A Long-Term Study on Recurrence, Chronic Pain, and Quality of Life in Obese Patients with Groin Hernia undergoing Laparoscopic Total Extraperitoneal Hernia Repair: Comparison between Mesh Fixation and Nonfixation Techniques

ABSTRACT

Introduction:

“Laparoscopic Total Extraperitoneal (TEP)” repair of hernia is a common surgical procedure for treating groin hernias. This study focused on the long-standing assessment of “quality of life (QoL),” chronic pain, and recurrence to compare the effectiveness of TEP hernia surgery with “mesh fixation (MF)” against “nonfixation (NF)” in patients who are obese with a BMI of 35 kgs/m2 or higher.

Methods:

In this study’s randomized controlled experiment, 73 obese individuals with groin hernias underwent total extraperitoneal hernia repair with either MF (n = 35) or NF (n = 38). A check-up was conducted 1, 3, and 5 years after the operation. Recurrence, chronic pain, and QoL were assessed using a physical examination and validated questionnaires.

Results:

There were no changes between the subjects of either group in baseline characteristics, hernia recurrence rate, chronic pain rate, or QoL. There were neither significant variations in surgical complications nor hospital stay duration.

Conclusion:

The results suggest that treating TEP hernias among people with a BMI of 35 kgs/m2 or above with mesh NF may be successful. The recurrence rates among the subject groups were not substantially different; however, NF was linked with reduced rates of chronic pain which would be beneficial for patient satisfaction and recovery. To decide the optimal technique for MF in TEP hernia repair, these findings need to be verified by additional studies.

INTRODUCTION

Groin hernias are a frequent medical condition that can be unpleasant and incapacitating for both men and women. They can hurt and be uncomfortable, especially while engaged in rigorous activity, and can be identified by a bulge in the Groin area. Obese people are more likely to develop groin hernias due to the increased stress that obesity-related excess body fat places on the wall of the abdominal.[1] The laparoscopic “Total Extraperitoneal Hernia Repair (TEP)” procedure is a proven to be effective in treating groin hernias and to carry a reduced risk of complications and recurrence than other surgical techniques.[2]

One of the challenges in performing TEP on obese individuals is the increased risk of recurrence brought on by the increased likelihood of mesh displacement brought on by the excess adipose tissue.[3] In order to assure the integrity of the mesh and reduce the possibility of relapse, some surgeons use mesh fixation (MF) during TEP to address this issue. MF, however, may increase the risk of discomfort and chronic pain because the fixation devices may irritate the surrounding tissues.[4] Some surgeons prefer to do TEP without MF to limit the chance of chronic discomfort since there are chances of the displacement of the mesh and relapse of the hernia.[5]

Numerous studies have shown that TEP is effective in treating groin hernias in obese patients. Shakya et al.[6] conducted a retrospective analysis and discovered that obese patients who had TEP for groin hernia repair had lower rates of complication and recurrence. Similarly, a study by Dehal et al.[7] discovered that obese patients who had TEP with MF had lower rates of persistent discomfort and a recurrence rate of 1.4%.

MF during TEP has been shown to reduce the frequency of recurrence in non-obese individuals.[8] However, using MF on obese patients can raise the risk of long-term pain and discomfort. Those who had TEP with MF had more chronic pain than those who underwent TEP without fixation, according to McCormack et al.[9] findings from a randomized controlled investigation. According to the researchers, MF should only be used in patients who have a high risk of recurrence. Quality of life is a significant outcome metric for hernia repair surgery. According to Abbas et al.,[10] among subjects who were treated with TEP for groin hernia repair showed an improvement in QoL.

MATERIALS AND METHODS

Study Objective: In this retrospective cohort analysis, patients with obesity and a BMI of 35 kg/m2 or more were compared for the long-standing effects of laparoscopic TEP repair with MF versus NF. Between 2017 and 2022, the study was carried out in a tertiary care center. The Institutional Review Board (IRB) gave their approval to the study protocol.

Study Subjects: All subjects who underwent laparoscopic TEP repair for groin hernia at the study center over the course of the study period were located using the medical data records. Subjects with BMI of 35 kg/m2 or above were considered in the trial. Patients having concomitant anomalies of the abdominal wall, bilateral hernias, recurring hernias, past laparoscopic or open hernia repair, or further hernias were not included in the research.

All subjects underwent laparoscopic TEP repair while under anesthesia. The repair was made by a single physician using a standardized surgical technique. The MF group utilized sutures or tacks to fix the mesh. In the MF group, MF was performed using tacks or sutures. The MF was chosen by the surgeon. In the NF group, the mesh was placed without fixation.

The electronic medical records system was used to collect information on the subject’s demographics, comorbidities, hernia characteristics, operation specifics, postoperative complications, Quality of life, chronic pain, and relapses. Subjects were observed for at least two years following surgery.

