Comparison of open preperitoneal and Lichtenstein repair
for inguinal hernia repair: a meta-analysis of randomized controlled trials Junsheng Li, M.D.*, Zhenling Ji, M.D., Tao Cheng, M.D. Department of General Surgery, Afliated Zhong-Da Hospital, Southeast University, 210009 Nanjing, Jiangsu, China Abstract BACKGROUND: The aim of this article was to compare the outcomes of the open preperitoneal approaches and the Lichtenstein technique in the repair of inguinal hernias. METHODS: A systematic literature review was undertaken to identify studies comparing the out- comes of open preperitoneal and Lichtenstein techniques in the repair of inguinal hernias. RESULTS: The present meta-analysis pooled the effects of outcomes of a total of 2,860 patients enrolled into 10 randomized controlled trials and 2 comparative studies. The preperitoneal technique was associated with a lesser incidence of recurrence (odds ratio .51; 95% condence interval, .28.92). However, statistically there was no difference in the incidence of chronic pain, hematoma, wound infection, testicular problem, urinary problem, numbness, inguinal parenthesis, and operative time. CONCLUSIONS: The open preperitoneal approach is a feasible alternative for the standard Lichten- stein procedure with similar complication rates and potentially less postoperative recurrence. 2012 Elsevier Inc. All rights reserved. KEYWORDS: Lichtenstein; Preperitoneal; Inguinal hernia; Repair; Randomized controlled trials Inguinal hernia repair is one of the most common surgi- cal procedures performed, and nearly 80 operative tech- niques have been described since Bassini reported his method in 1887. Surgeons continue to search for the ideal repair method with the best outcome. Because tension-free inguinal hernia repair has a low recurrence rate, parameters other than recurrence are becoming increasingly important to determine the effects of hernia repair (eg, postoperative inguinal pain and discomfort). Although the laparoscopic approach was reported to be associated with less pain, laparoscopic hernia repair is more expensive and has a longer learning curve and the need for general anesthesia; hence, most surgeons reserve this approach for specic indications and in specialized centers. 1 One of the most frequently used open techniques is the Lichtenstein herniorraphy. 2 Nowadays, chronic pain is the main problem associated with the Lichtenstein proce- dure with a reported rate of 15% to 40%. 3,4 The reason of the postoperative pain was complex, and the position of the mesh is probably 1 factor. Furthermore, this anterior method needs extensive dissection of the inguinal wall and the xation of the mesh. 5 Despite skepticism about the anterior placement of the mesh, Amid et al 6 supported their claims that Lichtenstein was a safe, easy, and effective inguinal hernia method, with a recurrence rate as low as .12% in their hands. 6 The open preperitoneal approach might benet from put- ting a mesh in the preferred preperitoneal space free of the disadvantages of an endoscopic procedure. In the preperi- * Corresponding author. Tel: 0086-25-13770927641; fax: 0086-25- 83272064 E-mail address: Lijunshenghd@126.com Manuscript received September 27, 2011; revised manuscript February 5, 2012 0002-9610/$ - see front matter 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2012.02.010 The American Journal of Surgery (2012) 204, 769778 toneal approach, the mesh is held in place with intra-ab- dominal pressure and, thus, needs relatively less or no xation. The open preperitoneal approach has been in use for more than 30 years. 7,8 Several different methods have been designed and proved to be successful, such as the transinguinal preperitoneal technique (TIPP) with a memory ring patch 9 and lower abdominal incision with a Kugel patch. 