24139670n

Review

Comparison of laparoscopic versus open procedure in thetreatment of recurrent inguinal hernia: a meta-analysis ofthe results

Junsheng Li, M.D.*, Zhenling Ji, M.D., Yinxiang Li, M.D.

Department of General Surgery, Affiliated Zhong-Da Hospital, Southeast University, 210009 Nanjing, JiangSu, PR China

KEYWORDS:Laparoscopic;Open procedure;Recurrent inguinalhernia repair;Meta-analysis

AbstractBACKGROUND: The aim of this meta-analysis was to compare the effectiveness and complications

of the laparoscopic procedure and open techniques in the treatment of recurrent inguinal hernias.METHODS: The electronic databases MEDLINE, Embase, PubMed, and Cochrane Library were

used to search for randomized controlled trials and comparative trials about laparoscopic and open pro-cedures on recurrent inguinal hernia repair from January 1999 to September 2012.

RESULTS: A total of 1,311 patients enrolled into 6 randomized controlled trials and 5 comparativestudies were included in this meta-analysis. Our pooled data showed that the laparoscopic procedurewas associated with a lower incidence of wound infection and a shorter sick leave. However, there wereno differences in other complication rates or the operation time between the 2 methods.

CONCLUSIONS: The laparoscopic technique in the treatment of recurrent inguinal hernia was asso-ciated with less wound infection rates and a faster recovery to normal activity, whereas other compli-cation rates, including the re-recurrence rate, were comparable between these 2 methods. Laparoscopicand open procedures could be performed with equal operation time. 2014 Elsevier Inc. All rights reserved.

Inguinal hernia is one of the most frequently performedoperations in general surgery. The surgical techniques usedto manage inguinal hernias are primary open repair, opentension-free repair with mesh, and laparoscopic repair withmesh. Despite the achievement in the field of treatinghernias, the main concern for patients and surgeons ispreventing recurrence. Recurrent rates of 1.1% to 33% havebeen reported depending on the technique and the type and

size of the mesh used to repair the original hernia.14 Reop-erations account for 8% to 17% of all inguinal hernia re-pairs.2,3,5 Recurrent inguinal hernia repair is a demandingprocedure; this type of repair does not always have success-ful results, and higher recurrence and complication rateshave been reported. The risk of re-recurrence for recurrentinguinal hernias is higher than the risk of recurrence afterprimary inguinal hernia repair; a recurrence rate of 8.3%was reported even in specialized centers,6 and a recurrencerate as high as 40% has also been reported.7

The repair of recurrent inguinal hernia is frequentlyassociated with increased technical difficulty, high morbid-ity, and a greater risk for further recurrence. However,although there is no doubt that recurrent inguinal herniashould be repaired usingmesh,8 the questions concerning the

The authors declare no conflict of interest.

* Corresponding author. Tel.: 186-25-8326-2302; fax: +86-25-8327-2000.

E-mail address: [email protected]

Manuscript received January 15, 2013; revised manuscript April 29,

2013

0002-9610/$ - see front matter 2014 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.amjsurg.2013.05.008

The American Journal of Surgery (2014) 207, 602-612

most appropriate treatment for this condition have not yetbeen answered. Some surgeons recommend laparoscopic re-pair, whereas others prefer open tension-free repair.9,10 Theopen tension-free methods have the disadvantages of reoper-ating through scar tissue with the risk of testicular and nervedamage, whereas the main advantages are lower cost and ashorter learning curve.11 The theoretical advantage of thelaparoscopic technique is the avoidance of scarred tissueof the primary operation, permitting relative uncomplicateddissection for mesh placement, whereas the main drawbacksare the need for general anesthesia and the increased cost ofthe operating room and the disposable supplies used. Earlyreports indicated that the laparoscopic technique couldhave advantages over the open technique in terms of postop-erative pain and the time to full recovery.12

However, these results are controversial because fewstudies have compared the different surgical techniques usedto treat recurrent inguinal hernias, and some of the studiesare small. Because of the obvious difficulties in recruitingpatients, large randomized trials of recurrent hernia repairsdo not exist; thus, meta-analysis studies on this topic wouldbe essential for evaluating the results.

