World J Surg

DOI 10.1007/s00268-014-2710-0

SCIENTIFIC REVIEW

Mesh Repair Versus Non-Mesh Repair for Strangulated Inguinal

Hernia: Systematic Review with Meta-Analysis
Hassen Hentati • Wajih Dougaz • Chadli Dziri

Ó Société Internationale de Chirurgie 2014

Abstract
Background The optimal technique to cure strangulated inguinal hernia remains controversial. The use of mesh in
cases of strangulated hernia is still debated due to the potential risk of infection.
Objective This systematic review aimed to determine whether or not the mesh repair technique is associated with a
higher risk of surgical site infection than non-mesh techniques for strangulated inguinal hernias in adults.
Methods An electronic search of the relevant literature was performed on 15 December 2012 using the following
databases: MEDLINE, the Cochrane Library, Scopus, Embase, and the Web of Science. Articles reporting a com-
parison between the mesh repair technique and a non-mesh technique to treat strangulated inguinal hernias in adults,
and published in the English or French language in a peer-reviewed journal, were considered for analysis. The quality
of randomized controlled trials (RCTs) was assessed using the Jadad scoring system. To assess the quality of non-
randomized trials, we used the Methodological Index for Non-Randomized Studies (MINORS).
Results A total of 232 papers was found in the initial search; nine were included in the meta-analysis. The wound
infection rate in the mesh repair technique group was lower than in the control group, with a trend towards
significance (odds ratio [OR] 0.46, 95 % confidence interval [CI] 0.20–1.07; p = 0.07). The hernia recurrence rate
was lower in the mesh repair group (OR 0.2, 95 % CI 0.05–0.78; p = 0.02).
Conclusion The mesh repair technique is a good option for the treatment of strangulated inguinal hernias in adults,
giving an acceptable wound infection rate and fewer recurrences than non-mesh repair. Our study does not allow us
to recommend the use of mesh in cases of bowel resection. We emphasize that, except the two RCTs, the results are
predicated on patient selection bias by careful surgeons. Further RCTs are required to obtain more powerful evi-
dence-based data.

Introduction Hernia Society guidelines state that the mesh repair

Inguinal hernia repair is the most frequent operation in
general surgery [1]. Approximately 10 % of inguinal her-
nias are diagnosed with incarceration [2, 3]. European
H. Hentati
W. Dougaz (&)
C. Dziri
Department B of General Surgery, Charles Nicolle Hospital,
Tunis, Tunisia
e-mail: wejih.dougaz@gmail.com
according to the Lichtenstein technique is the standard
treatment of elective inguinal hernia in adults [4]. The
optimal technique to cure strangulated inguinal hernia
remains controversial. The use of mesh in cases of stran-
gulated hernia is still debated due to the potential risk of
infection [3–7].
This systematic review aimed to determine whether or
not mesh repair is associated with a higher risk of surgical
site infection (SSI) than non-mesh techniques for strangu-
lated inguinal hernias in adults.

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Fig. 1 Study flow diagram.
RCT randomized clinical trial
Methods
Search strategy
An extensive electronic search of the relevant literature
was performed on 15 December 2012 using the following
databases: MEDLINE, the Cochrane Library, Scopus,
Embase, and the Web of Science. Keywords used for
the final search in all databases were ‘strangulated hernia,’
‘incarcerated hernia,’ ‘Lichtenstein,’ ‘mesh,’ and
‘prosthesis’.
Inclusion and exclusion criteria
All relevant studies reporting a comparison between mesh
repair technique and a non-mesh technique to treat
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World J Surg
strangulated inguinal hernias in adults, and published in
English or French in a peer-reviewed journal, were con-
sidered for analysis. Studies comparing small bowel
resection and no bowel resection in strangulated inguinal
hernias treated with mesh repair technique were also con-
sidered. Data from editorials, letters to editors, review
articles, and case series (fewer than ten cases) were
excluded from analysis.
Adults (age C18 years) of either sex operated on for
strangulated inguinal hernia were included. We excluded
patients referred for femoral or ventral hernias.
Interventions
The treatment group comprised patients who underwent
inguinal hernia mesh repair according to the Lichtenstein
World J Surg

