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Table 63.Key Question 6: Treatment detailsStudyTreatment ATreatment BTreatment CTreatment DCommentsKim-Fuchs et al., 2011710,711Lichtenstein with sutures (PDS 2.0, polydioxanone; Ethicon). Vypro II mesh used in procedure.Lichtenstein with tissue glue (Histoacryl, Braun?Medical). Vypro II mesh used in procedure.Senior surgeon supervised all operations performed by residents. As hernia repair is one of the primary teaching operations, the performing residents were in the 2nd or higher year of education. Post operative procedure was identical in both groups. The patients moved freely byt lifting was restricted to 7 kg for the first 2 weeks. Garg et al., 2011698TEP with mesh fixed with staples (ProTack, Covidien). Mesh size, 15?x 10 cm, polypropyleneTEP with non-fixated mesh. Mesh size, 15?x?10?cm polypropylene.An injection of diclofenac intramuscularly was given 4 hours after the procedure. All cases done with the patient under spinal anesthesia. Bilateral hernia repair was performed on patients who had bilateral hernia, cough impulse, or bubonocele on the other side, and on those who opted for it. All operations were done by a single experience surgical team. The members of the team had crossed their learning curve by performing more than 4000 TEP repairs from 1994 to 2008.Paajanen et al., 2011782Lichtenstein with sutured mesh (Absorbable polyglycolic acid 3/0 sutures, Dexon).Lichtensteing with mesh fixated with 1 ml butyl-2-cyanoacrylate tissue glue (Gluban, GEM).Optilene mesh (60 g/m2) 9x13 cm trimmed lightweight polypropylene mesh. Four surgeons did all the surgery on study patients during weekly operative schedule (average 3 patients per week per surgeon). All surgeons were senior consultants with wide experience of open inguinal hernia surgery. Procedures carried out under local anesthesia as an outpatient. No prophylactic antibiotics were used. Wong et al., 2011835Open repair with sutured mesh. Sutures (Ethicon) were polyglactin monofilament sutures coated Vicryl. Three sutures, loosely tied, were used to fix the onlay mesh on the upper later in each case. Open repair, mesh fixedwith fibrin glue (2?mL?of Tissucol/Tisseel).Two kinds of bilayer monofilament polypropylene mesh were used at the discretion of the surgeon: Prolene Hernia System (PHS, Ethicon) and Bard Modified Kugel Hernia Patch (Davol, Inc.). In patients who had a relative localized defect of the posterior wall, the PHS system was used; in patients with severe destruction of the posterior wall, the modified Kugel was used. During the study period, one experience surgeon performed 97 primary open inguinal; hernia repairs. Fortelny et al., 2011695TAPP with mesh fixed with fibrin sealant (TISSEEL, baxter healthcare coporation). Mesh was fixed with 2?mL fibrin sealant per side.TAPP with mesh fixed with staples (ENDOPATH endoscopic multifeed stapler, Ethicon). Mesh was fixed ith 4 to 5 staples in defined locations, preserving the pubic tubercle and the area of the course of the iliohypogastric nerve.TiMESH extra light (16?g/m2) for lateral hernias and TiMESH light (35 g/m2) for medial hernias. All meshes were 10 cm x 15 cm and were not tailored. For bilateral repair, the meshes were positioned with an overlap of a t least 3 cm in the midline. Boldo, 2008639TAPP with FG: mesh fixed with autologous fibrin sealant derived from the patients. Autologous fibrin was prepared by the Vivostat (Vivolution A/S) system.TAPP with SG: The ProTrack device was used (USSC Auto Suture). Staples were applied, when possible, pushing gently the tip of the Protrack device against the gron tissues externally compressed by the surgeons (or assistant’s) left hand.NANAA 6x6 in2 polypropylene mesh was used, trimmed according to need. Mesh was introduced, unrolled in the preperitoneal space, and positioned to cover the entire space from the symphysis pubis in the midline to the anterior superior iliac spine laterally. If hernias were bilateral, two pieces of mesh were used and overlapped.Canonico et al., 1999650Lichtenstein with Marlex Mesh (CR Bard) with Human Fibrin Glue (HFG): (Tissucol, Immuno AG, Vienna Austria). The glue is aprotinin (3000 kallidinogenase inactivator units/mL) and lyophilized thrombin (500?units/mL) mixed during the operation to form fibrin and sprayed by a spraying device, allowing an even covering of all layers of the wound.Lichtenstein with Marlex?Mesh (CR Bard) without HFGNANASurgery was performed by 1 surgeon with advanced personal experience in hernia repair, and electrocautery was always used to minimize postoperative bleeding.Douglas et al., 2002676Lichtenstein with Sutures: 2-0 polypropylene sutureLichtenstein with tacks: Tacker (Origin Stat tack) used to secure mesh, disposable instrument with a 5 mm tip containing 15 titanium tacks that resemble small coils. Mesh was initially secured to the pubic tubercle using either one polypropylene simple suture or tack. However, it?was soon noted that strong and easy approximation of the mesh to the pubic tubercle was possible using the tacker, and the remaining patients therefore underwent placement of mesh using only the tacker, except for the suture used to approximate the tails. Care was taken to avoid penetration of the pubic tubercle. tacks were then placed along the inferior edge of the mesh to the level of the internal ring laterally making certain not to penetrate the femoral vessels. Fewer numbers of tacks were also placed in the mesh and transversalis fascia superiorly. NANAAll operations were performed under local anesthesia (mixture of 0.5% bupivacaine and 1%?lidocaine) by one surgeon (senior assistant).Ferzli et al., 1999687Laparoscopic with stapled mesh: performedat the level of the symphysis pubis, the?Cooper’s ligament medially, and the transverse abdomins laterally. Four staples were placed with the Endoscopic Hernia Stapler (Ethicon). Laparoscopic technique with unstapled mesh: mesh left free to accommodate the defect.NANAApplied implant was in all cases a propylene mesh (Prolene, Ethicon)Helbling and Schlumpf, 2003710,711Lichtenstein with Vypro II and Sutures: mesh 14?x?8?cm. Prothesis was fixed to the aponeurotic tissue above the pubic tubercle (avoiding the periost) and along the inguinal ligament with a running suture and to the internal oblique with interrupted sutures. Laterally to the inner ring, the overlaying cranial part of the mesh was fixed to the lower part of the mesh and to the inguinal ligament with interrupted sutures (all sutures made with PDS 2/0)Lichtensten with Vypro II: mesh 14 x 8 cm. Positioning of the prosthesis was equal, but?it was glued on to the pubic tubercle, the inguinal ligament and the internal oblique with small?dots of n-butyl-cyanoacrylate (Histoacryl?B. Braun Melsungen, Germany).NANAXKoch et al., 2006723TEP with mesh fixation: polypropylene mesh (Prolene, Ethicon) trimmed to appropriate size to cover entire myopectineal orfice including defect. Mesh coapted to Cooper’s ligament and anterior abdominal wall using 5 to 8 spiral tacks in patients enrolledTEP without fixation: pre-formed 15 x 10 cm mesh (3D-MAX, Davol Inc) used without tack fixationNANANo baseline data reported in this articleLau, 2005738TEP with Prolene (Ethicon) mesh and fibrin sealant: two Prolene meshes, each measuring abou 10x15 cm2. Patients had fixation of the mesh with TISSEEL?VH 2 mL (Baxter Healthcare). The?2 components of FS, sealer protein solution 2?mL and thrombin solution 2 mL, were reconstituted using the fibrinotherm heating and stirring device (Baxter Healthcare) at the commencement of surgery. The 2 solutions were drawn into 2 separate syringes, which were then fitted into the laparoscopic applicator, Duplocath 35 M.I.C. (Baxter). Once 2 meshes were deployed to desired position, FS 1 mL was applied over each Cooper’s ligament. The?rest of FS (2 mL) was?applied to the inferior edge and upper medial corner of the meshes. To ensure the setting FS adhere firmly to the underlying structures, the mesh was steadied in position by graspers for a few minutes until the FS appeared opalescent on the television monitor.TEP with Prolene (Ethicon) and staples: 2?Prolene meshes 10?x?15?cm2. Endoscopic stapler (EMS Hernia Stapler, Ethicon), used to anchor each mesh over the Cooper’s ligament, along its medial edge and upper lateral corner. No staples were placed below the iliopubic tract lateral to the Cooper’s ligament.NANAXLeibl et al., 2002740TAPP incised: mesh was implanted with a central incision, creating a deep inguinal ring by overlapping the two incised sides. Six staples applied, two alond Cooper’s ligament, one ventral of the symphisis, and two along the ventral-lateral edge of the meshTAPP non-incised mesh and clip fixation: non-incised mesh fixed with staples. Six staples applied, two alond Cooper’s ligament, one?ventral of the symphisis, and two along the ventral-lateral edge of the meshTAPP sutured mesh: non-incised mesh fixed with non-resorbable sutures (Prolene, Ethicon) fixed medially as?well as laterallyNAPatients found to have bilateral hernias at operation underwent repair of opposite side simultaneously. Two pieces of mesh, one on each side overlapping the midline. Dissection of opposite side to search for incipient hernias was not done routinely in all cases.Lovisetto et al., 2007749TAPP with staples: Endopath Multifeed Stapler 10 mm shaft (EMS, Ethicon Endosurgery) with