The objective of article was to use meta-analysis as atool to compare the outcome of laparoscopic versus openmesh repair in recurrent inguinal hernia repair. The primaryobjectives of this meta-analysis were to determine whetherthe 2 different approaches produce any difference in post-operative complications and recovery with respect to post-operative acute and chronic pain, wound infection,hematomas/seromas, testicular and urinary complications,

recurrence, and reoperation rate due to abdominal injuriesand bleeding.

Methods

By conducting an intensive search of literature in themajor database (PubMed, Embase, Springer, and CochraneLibrary), we identified all randomized controlled trials(RCTs) and comparative trials published from January1999 to and including September 2012 that comparedlaparoscopic and open mesh procedures for recurrent ingui-nal hernia repair. The term recurrent inguinal hernia wasused in combination with the medical subject headingslaparoscopic, open, and repair. Reference list andrelevant articles referenced in these primary studies weredownloaded from databases. The related article functionalso was used to widen the search results. All abstracts,comparative studies, nonrandomized trials, and citationsscanned were searched comprehensively. At last, the datafrom 11 publications (6 RCTs) including 1,311 patients weresummarized in a formal meta-analysis. We first excluded251 trials by using the keyword laparoscopic. Further-more, experimental trials, emergency trials, and reportsother than inguinal hernias were excluded for analysis.Techniques other than transabdominal preperitoneal (TAPP)and total extraperitoneal procedure (TEP) were also ex-cluded in the analysis (eg, intraperitoneal only mesh repair[IPOM], expanded polytetrafluoroethylene [ePTFE], andShouldice techniques [n 5 3]). Trials with incomplete

Potentially relevant trials identifiedand screened for retrieval

n=439

Trials retrieved for more detailed evaluation n=188

Trials includedn= 13

Potentially appropriate trials to be included in the meta-analysis

n=22

Trials with useable information, by outcome

n=11

Trials withdrawn n=2Incomplete information n=1Only reported in child n=1

Trials excluded n=9Bilateral or ventral hernias n=4Experimental cases study n=1Emergency n=1Other techniques n=3

Trials excluded n=166Non-comparative, case report, reviewnon-English language n=166

Trials excluded n=251Trials not relevant n=251

Figure 1 A flow diagram of the selection of trials.

J. Li et al. Recurrent inguinal hernia repair 603

information (eg, quality of life) that were not suitable forcomparison were also excluded. A flowchart of the literatureis shown in Fig. 1. Only published data were used in the anal-ysis. The laparoscopic TAPP and TEP techniques were sum-marized in 1 group.

The quality of trials was assessed with the CochraneHandbook for Systematic Reviews of Interventions Version5.0.113 and a quantitative analysis was performed to com-pare the following parameters: operating time, intra- andpostoperative total morbidity, intestinal and bladder lesions,lesions of major vessels, wound infections, hematomas/se-romas, urinary retention, time to return to normal work, tes-ticular problems, acute pain and long-term complicationssuch as chronic pain, and hernia recurrence. Each articlewas critically reviewed by 2 independent researchers for el-igibility in the meta-analysis, and data were extracted sep-arately by the 2 researchers. Disagreements were resolvedby consensus.

Each included trial was assessed independently to ascer-tain the following methodological qualities: sequence gener-ation, allocation concealment, blinding of participants,personnel and outcome assessors, incomplete outcome data,selective outcome reporting, and other sources of bias. Nosponsors were involved in the study design, data collection,analysis and interpretation, or the writing and submitting ofthe report for publication. All authors had access to the rawdata.

Pooled estimates of outcomes were calculated using afixed effects model, but a random effects model was usedaccording to heterogeneity. Tests for heterogeneity andoverall effects were provided for each total or subtotal. Weused the chi-square statistic to assess heterogeneity be-tween trials, and the I2 statistic to assess the extent of in-consistency. For dichotomous data, results for each trialwere expressed as an odds ratio (OR) or risk difference(RD) with 95% confidence intervals (CIs).

Forest plots were used for the graphic display of resultsfrom the meta-analysis. Statistical analysis were performedusing Review Manager (RevMan version 5.0), the CochraneCollaborations software for preparing and maintainingCochrane systematic reviews.

Bias was studied using sensitivity analysis by removingindividual studies from the data set and analyzing the overalleffects size and weighted regression test described by Eggeret al.14 Publication bias was tested using the Egger test.