Table 1 Characteristics of nine studies retained, in alphabetical order provided that there no signs of generalized peritonitis or
Author Type of study Jadad MINORS
contamination of the surgical field.
scale score
Outcome measures
Atila et al., 2010 [7] Prospective cohort 15/24
Bessa et al., 2007 [17] Prospective non- 19/24 The primary outcome was the occurrence of SSI. SSI was
randomized
defined as the presence of pus or proven bacterial con-
Derici et al., 2010 [6] Retrospective 9/24
tamination of the surgical site, whether or not further sur-
Elsebae et al., 2008 Randomized 2
[16] controlled gery for treatment was required [12]. This outcome was
Karatepe et al., 2008 Randomized 3
also evaluated when available in two subgroups: bowel
[2] controlled resection and no bowel resection.
Nieuwenhuizen et al., Retrospective 13/24 The secondary outcome was hernia recurrence. Recur-
2011 [5] rence was defined as a palpable swelling or defect at the
Papaziogas et al., Retrospective 14/24 previous surgical site in the groin.
2005 [3]
Topcu et al., 2013 Prospective non- 17/24 Validity assessment
[15] randomized
Wysocki et al., 2006 Retrospective 12/24
The full publications of all possibly relevant abstracts were
[18]
obtained and formally assessed for inclusion. All studies that
MINORS Methodological Index for Non-Randomized Studies met the selection criteria were assessed for methodological
quality by two authors (HH, WD). The quality of randomized
technique [8]. Polypropylene mono filament mesh was controlled trials (RCTs) was assessed using the Jadad scoring
used in all considered studies. system [13]. To assess the quality of non-randomized trials,
The control group comprised patients treated with any we used the Methodological Index for Non-Randomized
non-mesh repair technique: the Bassini technique [9], the Studies (MINORS) index [14]. This index contains 12 items
modified Bassini technique [10], and the Shouldice tech- that are scored 0 (not reported), 1 (reported but inadequate),
nique [11]. or 2 (reported and adequate). The ideal global score is 24 for
The surgeons chose the type of surgery, and no prefer- comparative studies and 16 for non-comparative studies.
ence criterion was employed for the repair method to be Non-randomized studies with a MINORS index higher than
used for all non-randomized studies. 12 for comparative studies and 8 for non-comparative studies
The presence of intestinal ischemia or necrosis was not were retained for analysis.
considered a contraindication for mesh repair in all studies,
Statistical analysis
SE(log[OR])
0
Heterogeneity among studies was assessed by means of the
I2 inconsistency test and Cochran’s Q test, a null hypoth-
esis test in which p \ 0.05 is taken to indicate the presence
0.5 of significant heterogeneity. Selection biases were detected
Derici
by funnel plots. Overall estimates of treatment effect with
their 95 % confidence intervals (CIs) were calculated using
1
the Mantel-Hansel method for fixed models. Results are
presented in forest plots. All calculations were carried out
using the Review Manager 5.2 software.

1.5

Results

2
OR Retrieved reports
0.01 0.1 1 10 100
A total of 232 studies were identified from the search
Fig. 2 Funnel plot of comparison: 1 Mesh repair versus non-mesh (Fig. 1); three were duplicates and were removed.
repair, outcome: 1.1 wound infection. OR odds ratio, SE standard According to the title or abstract, 213 studies were exclu-
error ded because they did not meet the inclusion criteria: 146

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Lichtenstein Non mesh repair Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Derici 2010 3 29 6 102 13.6% 1.85 [0.43, 7.89]
Elsebae 2008 1 27 3 27 16.5% 0.31 [0.03, 3.16]
Nieuwenhuizen 2011 1 51 3 25 22.5% 0.15 [0.01, 1.49]
Papaziogas 2005 2 33 4 42 18.9% 0.61 [0.11, 3.57]
Wysocki 2006 0 56 3 21 28.6% 0.05 [0.00, 0.95]

Total (95% CI) 196 217 100.0% 0.46 [0.20, 1.07]

Total events 7 19
Heterogeneity: Chi² = 6.87, df = 4 (P = 0.14); I² = 42%
0.01 0.1 1 10 100
Test for overall effect: Z = 1.80 (P = 0.07)
Favours [Lichtenstein] Favours [Non mesh repair]

Fig. 3 Forest plot of comparison: 1 Mesh repair versus non-mesh repair, outcome: 1.1 wound infection. CI confidence interval

0
SE(log[OR]) characteristics of all studies included are listed in Table 1.
The study flow diagram is presented in Fig. 1.

