Inguinal hernia repair stands as one of the most common surgical interventions worldwide, with more than 20 million of procedures performed annually.^1,2 The choice of the appropriate surgical approach is influenced by patient's condition, type of hernia, and surgeon's expertise, leading to considerable worldwide variation in practice. Therefore, various techniques are available for hernia repair, including mesh and non-mesh techniques. Throughout history, a range of materials have been used for hernia repair, from commonly used cotton and silk sutures to more modern options such as nylon, polyester, and polytetrafluoroethylene. However, these materials have had several disadvantages, such as susceptibility to sepsis, provocation of foreign body reactions, rigidity, and a reduction in tensile strength over time.^3,4 In 1959, F. Usher developed a knitted mesh in polyethylene, the forerunner of polypropylene. It showed better integration of collagen due to increased fibroblast activity, and improved strength of the whole system.⁵ The use of polypropylene mesh has strongly reduced hernia recurrence rates and improved patient recovery, due to its exceptional stretch, which exceeds physiological stress by approximately five times.⁶

However, there is now a heated discussion among surgeons over the optimum properties of polypropylene mesh, including its weight. Heavy-weight meshes weigh more than 80 g/m2, medium-weight meshes weigh between 50 and 80 g/m², light-weight meshes weigh between 35 and 50 g/m², and ultra-lightweight meshes weigh less than 35 g/m².⁶ Lightweight meshes ranged from 28 to 60 g/m², whereas heavy meshes ranged from 72 to 116 g/m², according to a recent systematic evaluation of 48 randomized controlled trials. This suggests a simplified classification: light meshes are defined as those weighing less than 60 g/m² and heavy meshes as those weighing more than 70 g/m².⁷ Although heavy-weight polypropylene (HW-PP) meshes were first preferred because of their apparent mechanical stability and durability, worries about possible side effects, such as persistent pain and foreign body reactions, have prompted researchers and medical professionals to look into other possibilities.

The purpose of lightweight polypropylene meshes (LW-PP) is to provide a compromise between tissue integration and decreased foreign body reaction. These meshes are made of thinner filaments with big pores, often greater than 1 mm. Reduced foreign body reactivity and improved defect site compliance are made possible by the use of lower density material and a different pore size, which is also showing promise as a remedy for the problems with HW-PP meshes.⁸Numerous studies compared the use of LW-PP with HW-PP meshes in open inguinal hernia repair, evaluating clinical outcomes and postoperative complications. These studies offered important insights.^9,10,11 The association between the usage of LW-PP and the risk of developing persistent groin discomfort remains unclear, despite the fact that the type of mesh does not influence the rate of hernia recurrence.^13,14

Additionally, not much research has been done on patient satisfaction and the recovery of daily living activities over several months. By contesting the conventional approach's standing as the industry standard and the best remedy for groin issues, the current paper aims to further the discussion of inguinal hernia repair. Our aim is to conduct a comprehensive evaluation of the advantages and drawbacks associated with both LW-PP and HW-PP polypropylene meshes, and to determine their impact on postoperative comfort and overall patient health-related quality of life (HRQoL).¹⁵

We design a retrospective cohort study aimed to assess the HRQoL and 1-year outcomes of patients who underwent open inguinal hernia repair using HW-PP meshes compared to LW-PP meshes. The study cohort included adult patients who underwent inguinal hernia repair under Spinal Anesthesia.

Patient selection

Subjects with a body-mass index (BMI) of less than 18.5 or greater than 29.9 were not allowed to participate in the study in order to maintain population homogeneity. Additionally, patients with recurring hernias or internal oblique hernias were not included. Additionally, patients who had recent pregnancy, sepsis, hospitalization, or urgent surgery upon presentation at the emergency room were not included, nor were those who had had prior abdominal surgery within the preceding three years.

Data collection

Retrospectively, pertinent information was taken from the patients' computerized medical records. Along with preoperative details like the hernia site, symptoms, and comorbidities (cardiovascular disease, asthma or chronic obstructive pulmonary disease, obstructive sleep apnea syndrome, cancer, diabetes, chronic kidney disease, constipation, and smoking), demographic data like age and sex were also documented. The length of the procedure, the kind of mesh (LW-PP or HW-PP), the size of the hernia (based on the EHS inguino-femoral classification^2,27), and the surgical details were all recorded. Patients were given either 95 g/m of HW-PP or 34–36 g/m² of LW-PP. Complications, length of hospital stay, recurrence, and HRQoL metrics were among the postoperative outcomes that were gathered.