Results

Eleven trials1525 on laparoscopic versus open tension-free repair of recurrent inguinal hernia repair encompassing1,311 patients were retrieved from electronic databases.Fig. 1 shows the flowchart of studies from the initial resultsof publication searches to the final inclusion or exclusion.Basic information and the methodological quality of the in-cluded trials are provided in Table 1.

Recurrence

There were 11 trials included in the present studythat compared postoperative recurrence with long-termfollow-ups.1525 There was no significant heterogeneityamong 11 trials (P 5 .32, I2 5 13%); therefore, the fixed-effect model was appropriate. There was no significant differ-ence in the recurrence rate between the laparoscopic and opengroups (RD 5 2.01; 95% CI, 2.04 to .01; Fig. 2A). In boththe fixed and random effects model, the result was the same.To test the sensitivity of this results, we reanalyzed the recur-rence rate in only RCT trials, and there was still no significantrecurrence in the 2 groups (OR52.01; 95% CI,2.06 to .03;Fig. 2B). Furthermore, this result was recalculated with rela-tive risk and OR; the same conclusion was obtained. We

Table 1 Basic information and quality of the included studies

Author, year (reference)Samplesize

Comparison oftechniques Parameters compared

Type ofpublication

Follow-uptime (mo)

Baselinecomparable

Demetrashvili, 201115 52 TAPP/LI 1, 2, 4, 5, 7, 8, 9 RCT 62.4 NAKouhia, 200917 96 TEP/LI 1, 2, 4, 5, 8, 9, 10 RCT 63.6 NAEklund, 200718 146 TAPP/LI 1, 2, 3, 4, 5, 6, 7 RCT 86.4 NADedemadi, 200619 82 TAPP/TEP/LI 1, 2, 3, 5, 6, 7, 8, 9 RCT 36 NABeets, 199922 108 TAPP/GPRVS 1, 2, 4, 5, 6, 7, 8, 9, 10 RCT 24 NANeumayer, 200423 159 TAPP/TEP/LI 1 RCT 24 NAShah, 201116 172 TAPP & TEP/LI, MG, BA, ST 1, 2, 4, 5, 7 RE 144 P . .05Feliu, 200420 207 TEP/LI 1, 2, 3, 5, 6, 7, 8 PR 36 P . .05Kumar, 199921 50 TEP/LI 1, 2, 6, 7 PR 44 P . .05Alani, 200625 99 TEP/ST 1, 2, 4, 5, 6 PR & RE 120 P . .05Richards, 200424 140 TEP/LI 1, 5 RE 120 P . .05

The parameters compared are as follows: 1, recurrence; 2, hematomas/seromas; 3, acute pain; 4, chronic pain; 5, wound infection; 6, testicular

problem; 7, urinary complication; 8, operating time; 9, recovery; 10, reoperation for bleeding or other reasons.

BA 5 bassini; F/U 5 follow-up; GPRVS 5 giant prosthetic reinforcement of the visceral sac; LI 5 Lichtenstein repair; MG 5 mesh plug; NA 5 notassociated; PR 5 prospective; RCT 5 randomized controlled trial; RE 5 retrospective; ST 5 Stoppa repair; TAPP 5 transabdominal preperitonealprocedure; TEP 5 total extraperitoneal procedure.

604 The American Journal of Surgery, Vol 207, No 4, April 2014

further investigated the recurrence rate within these 2 groupsduring the early postoperative stage (,2 years) and late stage(.2 years). Our results showed no difference in the recur-rence rate in the early period (RD 5 2.00; 95% CI, 2.03to .02) or late period (RD 5 2.01; 95% CI, 2.04 to .01;Fig. 2C). Publication bias was also tested with the Eggertest; no publication bias was detected among the present in-cluded articles (data not shown).

Pain

Eight1520,22,25 of the 11 trials reported postoperative pain.We analyzed acute pain and chronic pain (.3 months)

separately. The fixed effects model was used in the acutepain analysis because of the heterogeneity (P 5 .74, I2 50%), and the random effects model was used in the chronicpain group analysis because of the heterogeneity (P 5 .03, I2

5 61%). Result showed there was no significant differencein acute and chronic pain between the laparoscopic and opengroups (OR 5 .48; 95% CI, .14 to 1.69 and RD 5 2.04;95% CI, 2.10 to .02, respectively; Fig. 3A,B).