Outcomes measures
0.5

Surgical site infection

1 Five studies comprising 413 patients reported SSI, com-

1.5
2
0.01 0.1 1 10
Fig. 4 Funnel plot of comparison: 1 Mesh repair versus non-mesh
repair, outcome: 1.2 wound infection 2. OR odds ratio, SE standard
error
were case reports or small case series, 37 were not related
to inguinal hernia, 27 did not report mesh repair according
to the Lichtenstein technique, and three were published in
languages other than French or English (one in German,
one in Italian, and one in Swedish).
A total of 16 study reports were considered potentially
relevant, and the full text was sought. Seven studies were
excluded because they did not report data concerning
strangulated inguinal hernias. We retained nine studies for
final analysis [2, 3, 5–7, 15–18]: two RCTs, three non-
randomized prospective studies, and four retrospective
studies. Except the two RCTs, the results are predicated on
patient selection bias by careful surgeons. The
paring mesh repair technique with non-mesh techniques
(Figs. 2, 3) [3, 5, 6, 16, 18]. A total of 26 wound infections
were reported (seven in the mesh repair group and 19 in the
control group). The wound infection rate was lower in the
mesh repair group than in the control group, but the dif-
ference was not statistically significant (odds ratio [OR]
OR 0.46, 95 % CI 0.20–1.07). Heterogeneity was high
100 (I2 = 42 %). Four studies [3, 5, 16, 18] reported ORs
(ranging from 0.05 to 0.31) in favor of the mesh repair
group; only one [6] showed an OR in favor of the control
group, but it was not significant.
One study was located on the edge of the funnel plot and
was suspected to be a cause of heterogeneity (Fig. 2) [6].
Therefore, after removing this study, we performed a new
analysis on the four remaining studies (Figs. 4, 5). Heter-
ogeneity was good (I2 = 0 %). The infection rate in the
mesh repair group was statistically lower than in the con-
trol group (OR 0.25, 95 % CI 0.08–0.72).
Recurrence
Three studies [3, 6, 16], with a total of 260 patients
(Figs. 6, 7), reported significantly lower recurrence rates in
favor of the mesh repair group (OR 0.20, 95 % CI
0.05–0.78). Twenty-seven recurrences were reported (two
in the mesh repair group, 25 in the control group). Heter-
ogeneity was low (I2 = 0 %). The three studies [3, 6, 16]

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Lichtenstein Non mesh repair Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Elsebae 2008 1 27 3 27 19.1% 0.31 [0.03, 3.16]
Nieuwenhuizen 2011 1 51 3 25 26.1% 0.15 [0.01, 1.49]
Papaziogas 2005 2 33 4 42 21.8% 0.61 [0.11, 3.57]
Wysocki 2006 0 56 3 21 33.0% 0.05 [0.00, 0.95]

Total (95% CI) 167 115 100.0% 0.25 [0.08, 0.72]

Total events 4 13
Heterogeneity: Chi² = 2.43, df = 3 (P = 0.49); I² = 0%
0.01 0.1 1 10 100
Test for overall effect: Z = 2.56 (P = 0.01)
Favours [Lichtenstein] Favours [Non mesh repair]

Fig. 5 Forest plot of comparison: 1 mesh repair versus non-mesh repair, outcome: 1.2 wound infection 2. CI confidence interval

were in favor of the mesh repair group, with ORs ranging

SE(log[OR])
0 from 0.13 to 0.63 (Fig. 6).

Surgical site infection if bowel resection

0.5
Five studies [2, 3, 7, 15, 17], with a total of 221 patients,
reported the wound infection rates following mesh repair
for strangulated inguinal hernia in two subgroups: bowel
1 resection (experimental group) and no bowel resection
(control group). Three studies [2, 15, 17] reported no
events and were therefore excluded from the meta-analysis
(Figs. 8, 9). Three wound infections occurred (all in the
1.5
control group). Heterogeneity was low (I2 = 0 %). No
statistically significant difference was found between
wound infection rates in each group.
OR
2
0.01 0.1 1 10 100

Discussion
Fig. 6 Funnel plot of comparison: 1 Mesh repair versus non-mesh
repair, outcome: 1.3 recurrence. OR odds ratio, SE standard Our study showed that the mesh repair technique is a good
error option for treating strangulated inguinal hernia in adults