Health-related quality of life assessment

Using the Short Form 36 (SF-36) questionnaire to measure Health-Related Quality of Life (HRQoL), this study used a cross-sectional approach to investigate the effects of hernia repair. A popular generic measure that assesses several aspects of mental and physical health is the SF-36. Physical functioning, role constraints, physical discomfort, general health, vitality, social functioning, role restrictions brought on by emotional issues, and mental health are all evaluated by its eight scaled scores. Weighted sums of the questions in each part are represented by scores, which range from 0 to 100. 18 Patients filled out the questionnaire at different intervals, such as before surgery and one year later at follow-up outpatient appointments.

Follow-up

One month following the procedure and then again a year later, patients were regularly scheduled for follow-up sessions at the surgical outpatient clinic. The final cohort did not include patients who were lost to follow-up. A physical examination and a comprehensive review of the patient's medical history were part of the normal follow-up protocol. An ultrasound was done if there was continued uncertainty about a hernia recurrence.

Surgical procedure

All surgeries were performed by the same senior surgeon (N.C.). All surgeries were done under Spinal anesthesia using 0.5 % Bupivacane (heavy). were determined independently of the investigators.

The surgical technique (modified Lichtenstein hernia repair) included preparation of the aponeurosis of the external oblique muscle, followed by its opening to access the hernia site. The spermatic cord was isolated, and the elements of the funiculus were separated from the hernia sac, which was neither opened nor reduced in size. For direct hernias (“medial” in the EHS classification system), it was held below the level of the internal oblique and transverse muscles using anatomical forceps. Forward layer begins medially, leaving a sufficient end to tie the returning suture. For indirect hernias (“lateral”), the hernia sac was reduced in size. The transversalis fascia was prepared and flattened with 0 polypropylene suture behind the spermatic cord.

After completion the sutures, a polypropylene mesh was placed on the reconstructed floor of the inguinal canal, secured to the prepubic fibrous tissue with a single stitch, and the aponeurosis of the external oblique muscle was closed. Finally, the abdominal wall was closed in layers. Notably, no plugs were used in any of the procedures. 

Endpoints

Primary endpoint was to assess the impact of inguinal hernia repair on patients’ quality of life and to monitoring its modification after time (delta ratio). Secondary endpoints were post-operative complications and daily life disturbances.

Statistical analysis

Descriptive statistics, including means, standard deviations, frequencies, and percentages, were used to summarize the demographic and clinical characteristics of the study population. Continuous variables were analyzed using t-tests or Mann-Whitney U tests, depending on the data distribution. Categorical variables were compared using chi-square tests or Fisher's exact tests as appropriate. Statistical significance was set at p ​< ​0.05.

A total of 712 patients underwent open inguinal hernia repair in the enrollment period, whereas 312 were lost to 1-year follow-up. The inclusion criteria were met by a final cohort of 400 patients, comprising 200 individuals for each of the implanted prosthesis (60 females and 340 males). There were no statistically significant differences between the two groups, and the participants' ages ranged from 22 to 94 years (67 ± 15). In specifics, 46% of the cases were left inguinal hernias and 56% were right. Sixty-one percent of patients had symptoms. Additionally, there were no notable variations in comorbidities, BMI, or the physical status grade of the American Society of Anesthesiologists (ASA) Approximately 10% of people had previously had cancer, and 16% had previously had contralateral inguinal hernia surgery.

.
Table 1. Intra-operative data.

∗ EHS: European Hernia Society.

Regarding distinctive hernia features, there were 120 cases of "pantaloon hernias" and 40 cases where the transversalis fascia was entirely torn from the internal inguinal ring to the pubic tubercle. The EHS groin hernia categorization was used to determine the hernia size. There was no intestinal resection, and the average operating time for the LW-PP and HW-PP groups was 51 and 53 minutes, respectively. (Table 1)

Table 2. Post-operative course.

∗ POD: Post-operative day; VApS: Visual Analogue Pain Scale.

An assessment of intraoperative characteristics showed that placing the HW-PP was not difficult. However, following the initial ten cases, it was discovered that the LW-PP mesh was more appropriate for the patient's anatomical shape. When either type of mesh was placed, there were no intraoperative problems. There were no discernible variations in healing times between the two mesh types in terms of postoperative results. Only one patient needed an extra night in the hospital, and the average length of stay was short.

A self-administered Visual Analogue Pain Scale (VApS)¹⁹ was used to measure patient suffering following suture removal (about on the tenth postoperative day). The median values for LW-PP and HW-PP were 3 and 4, respectively. Seroma development was seen in 12 cases for both mesh types, but no incidences of superficial surgical site infection were found during wound examination. In contrast, 20 individuals with HW-PP and 14 instances with LW-PP experienced mild hemorrhagic suffusion. Urinary problems, hydrocele, or orchioepididymitis were not documented. However, 18 cases of LW-PP and 10 cases of HW-PP were found to have peri-incisional paresthesia.