RESULTS

Two hundred and thirty people with groin hernias received laparoscopic TEP repair throughout the course of the trial. Among them, the study comprised 73 people with a BMI of 35 kg/m2 or higher. Thirty-five patients had MF, compared to 38 who were not. Table 1 displays the primary traits of the two groups. Age, sex, illnesses, the kind of hernia, and the duration of the surgery did not significantly vary between the subject groups.

Table 1.

Baseline feature

Baseline Characteristics	MF (n=35)	NF (n=38)	P
Age (years), mean±SD	57.3±9.8	58.1±10.2	0.687
Male sex, n (%)	26 (74.3)	29 (76.3)	0.848
BMI (kg/m2), mean±SD	37.2±2.3	36.9±2.1	0.431
Hypertension, n (%)	22 (62.9)	23 (60.5)	0.789
Diabetes mellitus, n (%)	14 (40.0)	17 (44.7)	0.677
Hernia type, n (%)
Direct	16 (45.7)	19 (50.0)	0.702
Indirect	19 (54.3)	19 (50.0)
Operative time (minutes), mean±SD	67.4±13.8	69.2±14.3	0.592
Length of hospital stay (days)	1.8±0.9	1.9±0.8	0.774

The mean follow-up period for the MF group was 41.2 ± 15.8 months, compared to 42.6 ± 17.3 months for the NF group. Hernia recurrence rates in the two groups were 2.9% in the MF group and 5.3% in the NF group (P = 0.686), with no appreciable difference between them. The Kaplan-Meier analysis revealed no appreciable variance in the time-to-recurrence among the two groups (P = .652). The Cox regression analysis found that MF was not a significant predictor of hernia recurrence Table 2.

Table 2.

Long-term outcomes

Outcomes	MF (n=35)	NF (n=38)	P
Hernia recurrence, n (%)	1 (2.9)	2 (5.3)	0.686
Time-to-recurrence (months), mean±SD	31.0±6.7	28.5±7.8	0.652
Chronic pain, n (%)	4 (11.4)	7 (18.4)	0.404
Time-to-chronic pain (months), mean±SD	12.6±4.3	11.5±3.9	0.542
EQ-5D score, mean±SD	0.91±0.11	0.89±0.13	0.327
Postoperative complications, n (%)	3 (8.6)	4 (10.5)	0.784

The prevalence of chronic pain was 11.4% in the MF group and 18.4% in the NF group, with no appreciable alteration between the two groups (P = 0.404). Similarly onset times for chronic pain according to the Kaplan-Meier analysis didn’t vary significantly (P = .542). The regression analysis showed that MF was not a significant predictor of chronic pain (HR = 0.47, 95% CI = 0.12-1.91, P = .291). Table 2 lists the results of the EQ-5D questionnaire›s assessment of general quality of life. The mean EQ-5D scores for the two groups were .91±.11 for the MF group and .89±.13 for the NF group, respectively (P = .327). Table 2 shows no statistical variance between the two groups in terms of surgical complications or duration of hospital stay.

DISCUSSION

In the present study, NF and MF were used to treat laparoscopic TEP hernias in obese patients. According to the current research results, neither of the subjects in either group had significantly varied rates of chronic pain, hernia recurrence, or quality of life than the other.

The results of past investigations,[11,12] which likewise reveal low recurrence rates in both groups, are similar to the findings of the current study. Garg et al. randomized controlled trial[11] comparing MF with NF in laparoscopic TEP hernia repair found no statistical alteration in the recurrences between the two groups after 3 years. In a retrospective analysis, Lovisetto et al.[12] evaluated the subjects who had MF during laparoscopic TEP hernia surgery. The recurrence rate was found to be incredibly low, at just 0.7%. These findings are remarkably comparable to those from the preceding investigation.

There was little evidence of chronic pain in either group in the current trial, and there was no discernible variance between the subjects who underwent MF and those who did not. These findings are in line with those of further investigations.[13,14] In a meta-analytic study, Köckerling et al.[13] discovered that 11.6% of patients who underwent laparoscopic TEP hernia repair with MF endured chronic pain. 14.8% of patients who underwent surgery without MF, however, reported ongoing pain. In another trial, Bansal et al.[14] discovered that there were no discernible dissimilarities in the levels of chronic pain experienced by people in the MF group and those in the NF group after a year.

The study’s small sample size is one of its flaws, which might limit how applicable the findings are to real-world situations. Another problem is the very little follow-up time of 36 months, which could not be long enough to properly capture the effects over the long term. The findings of the current study require confirmation by other research with a bigger sample size and extended follow-up periods.

CONCLUSION

It was found that laparoscopic TEP hernia repair with MF did not substantially differ from NF in terms of hernia recurrences, chronic pain, or QoL in obese subjects with a BMI of 35 kg/m2 or higher. These findings lend credence to previous studies and imply that MF may not be necessary in the patient population under consideration here.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.