Wound infection

Nine studies1520,22,24,25 reported wound infection afteroperation. The main meta-analysis with the fixed effects

Study or Subgroup

Alani 2006Beets 1999Dedemadi 2006Demetrashvili 2011Eklund 2007Feliu 2004Kouhia 2009Kumar 1999Neumayer 2004Richard 2004Shah 2011

Total (95% CI)

Total eventsHeterogeneity: Chi = 11.50, df = 10 (P = 0.32); I = 13%Test for overall effect: Z = 0.91 (P = 0.36)

Events

0740

12101814

38

Total

45565024738649258138

111

638

Events

0150

12232

1115

42

Total

5452322873

121472578

10261

673

Weight

7.8%8.6%6.2%4.1%

11.6%16.0%7.6%4.0%

12.7%8.8%

12.5%

100.0%

M-H, Fixed, 95% CI

0.00 [-0.04, 0.04]0.11 [0.01, 0.20]

-0.08 [-0.22, 0.07]0.00 [-0.07, 0.07]0.00 [-0.12, 0.12]

-0.00 [-0.04, 0.03]-0.06 [-0.14, 0.01]-0.04 [-0.17, 0.09]-0.04 [-0.14, 0.06]0.02 [-0.04, 0.07]

-0.05 [-0.12, 0.03]

-0.01 [-0.04, 0.01]

Laparoscopic Open Risk Difference Risk Difference

M-H, Fixed, 95% CI

-0.2 -0.1 0 0.1 0.2Favours laparoscopic Favours open

Study or Subgroup

Beets 1999Dedemadi 2006Demetrashvili 2011Eklund 2007Kouhia 2009Neumayer 2004

Total (95% CI)


Events

740

1208

31

Total

565024734981

333

Events

150

123

11

32

Total

523228734778

310

Weight

16.9%12.2%8.1%

22.9%15.0%24.9%

100.0%

M-H, Fixed, 95% CI

0.11 [0.01, 0.20]-0.08 [-0.22, 0.07]0.00 [-0.07, 0.07]0.00 [-0.12, 0.12]

-0.06 [-0.14, 0.01]-0.04 [-0.14, 0.06]

-0.01 [-0.06, 0.03]


M-H, Fixed, 95% CI


A

B

Figure 2 (A) Postoperative inguinal hernia recurrences. (B) Postoperative recurrence with only RCT trials. (C) Postoperative inguinalhernia recurrence in the early and late groups.


model showed statistically less wound infection in the lap-aroscopic group than the open group (RD 5 2.02; 95% CI,2.04 to 2.00). The heterogeneity was not significant (P 5.57, I2 5 0%) (Fig. 4A). Sensitivity analysis was made totest the results in only RCT trials, and the same conclusionwas obtained (OR 5 .23; 95% CI, .07 to .76; Fig. 4B).

Hematomas and seromas

Fig. 5 shows the incidence of hematomas/seromas after lap-aroscopic and open surgeries; 9 studies were included.1522,25

The random-effects model was used because of the heteroge-neity (P5 .009, I25 59%). The results showed that there was

no significant difference of hematomas/seromas between thelaparoscopic and open repair groups (OR 5 .68; 95% CI,.36 to 1.30; Fig. 5).

Testicular problems

Six studies1822,25 reported postoperative testicularproblems (including orchitis and pain). There was noheterogeneity among the trials (P 5 .17, I2 5 36%),and therefore, the fixed effects model was used; the re-sults showed no significant difference of testicular prob-lems between the 2 groups (RD 5 2.02; 95% CI, 2.04to .01).

Study or Subgroup

2.1.1 early recurrence

Alani 2006Beets 1999Dedemadi 2006Demetrashvili 2011Eklund 2007Feliu 2004Kouhia 2009Kumar 1999Neumayer 2004Richard 2004Shah 2011Subtotal (95% CI)


2.1.2 late recurrence

Alani 2006Dedemadi 2006Demetrashvili 2011Eklund 2007Feliu 2004Kouhia 2009Richard 2004Shah 2011Subtotal (95% CI)


Events

07405101814

31

00070000

7

Total

4556502473864925813864

591

4550247386493847

412

Events

01408202

1111

30

01040304

12

Total

5452522873

121472578

10219

651

54322873

12147

10242

499

Weight

8.3%9.1%8.6%4.4%

12.4%17.0%8.1%4.2%

13.5%9.4%5.0%

100.0%

11.3%9.0%5.9%

16.8%23.1%11.0%12.7%10.2%

100.0%

M-H, Fixed, 95% CI

0.00 [-0.04, 0.04]0.11 [0.01, 0.20]

