence of foreign material, thus lower probability of inflammatory reaction). The only drawback observed in case of lightweight meshes was higher risk of adhesions.
Patients in whom lightweight mesh and HFG glue were used not only during open surgery, but also in laparoscopic method reported reduced postoperative pain. What is more, HFG was more effective in prevention of postoperative hemorrhage and hematomas in patients with coagulation disorders.
Types of mesh and ways of their fixation will certainly be an object of many research in order to provide patients with the best convalescence and the fastest recovery.
Written by: Aleksandra Tańska, Jerzy Bednarski
Source:
1.W. Noszczyk. Chirurgia. Wydawnictwo Lekarskie PZWL. Warszawa 2009
2.Silvestro Canonico et. al. Sutureless fixation with fibrin glue of lightweight mesh in open inguinal hernia repair: Effect on postoperative pain: A double-blind, randomized trial versus standard heavyweight mesh. Surgery Volume 153, Issue 1, Pages 126–130, January 2013
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