titanium staples was used. The mesh was cut with a slit for the cord structures. The technique involved positioning 3?metal clips at the level of Cooper’s ligament and the pubic tubercle. Some fixations were carried out laterally at the level of the deep inguinal ring. The inferior branch of the mesh was passed beneath the spermatic cord to reconstruct the internal inguinal ring and was successively anchored to the superior branch with metal clips.TAPP with fibrin glue: Tissucol fixation (Baxter Healthcare), the tails of the mesh were wrapped around the spermatic cord and the mesh was anchored with 1 mL of fibrin glue applied both anterior and posterior to the mesh using a dedicated laparoscopic tool (Dulplotip, Baxter Healthcare) inserted in a 5 or 10 mm trocar. slight pressure was applied to the entire perimeter of the mesh using Dulplotip. The Tissucol was applied to the entire perimeter of the mesh and in particular at the level of the superior margin, the “triangle of disaster” and in proximity of the prevesical fat to assure good adhesion. The peritoneal flaps were then closed using small, continuous, resorbable 2/0 sutures.NANAPolpropylene prostheses (14 x 13 cm) mesh. All?patients received one 100?mg dose of Ketoprofene to manage postoperative pain. Local infiltration at the incision sites was not used, and the abdomen was not irrigated with any form of analgesic solution after closure of peritoneum over the mesh.Mills et al., 1997751Lichtenstein with Polypropylene mesh and Polypropylene sutures: mesh 11 x 6 cm cut to shape; mesh fixed in position by a continuous suture of 2/0 polypropylene along the inguinal ligament inferiorly from the pubic tubercle to the lateral edge of the mesh. Interrupted polypropylene sutures were then placed medially and supperiorly into the internal oblique and transversalis muscles. Skin closure was completed using a continous suture of subcuticular 3/0 polydioxanone which was subsequently left in place. Lichtenstein with Polypropylene mesh and staples: mesh 11 x 6 cm cut to shape; Mesh positioned with a Proximate RH rotating Head Skin Stapler (Ethicon), containing 35?preloaded stainless steel staples, was used to secure it. A staple was placed into the pubic tubercle with between seven and nine staples along wth inguinal ligament placed 1-2 cm apart. A further eight to ten staples were placed in the internal oblique and transversalis muscles medially and superiorly and the overlapping free edges of the mesh were stapled together with two staples lateral to the cord. Skin closure was completed using staples from the same staple gun and these were removed 7?days after operation. NANAIn both groups the external onlique aponeurosis was closed with a continuous suture of 2/0 Vicryl (Ethicon) and the subcutaneous tusses were then approximated with the same suture. All operations were performed under general anesthesia by a consultant surgeon (D.A.R.)Moreno-Egea et al., 2004752TEP with Parietex mesh (Sofradim, Villefranche sur Saone, France): Mesh was a self- expandable, 3D, anatomical mesh. Mesh fixated with stapling to the Cooper’s ligamentTEP with Parietex mesh and no fixation: Mesh was self-expanadable, 3D, anatomical mesh.NANAAll operations were performed by 2 surgeons with previous experience (more than 3 years and 60 cases)Nowobilski et al., 2004774Lichtenstein with butyl-2-cyanoacrylate: adhesive (Indermil, Loctite) applied over the surface of the mesh (polypropylene). Adhesive permeated through the perforations in the mesh thus fixing it to the underlying tissues. Approximately 10?seconds was allowed for adhesive to set. The spermatic cord and genitofemoral nerve was lifted in order to avoid anyy direct contact until the glue was dried. Tails of the mesh were also overlapped with glue. The external aponeurosis and skin was approximated by linear traction between forceps and the adhesive applied to the edges and allowed to set. To complete the entire procedure, about 0.5?grams of adhesive was required.Lichetenstein with sutures: polypropylene mesh was fixed in position by a running suture (3/0 dexon, Tyco) along the inguinal ligament inferiorly from the pubic tubercle to lateral edge of the mesh. Interrupted sutures were placed medially and superiorly into the internal oblique and transverse muscles. Tails?of mesh allowed the spermatic cord to pass between them, and they were overlapped with a suture. The external oblique aponeurosis, similar as the subcutaneous tissue, was closed with a continuous suture. Skin closure was completed using a continuous subcuticular suture (3/0?Monosof, Tyco).NANAAll repairs involved polypropylene mesh. All participating surgeons (four) were trained at the same surgery