0.00 [-0.10, 0.11]0.00 [-0.07, 0.07]

-0.04 [-0.13, 0.05]-0.00 [-0.04, 0.03]0.00 [-0.04, 0.04]

-0.04 [-0.17, 0.09]-0.04 [-0.14, 0.06]0.02 [-0.04, 0.07]0.01 [-0.11, 0.13]

-0.00 [-0.03, 0.02]

0.00 [-0.04, 0.04]-0.03 [-0.11, 0.04]0.00 [-0.07, 0.07]0.04 [-0.04, 0.13]0.00 [-0.02, 0.02]

-0.06 [-0.14, 0.01]0.00 [-0.04, 0.04]

-0.10 [-0.19, 0.00]-0.01 [-0.04, 0.01]


M-H, Fixed, 95% CI


C

Figure 2 (Continued)


Urinary problems

Seven studies15,16,1822 reported the urinary retention and in-fection after hernia repair. The fixed effects model was used be-cause of the heterogeneity (P 5 .46, I2 5 0%). The resultsshowed that therewas no significant difference of urinary prob-lems between the 2 groups (OR 5 .82; 95% CI, .38 to 1.79).

Operation time

Five trials compared the operation time between the 2groups.1517,19,20 One trial reported the results in 3 groups19;thus, we presented the results in 2 subgroup analysis (sub-groups 1 and 2). There were significant heterogeneities inboth subgroups (P , .00001, I2 5 92% and P , .00001,I2 5 94%, respectively), and the random effects modelwas used in both subgroups. The results showed no differ-ence in the operation time in the results of both subgroups(P 5 .4 in both subgroups) (Fig. 6).

Time to return to work

Four RCT trials reported the time to return to work ornormal activity (sick leave) after laparoscopic and open

repair.15,17,19,22 Again, the results of 2 subgroups were pre-sented because 1 trial reported results in 3 groups.19 The ran-dom effects model was used because of heterogeneity (P 5.02, I2 5 69% and P 5 .01, I2 5 72%, respectively). The re-sults showed a significantly shorter convalescence period afterlaparoscopic repair (P , .00001) in both subgroups (Fig. 7).

Reoperation rate

Only 2 trials17,22 contributed to the combined analysis ofreoperation rates; the reason for reoperation was eitherbleeding or ileus. There was no significant heterogeneityamong trials (P 5 .26, I2 5 22%). There was no significantdifference in the reoperation rate accordingly (OR 5 1.34;95% CI, .26 to 6.89).

Comments

The repair of recurrent inguinal hernia is a problematicissue; it is far more complex than the treatment of primaryhernias. There is no doubt that recurrent inguinal herniashould be repaired with the application of meshes.8 Severalmethods are proposed to solve this problem, including bothopen and laparoscopic methods; however, there are still

Study or Subgroup

Dedemadi 2006Eklund 2007Feliu 2004

Total (95% CI)


Events

211

4

Total

507386

209

Events

215

8

Total

3273

121

226

Weight

31.5%13.3%55.2%

100.0%

M-H, Fixed, 95% CI

0.63 [0.08, 4.68]1.00 [0.06, 16.30]0.27 [0.03, 2.38]

0.48 [0.14, 1.69]

Laparoscopic Open Odds Ratio Odds Ratio

M-H, Fixed, 95% CI

0.002 0.1 1 10 500Favours laparoscopic Favours open

Study or Subgroup

Alani 2006Beets 1999Demetrashvili 2011Eklund 2007Kouhia 2009Shah 2011

Total (95% CI)

Total eventsHeterogeneity: Tau = 0.00; Chi = 12.76, df = 5 (P = 0.03); I = 61%Test for overall effect: Z = 1.22 (P = 0.22)

Events

20184

12

27

Total

4556246849

111

353

Events

403

1213

5

37

Total

545228674761

309

Weight

17.9%27.6%11.6%13.9%10.7%18.2%

100.0%

M-H, Random, 95% CI

-0.03 [-0.12, 0.06]0.00 [-0.04, 0.04]

-0.07 [-0.21, 0.07]-0.06 [-0.18, 0.06]

-0.19 [-0.34, -0.05]0.03 [-0.06, 0.12]

-0.04 [-0.10, 0.02]