10 In addition, a currently common used technique, the Prolene hernia system (PHS; Ethicon, South San Fran- cisco, CA) with a bilayer mesh, reinforcing both the pre- peritoneal space and inguinal oor, has the benet of less xation and less dissection of the inguinal oor and pre- serves the advantages of open preperitoneal position of the mesh. 11 To date, there is no meta-analysis specially comparing the effects of open preperitoneal mesh placement and the subaponeurotic location. In the present article, we included several different preperitoneal repair methods based on the point that, in these methods, the meshes were all placed in the preperitoneal space, and which is the most important aspect of these methods, and this is the truly clinical sig- nicance of the preperitoneal approach. Methods By conducting an intensive search of the literature in the major databases (ie, PubMed, EMBase, Springer, and Co- chrane Library), we identied all trials published up to and including May 2011 that compared the open preperitoneal and Lichtenstein procedures for the repair of inguinal her- nias. The term inguinal hernia was used in combination with the following medical subject headings: preperito- neal, Lichtenstein, Kugel, PHS, tension-free, and repair. The reference lists and relevant articles referenced in these primary studies were downloaded from the data- bases. The relevance function of the articles in the database was used to widen the search results. All abstracts, compar- ative studies, nonrandomized trials, and citations scanned were searched comprehensively. Ten randomized controlled trials and 2 well-designed comparisons were identied for study. The 2 comparative studies had a large number of cases, long-term follow-up, and comparable baseline char- acteristics. A total of 2,860 patients were summarized in a formal meta-analysis. All the nonrelevant articles (eg, arti- cles that did not compare these 2 procedures, trials that reported on only 1 technique, and articles that reported pure surgical experiences) were excluded from this study. A ow chart of the literature is shown in Figure 1. To be included, studies had to be published as full-length articles or letters in peer-reviewed journals. For duplicate publications, the smaller dataset was excluded. These trials reported at least 1 of the following outcomes: seroma or hematoma, infection, numbness, parenthesis, chronic pain, testicular problems, operating time, urinary problem, or recurrence (Table 1). Each article was critically reviewed by Potentially relevant trials identified and screened for retrival n=367 Trials retrieved for more detailed evaluation n=65 Trials included n= 14 Potentially appropriate trials to be included in the meta-analysis n=18 Trials with usuable information, by outcome n=12 Trials withdrawn n=2 Incomplete information n=1 Different outcome n=1 Trials excluded n=4 Femoral hernia trials n=1 Emergency cases studie n=1 Other techniques n=2 Trials excluded n=47 Non-comparative, case report, or review. n=47 Trials excluded n=302 Trials not relevant n=302 Figure 1 A ow diagram of trial selection. 770 The American Journal of Surgery, Vol 204, No 5, November 2012 2 independent researchers for eligibility in the meta-analy- sis, and data were extracted separately by the 2 researchers. Disagreements were resolved by consensus. The following variables were extracted from each article: author(s), pub- lication year, journal, country of origin, study design, inter- vention, and outcome. Table 1 Basic information of the trials Study Type of inguinal hernia Sample size (exp/con) Experimental group Control group Outcome (extracted for meta-analysis) Follow-up Nienhuijs et al, 2007 14 Primary unilateral 82/84 Kugel Lichtenstein Recurrence Pain Numbness Parenthesia Testicular problem Urinary problem 3 mo Dogru et al, 2006 15 Primary unilateral 69/70 kugel Lichtenstein Recurrence Wound infection Hematoma Testicular problem Operative time 2 y Muldoon et