Lichtenstein Non mesh repair Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Derici 2010 1 29 20 102 62.4% 0.15 [0.02, 1.14]
Elsebae 2008 0 27 3 27 25.1% 0.13 [0.01, 2.59]
Papaziogas 2005 1 33 2 42 12.5% 0.63 [0.05, 7.21]

Total (95% CI) 89 171 100.0% 0.20 [0.05, 0.78]

Total events 2 25
Heterogeneity: Chi² = 1.01, df = 2 (P = 0.60); I² = 0%
0.01 0.1 1 10 100
Test for overall effect: Z = 2.32 (P = 0.02)
Favours [Lichtenstein] Favours [Non mesh repair]

Fig. 7 Forest plot of comparison: 1 Mesh repair versus non-mesh repair, outcome: 1.3 recurrence. CI confidence interval

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compared with non-mesh techniques, giving better results
in terms of SSI and recurrence. Comparing bowel resection
and no bowel resection, both mesh repair and non-mesh
techniques result in similar SSI rates.
Risks of recurrence and complications have to be con-
sidered when choosing hernia treatment. It is now estab-
lished that operation techniques using mesh provide fewer
recurrences than non-mesh repairs. The European Hernia
Society recommends mesh repair according to the Lich-
tenstein technique as the ‘best evidence-based option’ for
the elective repair of a primary unilateral hernia in adults
[4]. However, there has been widespread concern that
synthetic materials in emergency interventions for incar-
cerated and strangulated hernias are too susceptible to
SE(log[OR])
0
0.5
surgical field infection. While there is a common consensus
in frankly contaminated fields, such as peritonitis, that
prosthetic material should be avoided due to a high risk of
infection, mesh repair is still debated in cases of possible
infection, such as strangulation, with or without bowel
resection. In 2009, a Swedish meta-analysis reported a low
risk of wound infection after mesh repair for strangulated
inguinal hernia [19]. However, on one hand, the results
were not given by means of forest plot, and, on the other
hand, the quality assessment and homogeneity of the
included studies were not explained.
This is the first meta-analysis to compare the mesh
repair technique and non-mesh repairs for the treatment of
strangulated inguinal hernias in adults. Even though our
results seem encouraging in favor of the mesh repair
technique, our systematic review is flawed by some prob-
lems: the quality of included studies, with only two RCTs;
the outcome assessor was not blind in the majority of
studies; the data on peri-operative treatment were missing
or not comparable, particularly the type and duration of
prophylactic antibiotics and the use of suction drainage;
and the small number of participants in some studies.

1
Conclusion

The mesh repair technique is a good option for the treat-

1.5
ment of strangulated inguinal hernias in adults, giving an
acceptable wound infection rate and fewer recurrences than
non-mesh repair. Our study does not allow us to recom-
OR
2 mend the use of mesh in cases of bowel resection. We
0.01 0.1 1 10 100
emphasize that, except for the two RCTs, the results are
predicated on patient selection bias by careful surgeons.
Fig. 8 Funnel plot of comparison: 2 Mesh repair technique: Bowel
resection versus no bowel resection, outcome: 2.1 wound infection. Further RCTs are required to obtain more powerful evi-
OR odds ratio, SE standard error dence-based data.

Bowel resection No bowel resection Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Atila 2010 0 12 1 72 40.4% 1.91 [0.07, 49.50]
Bessa 2007 0 4 0 21 Not estimable
Karatepe 2008 0 5 0 16 Not estimable
Papaziogas 2005 0 4 2 29 59.6% 1.22 [0.05, 29.86]
Topcu 2012 0 8 0 50 Not estimable

Total (95% CI) 33 188 100.0% 1.50 [0.15, 14.61]

Total events 0 3
Heterogeneity: Chi² = 0.04, df = 1 (P = 0.85); I² = 0%
0.01 0.1 1 10 100
Test for overall effect: Z = 0.35 (P = 0.73)
Favours [Bowel resection] Favours [No bowel resect]

Fig. 9 Forest plot of comparison: 2 Mesh repair technique: Bowel resection versus no bowel resection, outcome: 2.1 wound infection. CI
confidence interval

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Conflict of interest The authors declared no conflicts of interest.
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