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

32. Chronic Groin Pain: Mesh or No Mesh
421
hundred patients were reviewed with follow-up in 153 of the patients out
to a median of 129 months. None of the patients in either group had pain
as defined by persistent pain or pain interfering with daily activities.
Autogenous repairs including Bassini, McVay, and Shouldice techniques
were compared to the Lichtenstein repair. At all time points, pain
was similar with mesh repair trending toward less pain compared to
non-mesh repairs, except at 10 years when neither group had chronic
pain. This agrees with most comparative studies that have found the
incidence of CGP to be similar between the open mesh repairs versus the
autogenous repairs. The Hernia Trialists reviewed 20 trials and over
5000 repairs comparing mesh- based and non-mesh-based repairs for
inguinal hernia [ 10 ]. The incidence of CGP was equal in both groups.
Nordin et al. found similar results when comparing the mesh-based
Lichtenstein repair versus the autogenous Shouldice repair [ 11 ]. At
3-year follow-up, the incidence of CGP was 4.2 % in the Shouldice
repair and 5.6 % in the Lichtenstein group.
The differences between laparoscopic inguinal hernia repair with
mesh and the open autogenous Shouldice repair are even more pronounced.
Bittner et al. completed a meta- analysis showing CGP in 2.2 %
of laparoscopic repairs and 5.4 % of Shouldice repairs [ 12 ]. The SMIL
study reviewed laparoscopic transabdominal pre-peritoneal (TAPP)
repair versus open autogenous Shouldice repair and found CGP to be
similar between the two groups (8.5 % TAPP vs. 11.4 % Shouldice) [ 13 ].
Koninger et al. looked at 280 patients at 52 months follow-up and compared
the incidence of CGP in those having a Shouldice, Lichtenstein, or
TAPP repair [ 14 ]. CGP was found in 36 % of the Shouldice repairs, 31 %
of the Lichtenstein repairs, and 15 % of those with TAPP.
Looking at the collection of studies including autogenous and mesh
repairs, it becomes evident that mesh use may not be the sole cause of
chronic pain. An objective review of the data actually indicates that the
laparoscopic repair, which is a mesh repair, has the lowest incidence of
CGP. These findings indicate the complex nature of inguinal hernia
repair. Also of importance is the technical detail of each approach.
Mesh Weight
To complicate matters and to reinforce the concept of mesh and the
foreign body response, mesh weight has been speculated to contribute to
CGP. The general principle is that less synthetic mesh implies less foreign
body, less inflammatory response, and therefore less pain.