Common drugs were used to treat postoperative pain, and patients usually returned to their regular activities—including going back to work—within seven days. Eight cases in the HW-PP group and two in the LW-PP group experienced sleep disturbances, which are defined as any disruptions in a patient's regular sleep patterns (insomnia, non-restorative sleep, delayed sleep onset, or fragmented sleep). These disturbances were assessed during the first ten days following surgery. Twenty cases with HW-PP and eight cases with LW-PP had impairment of daily living, which usually consists of physical limits including decreased mobility, exhaustion, and pain that interfere with everyday activities like walking, working, driving, and cleaning. (Table 2).

Table 3. Follow-up SF-36.

The SF-36 questionnaire, assessing Health-Related Quality of Life (HRQoL), comprised 36 items across eight different health domains. At the 30-day follow-up, patients with LW-PP mesh reported a higher level of well-being compared to those with HW-PP meshes. Specifically, within 30 days postoperatively, patients who received the HW-PP reported discomfort in 36 ​% of cases, primarily in the form of a foreign body sensation in the inguinal canal. This discomfort was accentuated in certain postures or movements. Another 11 ​% of patients complained of burning along the inguinal ligament.

Interestingly, no statistically significant differences were observed in any of the eight domains of the SF-36 health survey. Median follow-up was 1 year (range 11–14 months). Thus, the 1-year follow-up with the SF-36 questionnaire revealed no significant differences in outcomes between the two types of mesh, although there is a positive trend that LW-PP mesh provides fewer functional limitations, greater social and emotional well-being, reduced discomfort, and better overall health (Table 3).

Although we report four cases of fermoral hernias that occurred after three months in patients with thick meshes, no incidences of hernia relapse were found among the patients who underwent surgery. Furthermore, a US examination revealed no mispositioning.

The use of mesh in hernia repair surgery has become a common practice, with polypropylene mesh being the predominant choice due to its excellent stretch and tensile strength. Despite the widespread use of HW-PP meshes, a significant proportion of patients (up to 25 ​%) continue to experience postoperative discomfort or interference with daily activities, even for several months.^20,21 These studies suggest that LW-PP meshes, consisting of a lower density material, may have potential advantages over HW-PP, offering increased patient comfort and reducing the postoperative complication rates. A randomized clinical trial, on a similar cohort of patients underwent unilateral primary inguinal hernia via the Lichtenstein technique, confirmed that fewer patients in the LW-PP mesh group reported numbness around the groin or along the thigh after surgery, whereas with no differences in terms of chronic pain incidence and recurrence rate.²² In our study, 1-year HRQoL evaluation, using a reliable and easy-to-use questionnaire, highlights the non-inferiority of LW-PP. These findings appear to be consistent with the 6-month results reported by the SUPERMESH study group in 2018.²³ It is also coherent with the biologic-functional role of the prosthesis as a scaffold for the development of fibrosis necessary for the containment and long-term resolution of hernia disease.

Previous results call for a critical evaluation of LW-PP product, requiring a thorough analysis of its features, technical difficulties, and the implications of its preference. Two main strengths of our study are that variability was reduced by having the same main surgeon using the same technique, and that the type of mesh was usually blinded to the patient and their reported symptoms were not influenced by the surgeon's choice. Our intra-operative evaluation revealed that LW-PP meshes have some practical advantages. They are easier to handle and more transparent, allowing better visualization of the underlying tissues. The LW-PP mesh also conforms better to the roundness of the tissue and offers less resistance to cutting. These characteristics support the notion that they may provide better anatomical integration and reduce the risk of postoperative complications, such as a lower incidence of seroma formation and peri-incisional paresthesia. However, it is crucial to note that early post-operative course did not show significant differences between the two groups, apart from a greater number of patients who underwent HW-PP mesh placement experiencing generic daily life disturbances or sleep disturbances, further supporting their potential benefits in terms of patient comfort. According to Smedberg et al. the placement of either mesh does not affect short-term complications, with comparable rates of postoperative pain, as well as the occurrence of wound hematoma and seroma.²⁴ Compared with recent literature, our cohort has a higher rate of seroma than wound hematoma.

At mid-term follow-up, the self-administered scale, assessing postoperative comfort, strongly indicated higher scores for patients with LW-PP meshes compared to those with HW-PP meshes. These results suggest that LW-PP meshes may contribute to a better overall patient experience, potentially leading to improved postoperative recovery and well-being. Interestingly, patients who received HW-PP mesh placed rarely achieved full satisfaction in the physical and mental health domains examined one year after surgery, although baseline scores were similar in both groups. On the other hand, the same domains are more likely to improve in patients who have placed a LW-PP mesh, with complete satisfaction in physical functioning, role physical as well as role emotional. Indeed, this finding is consistent with previous literature and with the biologic-functional role of the prosthesis as a scaffold for the development of the fibrosis necessary for the containment and long-term resolution of hernia disease.²⁵ Consequently, smaller filament spacing, and pores increase the risk of bridging by scar tissue, which takes several months to develop.

