Mesh fixation versus non-fixation in laparoscopic inguinal hernia repair: absolute burden and clinical relevance of chronic pain - a systematic review and meta-analysis of randomized controlled trials.
Gustavo Magalhães Albuquerque, Victoria Frasson, Lorraine Michelle da Silva de Almeida et al.
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In 30 seconds
This systematic review and meta-analysis of 28 randomized controlled trials (3,702 adults) compared mesh fixation with non-fixation during laparoscopic inguinal hernia repair using TEP or TAPP techniques. Postoperative pain generally favored non-fixation. At six months, the pooled pain-score difference was approximately 0.6 points on a 0–10 scale (95% CI, 0.4 to 0.8), below proposed thresholds for clinical importance, although no threshold is validated for chronic post-herniorrhaphy pain. Chronic pain was higher with fixation in TAPP but not TEP; the TAPP signal was sensitive to trial exclusion. Recurrence, SSI, and seroma did not differ significantly.
Key findings
- At six months, the pooled pain-score difference was approximately 0.6 points on a 0–10 scale (95% CI, 0.4 to 0.8).
- Chronic pain was higher with fixation in TAPP (RR, 5.9; 95% CI, 1.6 to 21.7; NNTH, 9), but not TEP (RR, 1.3; 95% CI, 0.9 to 1.9); the TAPP result was not robust to sensitivity analyses.
- No significant differences were observed in SSI, seroma formation, or hernia recurrence (all P > 0.05).
- Fixation prolonged operative time by approximately 4.3 min (P < 0.0001); reported procedural costs were higher with fixation in all six trials reporting costs.
Why it matters
The findings quantify the pain difference associated with fixation and suggest that its average magnitude at six months may be small, while a possible chronic-pain signal in TAPP remains uncertain. The absence of detected differences in recurrence, SSI, or seroma is relevant when weighing fixation’s potential benefits against added operative time and cost, but imprecise estimates and variable evidence certainty limit firm conclusions.
What to keep in mind
Certainty ranged from very low to moderate. The TAPP chronic-pain estimate was not robust to sensitivity analyses, and SSI and recurrence estimates were imprecise. Cost estimates came from heterogeneous health-care settings.