al, 2004 16 Primary unilateral 121/126 Read-Rives Lichtenstein Recurrence Pain Numbness Wound infection Hematoma Testicular problem Urinary problem 2 y Berrevoet et al, 2010 17 Primary unilateral 142/136 TIPP Lichtenstein Recurrence Pain Hematoma Urinary problem 1 y Koning et al, 2011 18 Primary unilateral 225/271 TIPP Lichtenstein Recurrence Numbness Hematoma 3 y Mayagoitia et al, 2006 19 Primary including recurrent 36/214 PHS Lichtenstein Recurrence Pain Wound infection Hematoma Parenthesia Testicular problem 2 y Sanjay et al, 2006 20 Primary unilateral 31/33 PHS Lichtenstein Recurrence Pain Wound infection Hematoma Operative time 4 y Dalenback et al, 2009 21 Primary 155/158 PHS Lichtenstein Recurrence Pain Wound infection Hematoma Parenthesia Testicular problem Urinary problem Operative time 3 y Al Gun et al, 2007 22 Primary unilateral 39/42 Nyhus Lichtenstein Recurrence Testicular problem Urinary problem Operation time 8 y Vironen et al, 2006 23 Primary and recurrent 150/149 PHS Lichtenstein Recurrence Pain Numbness Wound infection Hematoma Testicular problem 1 y Nienhuijs et al, 2005 24 Primary unilateral 111/110 PHS Lichtenstein Recurrence Hematoma Wound infection 7 mo Kingsnorth et al, 2002 25 Primary unilateral 103/103 PHS Lichtenstein Recurrence 12 mo 771 J. Li et al. Preperitoneal and Lichtenstein techniques in inguinal hernias The quality of trials was assessed with the Cochrane Handbook for Systematic Reviews of Interventions version 5.0.1 12 (Table 2). Each included trial was assessed indepen- dently to ascertain the following methodologic qualities: sequence generation, allocation concealment, blinding of participants, personnel and outcome assessors, incomplete outcome data, selective outcome reporting, and other sources of bias. No sponsors were involved in the study design, data collection, analysis, interpretation, and the writ- ing and submitting of the report for publication. All authors had access to the raw data. Pooled estimates of outcomes were calculated using a xed-effects model, but a randomized-effects model was used according to heterogeneity. Tests for heterogeneity and overall effect were provided for each total or subtotal. We used the chi-square statistic to assess the heterogeneity between trials and the I 2 statistic to assess the extent of inconsistency. For dichotomous data, results for each trial were expressed as odds ratios (ORs) or risk differences (RDs) with 95% condence intervals (CIs). 12 Forest plots were used for the graphic display of the results from the meta-analysis. Statistical analysis was per- formed by Review Manager (RevMan version 5.0), the Cochrane Collaborations software for preparing and main- taining Cohrane systematic reviews. Bias was studied using sensitivity analysis by removing individual studies from the dataset and analyzing the overall effect size and the weighted regression test described by Egger et al. 13 Publi- cation bias was tested using the Egger test. Results Figure 1 shows the owchart of studies from the initial results of publication searches to the nal inclusion or exclusion. Only randomized controlled trials and well-de- signed comparative studies that were published in English were included in the present analysis. The electronic searches yielded 367 items from PubMed, EMBase, Springer, and the Cochrane Library. After reviewing these, we identied 12 original studies. 