A recent meta-analysis reported no statistically significant difference in recurrence between the two types of mesh, contradicting the notion that there is a higher incidence of recurrence due to the smaller amount of material in the LW-PP mesh.²⁶ An important role in influencing recurrence is played by mesh shrinkage. The percentage of mesh shrinkage is highly variable, depending on the material, structure, geometry, and direction of the mesh.²⁷ Jerabek et al. describe how the implantation of a polypropylene mesh with a pore size of 3 ​mm is associated with a significant reduction in shrinkage compared to a mesh with a pore size of 1 ​mm and a mesh with a pore size of 0.5 ​mm.²⁸ Meanwhile, Silvestre et al. concluded that shrinkage was significantly higher for HW-PP, although the difference was not large.²⁹ In our sample case, two cases of femoral hernia and no recurrence were recorded. It's essential to interpret this result with caution. First, we hypothesize that the placement of a HW-PP resulted in an upward detraction of tissue, leading to the formation of a new area of weakness below the Poupart's ligament. Second, the relatively small sample size and the limited follow-up period could affect our results. We strongly emphasize the need for further research with larger cohorts and longer follow-up periods to gain a more comprehensive understanding of the surgical outcomes associated with each mesh type. Other contributing factors to the absence of hernia relapse could be that all procedures were performed by a high-volume surgeon,³⁰ as well as the preference of the modified Lichtenstein hernia repair.

More recently, the Hernias, Pathway and Planetary Outcomes for Inguinal Hernia Surgery Project (HIPPO) has been run in a prospective way by the NIHR Unit on Global Surgery. Main goals are to investigate technical variations and surgical outcomes of inguinal hernia surgery, with a focus on the impact of waiting times and environmentally sustainable measures adopted by surgical teams. Preliminary results from this study show a lack of access to mesh in low- and middle-income countries and limited use of minimally invasive approach across all income groups, with only a quarter of patients operated on using minimally invasive techniques.³¹

Our study has several limitations. First, its nature of retrospective single-center single-surgeon study introduces the possibility of selection bias and incomplete data. Secondly, the limited sample size may require validation in a larger cohort. As is increasingly recognized in the scientific community, preoperative planning is becoming crucial for the successful outcome of surgery and the reduction of complications of any kind. It is therefore crucial to consider individual patient features, such as age, comorbidities, and frailty status, as well as hernia characteristics, when selecting the appropriate mesh type.³² Customizing mesh selection based on patient-specific factors may help to optimize outcomes and minimize postoperative complications.^33,34 Thirdly, as the study investigated the open inguinal hernia repair, the results may not be directly applicable to other types of hernias or surgical techniques, such as laparoscopic or robotic hernia repair surgery. Two recent meta-analyses described a significant superiority of HW-PP mesh in terms of hernia recurrence after laparo-endoscopic surgery, although with equivalent outcomes for postoperative pain, seroma, foreign body sensation, surgical site infection, and numbness. Minimally invasive approaches are gaining popularity and may present unique considerations.³⁵

Further studies with larger sample sizes and longer follow-up could better explore the potential impact of mesh selection on outcomes and assess the incidence of hernia recurrence. Monitoring patients over an extended period will provide a more comprehensive understanding of the durability and efficacy of lightweight mesh in hernia repair.

Moreover, to place these results in the context of inguinal hernia surgery, it is necessary to consider both technical and economic aspects. From a technical perspective, ongoing trials are exploring the effectiveness of the Desarda technique,³⁶ which proposes a mesh-free approach with a recurrence rate comparable to the Lichtenstein technique.^37,38 In addition, technological advances are introducing not only meshes of different weights and materials but also anatomically shaped meshes (3D meshes) and meshes with different fixation technologies (self-anchoring or adhesive).

It is conceivable that in the future a different approach to the current “one-size-fits-all” approach will be adopted in many centers. This would involve defining tailored treatments based on the characteristics of both the hernia and the patient. From a pharmaco-economic point of view, it is important to remember that in the era of Health Spending Reviews, the opinions of administrative authorities play an increasingly significant role in the selection of devices for clinical practice.

In conclusion, our study provides valuable insights into the impact of mesh selection on patient outcomes in inguinal hernia repair surgery. LW-PP mesh placement showed comforting data regarding both patient outcomes and complications, although without a clear superiority over HW-PP meshes. Mesh selection should be individualized, taking into account patient-specific factors and considering alternative mesh materials, ultimately improving the quality of life for patients undergoing hernia repair.

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