Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

28. Prevention of Pain Optimizing the Open Primary Inguinal…
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Choice of the Prosthesis: Plug, Mesh,
Lightweight Versus Heavyweight,
and Absorbable Versus Nonabsorbable
Polypropylene meshes were developed in 1959 and have been used
commonly since then. Although the use of synthetic mesh substantially
reduces the risk of hernia recurrence [ 42 ], polypropylene meshes have
been found to cause chronic inflammatory reactions that persist for years
and can have potentially negative effects, including chronic pain [ 43 ].
It has been surmised that the extent of the foreign body reaction with
its provoked scar tissue is correlated with the amount of the synthetic
material used [ 44 ]. This led to the development of so-called lightweight
mesh characterized by a reduction in the polypropylene volume, an
increase in the pore size, or different web structures [ 45 , 46 ].
The meta-analysis of RCTs reported by Uzzman et al. [ 47 ] shows that
lightweight mesh is associated with significantly less chronic groin pain
(14.3 %), compared with heavyweight mesh (20.3 %) in Lichtenstein
inguinal hernia repair, and less foreign body sensation (15.2 % vs. 26.1
%). These benefits did not appear to be at the expense of an increased
rate of hernia recurrence. Smietanski [ 48 ] performed a meta-analysis
including two more studies in addition to those included in Uzzaman
et al. study: results were similar, but there was no difference in the two
groups for severe chronic pain. Therefore, while there is clearly a benefit
with regard to foreign body sensation, it is still uncertain whether lightweight
mesh has a real clinical benefit over heavyweight with regard to
severe inguinodynia. No statistical significance was found regarding
chronic pain at 5 years in an RCT comparing Lichtenstein with the PHS
[ 49 ]. We advise lightweight meshes especially in thin patients and in
case of small indirect inguinal hernia.
Choice of Fixation
Another factor that should be addressed concerning the prevention of
pain is the influence of fixation of the mesh. Penetrating fixating or
traumatic devices like sutures, staples, and tacks cause local trauma that
may result in nerve injury and chronic pain and should, therefore, be
used with caution.