1425 The publication dates ranged from 2004 to 2011. A total of 2,860 patients were enrolled in these eligible trials. Recurrence There was no signicant heterogeneity among the 12 trials 1425 (P .94, I 2 0%); therefore, the xed-effects model was appropriate. Compared with the Lichtenstein group, the preperitoneal group showed less postoperative recurrence (OR .51; 95% CI, .28.92; Fig. 2A). To test the sensitivity of these results, we excluded 2 trials with small sample sizes 20,22 and obtained similar results (OR .48; 95% CI, .25.91; Fig. 2B). We also excluded the trial with the shortest follow-up time 14 and got the result did not changed (OR .44; 95% CI, .22.87, Fig. 2C). Further- more, these results were recalculated with relative risk and RD, and the same conclusion was obtained. Publication bias was also tested with the Egger test, and no publication bias was detected among the present included trials (Fig. 2D). Pain Seven 14,16,17,1921,23 of the 12 studies reported chronic pain (6 months). The random-effects model was used because of the heterogeneity (P .0001, I 2 80%). The results showed that there was no signicant difference in chronic pain between the preperitoneal and Lichtenstein groups (OR .55; 95% condence interval [CI], .221.39; Fig. 3). Table 2 Quality assessment of the randomized controlled trials Study Randomization Allocation concealment Blinding Incomplete outcome data ITT analysis Selecting outcome reporting Other sources of bias Nienhuijs et al, 2007 14 Computer generated Central allocation Single blind Yes No Unclear Unclear Dogru et al, 2006 15 Admittance order Central allocation Unclear Yes No Unclear Unclear Muldoon et al 2004 16 Computer generated Sealed envelope Unclear Yes No Unclear Unclear Mayagoitia et al 2006 19 Unclear Unclear Unclear Yes No Unclear Unclear Sanjay et al 2006 20 Unclear Sealed envelope Unclear Yes No Unclear Unclear Dalenback et al 2009 21 Unclear Central allocation Single blind Yes No Unclear Unclear Al Gun et al, 2007 22 Unclear Unclear Unclear Yes No Unclear Unclear Vironen et al, 2006 23 Unclear Sealed envelope Double blind Yes No Unclear Unclear Nienhuijs et al, 2005 24 Computer generated Sealed envelope Single blind Yes No Unclear Unclear Kingsnorth et al, 2002 25 Unclear Unclear Double blind Yes No Unclear Unclear 772 The American Journal of Surgery, Vol 204, No 5, November 2012 Study or Subgroup Berrevoet F 2010 Dalenback J 2009 Dogru O 2006 Gunal O 2007 Kingsnorth 2002 Koning GG 2011 Mayagoitia JC 2006 Muldoon RL 2004 Nienhuijs 2005 Nienhuijs S 2007 Sanjay P 2006 Vironen J 2006 Total (95% CI) Total events Heterogeneity: Chi = 4.84, df = 11 (P = 0.94); I = 0% Test for overall effect: Z = 2.23 (P = 0.03) Events 4 3 0 1 0 1 0 1 1 2 1 0 14 Total 142 155 69 39 103 225 136 121 111 82 31 150 1364 Events 7 2 1 3 2 3 2 5 3 2 0 1 31 Total 136 158 70 42 103 271 214 126 110 84 33 149 1496 Weight 21.7% 6.1% 4.6% 8.8% 7.8% 8.5% 6.0% 15.2% 9.3% 6.0% 1.4% 4.7% 100.0% M-H, Fixed, 95% CI 0.53 [0.15, 1.87] 1.54 [0.25, 9.34] 0.33 [0.01, 8.32] 0.34 [0.03, 3.44] 0.20 [0.01, 4.14] 0.40 [0.04, 3.86] 0.31 [0.01, 6.53] 0.20 [0.02, 1.75] 0.32 [0.03, 3.17] 1.02 [0.14, 7.45] 3.30 [0.13, 83.97] 0.33 [0.01, 8.14] 0.51 [0.28, 0.92] o i t a R s d d O o i t a R s d d O n i e t s n e t h c i L l a e n o t i r e p e r P M-H, Fixed, 95% CI 0.01 0.1 1 10 100 Favours preperitonal Favours Lichtenstein Study or Subgroup Berrevoet F 2010 Dalenback J 2009 Dogru O 2006 Kingsnorth 2002 Koning GG 2011 Mayagoitia JC 2006 Muldoon RL 2004 Nienhuijs 2005 Nienhuijs S 2007 Vironen J 2006 Total (95% CI) Total events Heterogeneity: Chi = 3.47, df = 9 (P = 0.94); I = 0% Test for overall effect: Z = 2.24 (P = 0.02) Events 4 3 0 0 1 0 1 1 2 0 12 Total 142 155 69 103 225 136 121 111 82 150 1294 Events 7 2 1 2 3 2 5 3 2 1 28 Total 136 158 70 103 271 214 126 110 84 149 1421 Weight 24.1% 6.7% 5.1% 8.6% 9.4% 6.7% 16.9% 10.4% 6.7% 5.2% 100.0% M-H, Fixed, 95% CI 0.53 [0.15, 1.87] 1.54 [0.25, 9.34] 0.33 [0.01, 8.32] 0.20 [0.01, 4.14] 0.40 [0.04, 3.86] 0.31 [0.01, 6.53] 0.20 [0.02, 1.75] 0.32 [0.03, 3.17] 1.02 [0.14, 7.45] 0.33 [0.01, 8.14] 0.48 [0.25, 0.91] o i t a R s d d O o i t a R s d d O n i e t s n e t h c i L l a e n o t i r e p e r P M-H, Fixed, 95% CI 0.01 0.1 1 10 100 Favours preperitoneal Favours Lichtenstein A Study or Subgroup Berrevoet F 2010 Dalenback J 2009 Dogru O 2006 Kingsnorth 2002 Koning GG 2011 Mayagoitia JC 2006 