M-H, Random, 95% CI


A

B

Figure 3 (A) Postoperative acute pain. (B) Postoperative chronic pain.


conflicting views regarding the indications of the applica-tion of these methods. Some surgeons recommend laparo-scopic repairs,5,17,26 whereas others prefer the openprocedures.27

The laparoscopic procedure has the advantage of reducingthe hernia sac through virgin tissues and covering the entiremyopectineal orifice with a mesh. Furthermore, the laparo-scopic method was shown to have the superiority of reducedpostoperative pain, a shorter recovery period and earlier returnto work, and accessibility to different potential hernia de-fects.28,29 However, the laparoscopic procedure was reportedto be more often associated with serious intraoperative com-plications than the open repair although such complicationsare infrequent.30 Furthermore, the laparoscopic technique re-quires general anesthesia.31 However, the main drawbackwith open tension-free recurrent inguinal hernia repair is dis-section through the scarred tissue, which increases the risk ofcord and testicular vessels injury or nerve injury, causing po-tential damage to the inguinal ligament.11

Only a few randomized trials have compared the resultsof laparoscopic and open procedures for recurrent inguinalhernias, and because of obvious difficulties in recruitingpatients, large randomized trials of recurrent hernia repairsdo not exist. Thus, a meta-analysis on this issue would beessential to evaluate the results. The aim of our trial was toperform a combined analysis of the immediate- and long-term results of the 2 different surgical approaches, the opentension-free procedures and the laparoscopic methods. Inthe present article, we combined TAPP and TEP repair in1 group because a Cochrane database systemic reviewshowed no obvious difference between TAPP and TEPconcerning hematoma, vascular injuries, deep mesh infec-tion, and recurrence, and further subgroup analysis wouldonly hinder the statistical evaluation.32

From the patients point of view, recurrence is the majorconcern after hernia repair.5 It has been shown that the riskof recurrence is greater after surgery for a recurrent versus aprimary hernia.33 In the Swedish registry,5 the reoperation

Study or Subgroup

Alani 2006Beets 1999Dedemadi 2006Demetrashvili 2011Eklund 2007Feliu 2004Kouhia 2009Richard 2004Shah 2011

Total (95% CI)


Events

000010112

5

Total

4556502473864938

111

532

Events

041122412

17

Total

5452322873

12147

10261

570

Weight

9.4%10.3%7.5%4.9%

13.9%19.2%9.2%

10.6%15.0%

100.0%

M-H, Fixed, 95% CI

0.00 [-0.04, 0.04]-0.08 [-0.16, 0.00]-0.03 [-0.11, 0.04]-0.04 [-0.13, 0.06]-0.01 [-0.06, 0.03]-0.02 [-0.05, 0.01]-0.06 [-0.15, 0.02]0.02 [-0.04, 0.07]

-0.01 [-0.07, 0.04]

-0.02 [-0.04, -0.00]


M-H, Fixed, 95% CI


Study or Subgroup

Beets 1999Dedemadi 2006Demetrashvili 2011Eklund 2007Kouhia 2009

Total (95% CI)


Events

00011

2

Total

5650247349

252

Events

41124

12

Total

5232287347

232

Weight

33.6%13.1%

9.9%14.3%29.1%

100.0%

M-H, Fixed, 95% CI

0.10 [0.01, 1.82]0.21 [0.01, 5.26]0.37 [0.01, 9.62]0.49 [0.04, 5.56]0.22 [0.02, 2.08]

0.23 [0.07, 0.76]


M-H, Fixed, 95% CI


A

B

Figure 4 (A) Postoperative wound infection. (B) Postoperative wound infection analyzed in RCT trials.


rates were 4.6% after recurrent hernia repair versus 1.7%after primary hernia repair at the 24-month follow-up. Inparticular, the recurrence rate after recurrent hernia repaircould be as high as 39% after conventional open sur-gery,34,35 justifying the use of prosthesis for the

management of recurrent hernias. There were conflictingresults regarding the recurrence rate after laparoscopicand open procedure after recurrent inguinal hernia re-pair.17,22,23 In the present pooled analysis, we found no sig-nificant difference in the recurrence rates between

Study or Subgroup

14.1.1 subgroup 1

Dedemadi 2006Demetrashvili 2011Feliu 2004Kouhia 2009Shah 2011Subtotal (95% CI)

