Mesh fixation for inguinal hernia : Integrated and updated data of umbrella review with network meta-analysis and cost-utility analysis

Abstract

Surgical mesh repair is defined as the standard care for symptomatic inguinal hernia patient. Mesh fixation is used to secure the mesh to myopectineal orifice, the weakness area of inguinal hernia. However, the various types of mesh fixation both open and laparoscopic approach and their relative effects were still controversial. The aim of this study was to evaluated 6 various mesh fixations for inguinal hernia on clinical outcome and cost-utility analysis. The methodology used umbrella review and prospective cohort study designs. The umbrella review involved thirty systematic reviews and meta-analyses of inguinal hernia mesh fixation and two-hundred and sixty-one patients from two University hospitals in Thailand, with surgery for primary uncomplicated inguinal patients for prospective cohort study. The main outcomes were hernia recurrence, chronic groin pain, complications and cost-utility analysis. Among the 30 meta-analyses, mesh fixations not associated with hernia recurrence, glue was associated with suggestive evidence on lower chronic groin pain event more than suture/tacker. Glue and self-gripping mesh were associated with shorter operative time than tacker (laparoscopic) and suture (open), respectively. Among the 261 patients divided into 6 groups, A - laparoscopic with tacker (n=47), B - laparoscopic with glue (n=26) and C - laparoscopic with self-gripping mesh (n=30), D - open with suture (n=117), E - open with glue (n=18) and F - open with self-gripping mesh (n=23). Hernia recurrence was the most common in group C, the highest mean utility score was in group E and F with 0.99 (0.02), and 0.99 (0.03), respectively. The pre-operative utility score was fitted with baseline utility in multilevel mixed effect model and treatment model. The cost of treatment in laparoscopic surgery was higher than open surgery group, laparoscopic with self-gripping mesh was highest cost. The cost-effectiveness plane for utility view and hernia recurrence case prevented demonstrated laparoscopic with self-gripping mesh was less cost-effective. The cost-effectiveness acceptability curves showed that open with glue was associated with the highest probability of being cost-effective at level willingness-to pay from 0 to 80,000 Baht, and after this point open with self-gripping mesh was the most cost-effective. In conclusion and relevance, mesh fixation did not affect hernia recurrence, the main outcome of concern in hernia repair. The open surgery hernia using glue and self-gripping mesh demonstrated the alternative for cost-effectiveness.