Muldoon RL 2004 Nienhuijs 2005 Vironen J 2006 Total (95% CI) Total events Heterogeneity: Chi = 2.90, df = 8 (P = 0.94); I = 0% Test for overall effect: Z = 2.35 (P = 0.02) Events 4 3 0 0 1 0 1 1 0 10 Total 142 155 69 103 225 136 121 111 150 1212 Events 7 2 1 2 3 2 5 3 1 26 Total 136 158 70 103 271 214 126 110 149 1337 Weight 25.9% 7.2% 5.5% 9.3% 10.1% 7.2% 18.1% 11.1% 5.6% 100.0% M-H, Fixed, 95% CI 0.53 [0.15, 1.87] 1.54 [0.25, 9.34] 0.33 [0.01, 8.32] 0.20 [0.01, 4.14] 0.40 [0.04, 3.86] 0.31 [0.01, 6.53] 0.20 [0.02, 1.75] 0.32 [0.03, 3.17] 0.33 [0.01, 8.14] 0.44 [0.22, 0.87] o i t a R s d d O o i t a R s d d O n i e t s n e t h c i L l a e n o t i r e p e r P M-H, Fixed, 95% CI 0.01 0.1 1 10 100 Favours preperitoneal Favours Lichtenstein B C Figure 2 (A) Postoperative inguinal hernia recurrence. (B) Postoperative inguinal hernia recurrence; 2 trials with small samples were excluded from analysis (Sanjay [2006] and Gunal [2007]). (C) Postoperative inguinal hernia recurrence; 1 trial with the shortest follow-up was excluded from analysis (Nienhuijs [2007] was excluded). (D) The Egger test publication bias plot for postoperative recurrence after the preperitoneal and Lichtenstein procedures. Using the Egger test, t .06; P .523; and 95% CI, 1.905346 to 1.033382 [includes 0]); no obvious publication bias was detected. 773 J. Li et al. Preperitoneal and Lichtenstein techniques in inguinal hernias Hematomas and seromas Ten studies 1524 reported the incidence of hematomas. The xed-effects model was used because of the heteroge- neity (P .24, I 2 22%). The results showed that there was no signicant difference in the incidence of hematomas between the preperitoneal and Lichtenstein repair groups (OR 1.04; 95% CI, .661.64; Fig.4). Wound infection Seven studies 15,16,1921,23,24 reported wound infection af- ter surgery. The main meta-analysis with the xed-effects model showed no statistically signicant difference between the 2 groups (RD .01; 95% CI, .00 to .03). The heter- ogeneity was not signicant (P .27, I 2 21%, Fig. 5). Testicular problems Figure 6 shows the testicular problems. Seven studies were included, 1416,19,2123 and the xed-effects model was used because of the heterogeneity (P .18, I 2 34%). The results showed no signicant difference in testicular prob- lems between the 2 groups (OR .67; 95% CI, .321.42). Urinary problems Five studies 14,16,17,21,22 reported urinary problems (ie, urinary retention/infection). The xed-effects model was used because of the heterogeneity (P .71, I 2 0%). The results showed that there was no signicant difference in urinary problems between the 2 groups (OR .83; 95% CI, .461.53; Fig. 7). Numbness The meta-analysis showed that there was no statistically signicant difference in postoperative numbness (OR .50; 95% CI, .181.43). The heterogeneity of the stud- ies 14,16,18,23 was signicant (P .01, I 2 74%), and the random-effects model was used. Inguinal parenthesis The results of the studies that included information about inguinal parenthesis 14,19,21 indicated that there was no dif- ference in the incidence of inguinal parenthesis between the preperitoneal and Lichtenstein groups (OR .82; 95% CI, .145.02). Operative time The analysis results of the operative time between the pre- peritoneal and Lichtenstein groups showed that there was no statistically signicant difference (mean difference 1.94%; 95% CI, 5.41 to 1.53). Comments Tension-free hernia repair has reduced the incidence of recurrence. Although the recurrence rate after tension-free Egger's publication bias plot s t a n d a r d i z e d