Heterogeneity: Tau = 71.99; Chi = 50.39, df = 4 (P < 0.00001); I = 92%Test for overall effect: Z = 0.83 (P = 0.40)

14.1.2 subgroup 2

Dedemadi 2006Demetrashvili 2011Feliu 2004Kouhia 2009Shah 2011Subtotal (95% CI)

Heterogeneity: Tau = 83.84; Chi = 63.86, df = 4 (P < 0.00001); I = 94%Test for overall effect: Z = 0.85 (P = 0.40)

Mean

5564.440.8

6967.47

5664.440.8

6967.47

SD

128.48.340

25.67

98.48.340

25.67

Total

50248649

111320

50248049

111314

Mean

4559.646.3

5868.92

4559.646.3

5868.92

SD

89.97.116

37.57

89.97.116

37.57

Total

3228

1214761

289

3228

1214761

289

Weight

22.8%22.2%24.3%14.6%16.2%

100.0%

23.1%22.1%24.1%14.5%16.1%

100.0%

IV, Random, 95% CI

10.00 [5.67, 14.33]4.80 [-0.17, 9.77]

-5.50 [-7.66, -3.34]11.00 [-1.10, 23.10]-1.45 [-12.02, 9.12]3.45 [-4.66, 11.57]

11.00 [7.27, 14.73]4.80 [-0.17, 9.77]

-5.50 [-7.72, -3.28]11.00 [-1.10, 23.10]-1.45 [-12.02, 9.12]3.74 [-4.92, 12.39]

Laparoscopic Open Mean Difference Mean Difference

IV, Random, 95% CI

-20 -10 0 10 20Favours laparoscopic Favours open

Figure 6 The operation time between the 2 groups.

Study or Subgroup

Shah 2011Richard 2004Demetrashvili 2011Kumar 1999Beets 1999Alani 2006Dedemadi 2006Kouhia 2009Eklund 2007Feliu 2004

Total (95% CI)

Total eventsHeterogeneity: Tau = 0.57; Chi = 21.89, df = 9 (P = 0.009); I = 59%Test for overall effect: Z = 1.16 (P = 0.25)

Events

1044

1057

136

10

60

Total

111382425564550497386

557

Events

073

125

12126

1713

87

Total

6110228255254324773

121

595

Weight

3.2%3.9%8.5%

10.3%11.6%11.7%12.2%12.2%12.8%13.7%

100.0%

M-H, Random, 95% CI

1.67 [0.07, 41.61]0.17 [0.01, 2.97]1.67 [0.33, 8.32]0.21 [0.05, 0.78]2.04 [0.65, 6.44]0.44 [0.14, 1.35]0.27 [0.09, 0.79]2.47 [0.85, 7.16]0.29 [0.11, 0.80]1.09 [0.46, 2.62]

0.69 [0.36, 1.30]


M-H, Random, 95% CI


Figure 5 Postoperative hematomas and seromas.


laparoscopic and open repair of recurrent inguinal hernia.In this study, sensitivity analysis was performed withinthe RCT trials, and publication bias was tested with the Eg-ger test, showing no publication bias, which justified ourcomparisons.

Recently, Shah et al16 reported that the laparoscopictechnique had a significantly lower re-recurrence rate thanthe open technique during long-term follow-up (.1.5years) in our meta-analysis. Therefore, we performed sub-group analysis for earlier (,2 years) and late recurrence(.2 years); contrary to Shahs study, we did not detectedthe different recurrence rates between the early and lateperiods.

A study by Arvidsson et al36 showed a correlation be-tween a low surgical performance score and the recurrencerate, which indicated that the recurrence rate is influencedby technical difficulties. It is argued that poor resultsof laparoscopic hernioplasty should be blamed on a lackof expertise and not the laparoscopic approaches per se.37

Therefore, it was suggested that laparoscopic repair for re-currence should be restricted to highly experienced laparo-scopic surgeons38 and highly specialized laparoscopiccenters.23,39

Pain after inguinal hernia repair was frequent. A study inEngland showed that chronic groin pain after hernia repairis 1 of the 2 most common causes of litigation.40 Chronicpain was reported to be 18% to 30% after mixed open tech-niques at 3 years postoperatively.41,42 An equal rate ofchronic pain with significant effects on daily activitieswas reported for 12% of patients after both open and

laparoscopic repair.43 Others reported a higher prevalenceof chronic pain after open hernia repair compared with alaparoscopic approach and attributed the reason for the dif-ficulty to identifying nerve structures when operatingthrough scar tissues formed after the previous surgical in-tervention. However, contrary results were also reported.44

Furthermore, Grant et al45 showed that the incidence ofpain at 1 year was greater in the open group comparedwith the laparoscopic group, but at the 5-year follow-up,the incidence of pain in both groups was equal. In our pre-sent combined analysis, the incidences of both acute painand chronic pain (.3 months) were analyzed, and both re-sults proved to be similar between the open and laparo-scopic groups.