unit under the supervision of the leading skilled surgeon (#1) who also trained the surgeons in TAPP hernia repair with Tissucol. The first experience of tension-free TAPP was performed in January 2003 and each member of the surgical team had carried out more than 50 TAPP procedures with Tissucol before beginning the trial. In patients with bilateral hernias the same procedures were performed sequentially to repair the hernia on the other side (generally smaller).Olmi et al., 2007778TAPP with Protrak (Tyco): an Endopath Multifeed stapler 10 mm shaft, used two L-shaped 14 x 13 cm meshes, positioned 2?tacks medially and 3?laterally to epigastric vessels and 2?tacks on the Cooper ligament. No?tacks were positioned on the “triangle of disaster” and “triangle of pain.” TAPP with EndoANCHOR (Ethicon): an Endopath Multifeed stapler 10 mm shaft, used two L-shaped 14x13cm meshes, positioned 2 tacks medially and 3 laterally to epigastric vessels and 2?tacks on the Cooper ligament. No tacks were positioned on the “triangle of disaster” and “triangle of pain.” TAPP with EMS (Ethicon)TAPP with Tissucol/Tisseal (Baxter healthcare): Used 1 mL of Tissucol for unilateral hernias and 2 mL for bilateral hernias. The prosthesis was fixed along its upper margin, from Cooper ligament to the “triangle of disaster” and to the “triangle of pain,” using a 3 mm catheter (Duplotip, Baxter?Healthcare).The surgoen, anesthesiologist, and the intraoperative and postoperative analgesic regimen were the same for all patients. Paajanen, 2002780Lichtenstein with Premilene (B. Braun Germany) mesh and resorbable : mesh 9?x?13?cm polypropylene; Continuous absorbable 20 braided polyglycolic acid (Dexon II, Tyco?Healthcare)Lichtenstein with Premilene (B. Braun Germany) mesh and nonresorbable: mesh 9x13 cm polypropylene; nonresorbable continuous?sutures of 20?polypropylene (Prolene, Ethicon)NANAAll patients were operated by the same senior consultant surgeon with good experience in inguinal hernia proceduresParshad et al., 2005785TEP with staples: polypropylene mes 15?x?11?cm to 15 x 13 cm based on patient’s habitusTEP without staples: polypropylene mesh 15?x?11 cm to 15 x 13 cm based on patients body habitusNANAXSevonius et al., 2009535,805-813Any operation, nonabsorbable suturesAny operation, long-term absorbable suturesAny operation, short-term absorbable suturesNAXSmith et al., 1999816TAPP, mesh unstapled: repaired using one umbilical 10 mm port and two lateral 5 mm ports, with dissection of the preperitoneal space to allow insertion of 15?x?10?cm polypropylene mesh with not fixation. The peritoneum then was closed with a continuous 2-0 Vicryl suture. Finally the 10 mm port was closed with 0-PDS to the linea alba.TAPP, mesh stapled: similar preperitoneal dissection, with the exception that the contralateral por to the hernia was 12 mm to allow access of the staplin device (EMS Ethicon). The mesh was fixed t o muscle and Cooper’s ligament. Then the peritoneum was closed with staples, and a port-site closure device was used for the 12 mm lateral port.NANAThe primary surgeons were first and second year general surgery residents and all procedures were performed under general anesthesia. Both groups underwent herniorrhaphy with placement of mesh. The mesh was secured to the pubic tubercle and Poupart’s ligament inferiorly and to the transversalis fascia superiorly. Tails of the mesh allowed the spermatic cord to pass between them and in both groups they were overlapped and secured to one another lateral to the spermatic cord using polypropylene suture. Taylor et al., 2008823TEP with Polypropylene mesh and spiral tacks: mesh 10 x 15 cm; fixation?was performed with titanium spiral tacks were used (Autosuture?Protack)TEP with Polypropylene mesh and nonfixation: mesh 10 x 15 cmNANAAll participating surgeons had performed at least 300 TEP repairs prior to commencement. All hernias repaired in the study were performed in a standardized way agreed upon by all surgeons and institutions prior to commencement. Testini et al., 2010824Plug and Mesh and sutures: preshaped monofilament knitted polypropylene mesh and plug (mesh PerFix plug, Bard); uninterrputed single layer of 3/0?polypropylene sutures and the mesh was positioned on this layerPlug and Mesh and human fibrin glue: preshaped monofilament knitted polypropylene mesh and plug (mesh PerFix plug, Bard); 2?mL?fibrin glue applied all?over meshPlug and Mesh and Nbutyl-2-cyanoacrylate: preshaped monofilament knitted polypropylene mesh and plug (mesh PerFix plug, Bard); 1 mL N-butyl-2-cyanoacrylate applied all over meshNASurgeon has experience in inguinal hernia surgey ................
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