e f f e c t precision 0 .5 1 1.5 -2 -1 0 1 D Figure 2 Continued Study or Subgroup Berrevoet F 2010 Dalenback J 2009 Mayagoitia JC 2006 Muldoon RL 2004 Nienhuijs S 2007 Sanjay P 2006 Vironen J 2006 Total (95% CI) Total events Heterogeneity: Tau = 1.17; Chi = 30.77, df = 6 (P < 0.0001); I = 80% Test for overall effect: Z = 1.26 (P = 0.21) Events 4 4 1 10 17 4 18 58 Total 142 155 136 121 82 31 150 817 Events 43 4 6 7 34 5 12 111 Total 136 158 214 126 84 33 149 900 Weight 15.1% 13.1% 9.4% 15.5% 17.1% 13.1% 16.7% 100.0% M-H, Random, 95% CI 0.06 [0.02, 0.18] 1.02 [0.25, 4.15] 0.26 [0.03, 2.16] 1.53 [0.56, 4.16] 0.38 [0.19, 0.77] 0.83 [0.20, 3.42] 1.56 [0.72, 3.36] 0.55 [0.22, 1.39] o i t a R s d d O o i t a R s d d O n i e t s n e t h c i L l a e n o t i r e p e r P M-H, Random, 95% CI 0.01 0.1 1 10 100 Favours preperitoneal Favours Lichtenstein Figure 3 Chronic pain after inguinal hernia repair. 774 The American Journal of Surgery, Vol 204, No 5, November 2012 repair was as low as 2% to 5% recently, 26 other variables such as postoperative pain and discomfort gained more attention considering the patients quality of life after sur- gery. There is still an ongoing debate on what the preferred technique is in the treatment of inguinal hernia. Commonly used tension-free repair techniques include the Stoppa pro- cedure, the Kugel technique, the PHS procedure, Gilbert procedure, mesh plug repairs, and laparoscopic hernia re- pairs. 14,19,20 Among these inguinal hernia repair techniques, the meshes were placed in 2 different positions: either the anterior or posterior (preperitoneal space) layer. Some surgeons prefer the anterior subaponeurotic tech- nique because it is technically easier and, when performed correctly, is associated with very low recurrence rates, 6,27 whereas others state that all the anterior approaches involve an extensive dissection (especially in the Lichtenstein po- cedure) of the inguinal canal; however, an open preperito- neal dissection approach might have the benet of a mesh in the preferred preperitoneal space, with limited inguinal ca- nal dissection, but without the disadvantages of an endo- scopic procedure. Until now, no consensus has been reached regarding the best surgical approach to inguinal hernia repair, 28,29 and there has been no meta-analysis comparing these 2 techniques published in the English literature. In the present study, we combined several preperitoneal tech- niques in 1 group including the Kugel, Read-Rives, Ny- hus, and Tipp procedures and PHS because all these techniques involve the preperitoneal placement of the mesh and have the same clinical signicance. In PHS repair, the upper part of the mesh is placed in the inguinal canal; however, the anterior inguinal canal dissection is limited. Furthermore, the large and lower important part is placed in the preperitoneal place, with the main aim of preventing any form of hernia recurrence through the myopectineal orice. 17,20 Therefore, there are no clini- cally relevant differences in these preperitoneal proce- dures. Further subgroup analysis would only hinder the statistical evaluation. The Lichtenstein operation is the most widely accepted anterior tension-free approach, so we used the Lichtenstein procedure as the control group in the present meta-analysis. In this meta-analysis, more recurrence was found in the Lichtenstein group compared with the preperitoneal group. The recurrence after inguinal hernia repair may be situated near the pubic tubercle, through the internal ring, or lateral Study or Subgroup Berrevoet F 2010 Dalenback J 2009 Dogru O 2006 Gunal O 2007 Koning GG 2011 Mayagoitia JC 2006 Muldoon RL 2004 Nienhuijs 2005 Sanjay P 2006 Vironen J 2006 Total (95% CI) Total events Heterogeneity: Chi = 11.61, df = 9 (P = 0.24); I = 22% Test for overall effect: Z = 0.19 (P = 0.85) Events 2 15 2 1 4 1 9 1 1 2 38 Total 142 155 69 39 225 136 121 111 31 150 1179 Events 4 8 0 1 3 1 7 3 0 11 38 Total 136 158 70 42 271 214 126 110 33 149 1309 Weight 11.0% 19.5% 1.3% 2.6% 7.3% 2.1% 17.3% 8.1% 1.3% 29.6% 100.0% M-H, Fixed, 95% CI 0.47 [0.08, 2.62] 2.01 [0.83, 4.88] 5.22 [0.25, 110.78] 1.08 [0.07, 17.86] 1.62 [0.36, 7.30] 1.58 [0.10, 25.44] 1.37 [0.49, 3.79] 0.32 [0.03, 3.17] 3.30 [0.13, 83.97] 0.17 [0.04, 0.78] 1.04 [0.66, 1.64] o i t a R s d d O o i t a R s d d O n i e t s n e t h c i L l a e n o t i r e p e r P M-H, Fixed, 95% CI 0.01 0.1 1 10 100 Favours preperitoneal Favours Lichtenstein Figure 4 Hematoma after hernia repair. Study or Subgroup Dalenback J 2009 Dogru O 2006 Mayagoitia JC 2006 Muldoon RL 2004 Nienhuijs 2005 Sanjay P 2006 Vironen J 2006 Total (95% CI) Total events Heterogeneity: Chi = 7.64, df = 6 (P = 0.27); I = 21% Test for overall effect: Z = 1.35 (P = 0.18) Events 6 1 0 0 12 2 3 24 Total 155 69 136 121 111 31 150 773 Events 3 0 2 0 8 1 2 16 Total 158 70 214 126 110 33 149 860 Weight 19.4% 8.6% 20.6% 15.3% 13.7% 4.0% 18.5% 100.0% M-H, Fixed, 95% CI 0.02 [-0.02, 0.06] 0.01 [-0.02, 0.05] -0.01 [-0.03, 0.01] 0.00 [-0.02, 0.02] 0.04 [-0.04, 0.11] 0.03 [-0.07, 0.14] 0.01 [-0.02, 0.04] 0.01 [-0.00, 0.03] Preperitoneal Lichtenstein Risk Difference Risk Difference M-H, Fixed, 95% CI -0.1 -0.05 0 0.05 0.1 Favours preperitoneal Favours Lichtenstein Figure 5 Wound infection. 775 J. Li et al. Preperitoneal and Lichtenstein techniques in inguinal hernias to the mesh. Recently, evidence was published suggesting that recurrent femoral hernias are 15 times more frequent than primary femoral hernias, 30 and these recurrences occur earlier than inguinal recurrences, suggesting the femoral hernia is overlooked at the primary operation. Furthermore, it has been reported that the incidence of femoral hernias after preperitoneal repair is half that observed after Lich- tenstein repair, which also proves the advantage of the preperitoneal approach in this situation. 30 The myopetineal orice is a large potential area of weakness in the lower abdominal wall that is closed by the fascia transversalis with the inguinal above and femoral canal below and transversed by the inguinal ligament and permits inguinal and femoral hernias. All the listed preperitoneal repair approaches in this meta-analysis (eg, Kugel, Tipp, PHS, and so on), close weakness at the myopectineal orice completely rather than partly in its anterior inguinal portion (as in the Lichtenstein approach). In the present meta-analysis, femoral hernia re- currence was clearly identied in only 1 trial. 21 Most of the recurrences in the Lichtenstein group were inguinal hernias rather than additional femoral hernias. This result is consis- tent with the observation of Muldoon et al, 16 who pointed out that the early failure in the Lichtenstein series was presumed to be secondary to surgical error. Shulman et al, 27 from the Lichtenstein Clinic states that it is not an onlay but an inlay technique because the prosthesis lies beneath the external oblique aponeurosis, and Kux 31 also believes this is the right layer for the patch. Although postoperative recurrence was a failure of in- guinal hernia repair, some authors regarded chronic pain as a more severe complication than recurrence because of its incapacitating character. 14 Chronic pain has signicant ef- fects on all daily activities, including walking, working, sleep, mood, relationships with other people, and the gen- eral enjoyment of life. 32 The exact incidence of chronic pain is unknown. Well-conducted, large, and unselected epide- miologic studies suggest that about 20% of patients after inguinal hernia repair are affected with chronic pain. 30,3234 Five issues have been addressed to minimize the postoper- ative pain including using a small incision, minimal dissec- tion around the inguinal nerves, a better location of the mesh in the preperitoneal space, minimal xation of the mesh, and a lesser amount of material to prevent severe local inam- mation and brosis around the nerves and the cord struc- tures during tissue ingrowth. 