Another severe complication after inguinal hernia repairis testicular atrophy, which was reported for 30% ofpatients after ischemic orchitis46,47 and occurs for .09% to.5% of patients after primary hernia repair and 3% to 5%after recurrent hernia repair.46,48 Our present study revealedsimilar testicular problem rates in both laparoscopic andopen recurrent hernia repair.

We did not compare the hospital stay in this studybecause some hernias were repaired as a day surgery andothers were not. With no surprise, we confirmed that thetime to return to work and normal activity was significantlyless in the laparoscopic group.

Previously, pooled analysis reported a significantly in-creased operating time in the laparoscopic repair group49;however, in our study, no significant difference in the oper-ating time was noted between the open and laparoscopic

Study or Subgroup

15.1.1 Recovery time group 1

Beets 1999

Dedemadi 2006

Demetrashvili 2011

Kouhia 2009

Subtotal (95% CI)

Heterogeneity: Tau = 3.37; Chi = 9.76, df = 3 (P = 0.02); I = 69%

Test for overall effect: Z = 4.43 (P < 0.00001)

15.1.2 Recovery time group 2

Beets 1999

Dedemadi 2006

Demetrashvili 2011

Kouhia 2009

Subtotal (95% CI)

Heterogeneity: Tau = 3.78; Chi = 10.65, df = 3 (P = 0.01); I = 72%

Test for overall effect: Z = 4.44 (P < 0.00001)

Mean

13

14

13.4

14.8

13

13

13.4

14.8

SD

8.2

9

1.7

2.7

8.2

8

1.7

2.7

Total

56

50

24

49

179

56

50

24

49

179

Mean

23

20

17.5

17.9

23

20

17.5

17.9

SD

12.4

11

2.6

6.7

12.4

11

2.6

6.7

Total

52

32

28

47

159

52

32

28

47

159

Weight

16.0%

13.4%

39.8%

30.8%

100.0%

15.9%

13.9%

39.5%

30.6%

100.0%

IV, Random, 95% CI

-10.00 [-14.00, -6.00]

-6.00 [-10.56, -1.44]

-4.10 [-5.28, -2.92]

-3.10 [-5.16, -1.04]

-5.15 [-7.43, -2.87]

-10.00 [-14.00, -6.00]

-7.00 [-11.41, -2.59]

-4.10 [-5.28, -2.92]

-3.10 [-5.16, -1.04]

-5.36 [-7.73, -3.00]

Laparoscopic Open Mean Difference Mean Difference

IV, Random, 95% CI

-10 -5 0 5 10

Favours Laparoscopic Favours open

Figure 7 The time to return to work (sick leave) after repair between the 2 groups.


procedures. Contrary to another meta-analysis from Dede-madi et al,50 which found all the compared outcomes wereequivalent between laparoscopic and open procedure in re-current hernia repair, we concluded in the present studythat laparoscopic recurrent inguinal hernia repair was asso-ciated with less wound infection, a faster return to postoper-ative normal work and activity, and an equal duration of theoperating time.

We also acknowledge the weak points in this meta-analysis. There were both RCTs and comparative studies inour analysis; although the baseline in each trial was com-parable (..05), it would be more apposite to only comparethe RCTs.

In summary, our current study findings showed that thelaparoscopic and open procedures are equally quick toperform with similar recurrence rates and postoperativeacute and chronic pain. However, the laparoscopic proce-dures have the advantages of fewer postoperative woundinfection rates and a quick return to normal work comparedwith open techniques.

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2014 Elsevier

Comparison of laparoscopic versus open procedure in the treatment of recurrent inguinal hernia: a meta-analysis of the resultsMethodsResultsRecurrencePainWound infectionHematomas and seromasTesticular problemsUrinary problemsOperation timeTime to return to workReoperation rate

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