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
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There were 100 patients in each arm. Chronic pain rate and time to pain
disappearance were higher among patients in the permanent suture
group. Similar comparisons have been done comparing adhesive and
tacks in laparoscopy. Lovisetto et al. reviewed 197 patients with TAPP
repair randomized to fibrin glue or tacks and followed them out to 2
years [ 22 ]. Patients who had fixation with fibrin glue had significantly
less acute and chronic postoperative pain. Topart et al. evaluated 168
patients undergoing totally extraperitoneal (TEP) technique hernia
repair [ 23 ]. Chronic pain occurred in 14.7 % of patients who had tacks
for mesh fixation versus 4.5 % of patients with fibrin glue.
Basic science studies evaluating different fixation methods and their
effects on mesh and CGP are lacking. A recent study by Stoikes et al.
compared fibrin glue fixation of lightweight mesh with permanent
suture fixation in an animal model [ 24 ]. Though sutures were stronger
than fibrin glue at 24 h, fibrin glue fixation was found to be adequate at
24 h. At 1 week postoperatively, the fixation strength was equal between
the groups. A secondary outcome was evaluation of mesh contraction
between the two groups. The contraction rate was consistently greater in
the suture group compared to the glue group, although not statistically
significant. Possibilities affecting mesh contraction may be that the
adhesive group fixates the entire surface of the mesh, thereby preventing
folding and wrinkling. This ultimately allows the full area of the mesh
to be fixed in granulation tissue. Such a finding links to the previously
mentioned study by Bendavid, which showed that disfigured mesh created
potential compartments for nerve entrapment, leading to CGP [ 3 ].
Within the spectrum of mesh repairs, one can see that fixation choices
and careful application of fixation can play a role affecting CGP, independent
of the actual type of mesh used. The difference found with fixation
alone is an example of the multitude of factors that can affect CGP
independent of mesh or mesh type.
Discussion
There is a full spectrum of opinions about the use of synthetic mesh
in inguinal hernia repair. There are valid points from both sides of the
controversy, but the data show that in reality CGP exists with both tissue
repairs and mesh repairs. Their etiologies are likely different. With tissue
repairs, CGP may be due to entrapment of nerves by layers of
sutures; with mesh, it may be due to nerve entrapment from mesh deformation
or a foreign body response causing nerve demyelination [ 2 , 3 ].