17 Researchers also imply that early postoperative pain intensity can reliably predict the likelihood of postoperative chronic pain, and the pain scores during the rst 14 days correlated well with the pain scores at the long-term follow-up. 24 The Lichtenstein procedure was reported with an inci- dence of chronic pain more than 15%, 32 and in this meta- analysis no difference in chronic pain was detected between Study or Subgroup Dalenback J 2009 Dogru O 2006 Gunal O 2007 Mayagoitia JC 2006 Muldoon RL 2004 Nienhuijs S 2007 Vironen J 2006 Total (95% CI) Total events Heterogeneity: Chi = 7.54, df = 5 (P = 0.18); I = 34% Test for overall effect: Z = 1.04 (P = 0.30) Events 0 1 0 0 2 1 6 10 Total 155 69 39 136 121 82 150 752 Events 1 1 7 0 5 0 2 16 Total 158 70 42 214 126 84 149 843 Weight 8.8% 5.8% 42.4% 28.6% 2.9% 11.4% 100.0% M-H, Fixed, 95% CI 0.34 [0.01, 8.35] 1.01 [0.06, 16.55] 0.06 [0.00, 1.09] Not estimable 0.41 [0.08, 2.14] 3.11 [0.12, 77.46] 3.06 [0.61, 15.42] 0.67 [0.32, 1.42] o i t a R s d d O o i t a R s d d O n i e t s n e t h c i L l a e n o t i r e p e r P M-H, Fixed, 95% CI 0.005 0.1 1 10 200 Favours preperitoneal Favours Lichtenstein Figure 6 Testicular problems after inguinal hernia repair. Study or Subgroup Berrevoet F 2010 Dalenback J 2009 Gunal O 2007 Muldoon RL 2004 Nienhuijs S 2007 Total (95% CI) Total events Heterogeneity: Chi = 2.16, df = 4 (P = 0.71); I = 0% Test for overall effect: Z = 0.59 (P = 0.56) Events 9 1 1 8 1 20 Total 142 155 39 121 82 539 Events 8 4 1 11 0 24 Total 136 158 42 126 84 546 Weight 33.2% 17.1% 4.1% 43.6% 2.1% 100.0% M-H, Fixed, 95% CI 1.08 [0.41, 2.89] 0.25 [0.03, 2.26] 1.08 [0.07, 17.86] 0.74 [0.29, 1.91] 3.11 [0.12, 77.46] 0.83 [0.46, 1.53] o i t a R s d d O o i t a R s d d O n i e t s n e t h c i L l a e n o t i r e p e r P M-H, Fixed, 95% CI 0.01 0.1 1 10 100 Favours preperitoneal Favours Lichtenstein Figure 7 Urinary retention/infection after inguinal hernia repair. 776 The American Journal of Surgery, Vol 204, No 5, November 2012 the Lichtenstein and preperitoneal approaches. As Berre- voet et al suggested, 7 chronic pain was affected not only by the position of the mesh but also by the length of the incision, the extent of the dissection, and the need for mesh xation. Hematomas and seromas are potential complications of placing the mesh in the preperitoneal layer, which were addressed by laparoscopic repair. However, in our meta- analysis, the incidence of hematomas and seromas when using the preperitoneal approach was not signicantly dif- ferent from that when using the Lichtenstein repair. Simi- larly, in this meta-analysis, no differences in urinary prob- lems (ie, urinary retention), numbness, wound infection, testicular problems, or parenthesis were found between the preperitoneal and Lichtenstein groups. The evaluation of long-term complications in the meta- analysis of randomized controlled trials is still difcult although the overall follow-up rates were indeed high, reaching above 95% in this meta-analysis. However, most of the follow-up periods were of a short duration (Table 1). Moreover, the mode of examination (eg, questionnaire, tele- phone interview, clinical examination, or ultrasound or sur- gical exploration) and the blinding status of the investiga- tors tend to be unclear. These problems might affect the recurrence rate after hernia repair. This study also had other limitations including the fact that there was heterogeneity among the trials in this meta- analysis (Table 1). The rst possible cause of heterogeneity in the included trials would be the different repair method in the preperitoneal group. The second possible cause of het- erogeneity would be the different anesthesia type because local epidural anesthesia and general anesthesia were all used in these trials. Third, all these trials were performed by different surgeons. Also, the follow-up time of several out- comes in these trials was not consistent, which could lead to high performance bias and measuring bias. 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