Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials

Abstract

Objective: To measure the effects of laparoscopic and open placement of synthetic mesh on recurrence and persisting pain following groin hernia repair.

Summary background data: Synthetic mesh techniques are claimed to reduce the risk of recurrence but there are concerns about costs and possible long-term complications, particularly pain.

Methods: Electronic databases were searched and experts consulted to identify randomized or quasi-randomized trials that compared mesh with non-mesh methods, or laparoscopic with open mesh placement. Individual patient data were sought for each trial. Aggregated data were used where individual patient data were not available. Meta-analyses of hernia recurrence and persisting pain were based on intention to treat.

Results: There were 62 relevant comparisons in 58 trials. These included 11,174 participants: individual patient data were available for 6,901 patients, supplementary aggregated data for 2,390 patients, and published data for 1883 patients. Recurrence and persisting pain were less after mesh repair (overall recurrences: 88 in 4,426 vs. 187 in 3,795; OR 0.43, 95% CI 0.34-0.55; P <.001) (overall persistent pain: 120 in 2,368 vs. 215 in 1,998; OR 0.36, 95% CI 0.29-0.46; P <.001), regardless of the non-mesh comparator. Whereas the reduction in recurrence was similar after laparoscopic and open mesh placement (OR 1.26, 95% CI 0.76-2.08; P =.36), persistent pain was less common after laparoscopic than open mesh placement (OR 0.64; 95% CI 0.52-0.78; P <.001).

Conclusions: The use of synthetic mesh substantially reduces the risk of hernia recurrence irrespective of placement method. Mesh repair appears to reduce the chance of persisting pain rather than increase it.

Figure 1. Mesh versus non-mesh: hernia recurrence. X denotes no recurrences in either mesh or non-mesh group. The solid squares denote individual odds ratio and the horizontal lines represent 95% confidence intervals. The diamonds denote pooled odds ratio. CI, confidence interval; df, degrees of freedom; OR, Odds Ratio; TAPP, transabdominal preperitoneal; TEP, totally extraperitoneal; MRC, Medical Research Council; SCUR, Scandinavian Clinics United Research. Data source codes: 1 = individual patient data; 2 = additional aggregate data; 3 = published data only.

Figure 2. Laparoscopic versus open mesh: hernia recurrence. X denotes no recurrences in either laparoscopic or open mesh group. The solid squares denote individual odds ratio and the horizontal lines represent 95% confidence intervals. The diamonds denote pooled odds ratio. CI, confidence interval; df, degrees of freedom; OR, Odds Ratio; TAPP, transabdominal preperitoneal; TEP, totally extraperitoneal; MRC, Medical Research Council; SCUR, Scandinavian Clinics United Research. Data source codes: 1 = individual patient data; 2 = additional aggregate data; 3 = published data only.

Figure 3. Cumulative recurrence rates (individual patient data studies only) with 95% confidence intervals.

Figure 4. Mesh versus non-mesh: persisting pain. X denotes no pain in either mesh or non-mesh group. The solid squares denote individual odds ratio and the horizontal lines represent 95% confidence intervals. The diamonds denote pooled odds ratio. CI, confidence interval; df, degrees of freedom; OR, Odds Ratio; TAPP, transabdominal preperitoneal; TEP, totally extraperitoneal; MRC, Medical Research Council; SCUR, Scandinavian Clinics United Research. Data source codes: 1 = individual patient data; 2 = additional aggregate data; 3 = published data only.

Figure 5. Laparoscopic versus open mesh: persisting pain. The solid squares denote individual odds ratio and the horizontal lines represent 95% confidence intervals. The diamonds denote pooled odds ratio. CI, confidence interval; df, degrees of freedom; OR, Odds Ratio; TAPP, transabdominal preperitoneal; TEP, totally extraperitoneal; MRC, Medical Research Council; SCUR, Scandinavian Clinics United Research. Data source codes: 1 = individual patient data; 2 = additional aggregate data; 3 = published data only.