Mesh size in Lichtenstein repair: a systematic review and meta-analysis to determine the importance of mesh size

Abstract

Small mesh size has been recognized as one of the factors responsible for recurrence after Lichtenstein hernia repair due to insufficient coverage or mesh shrinkage. The Lichtenstein Hernia Institute recommends a 7×15cm mesh that can be trimmed up to 2cm from the lateral side. We performed a systematic review to determine surgeons' mesh size preference for the Lichtenstein hernia repair and made a meta-analysis to determine the effect of mesh size, mesh type, and length of follow-up time on recurrence. Two medical databases, PubMed and ISI Web of Science, were systematically searched using the key word "Lichtenstein repair." All full text papers were selected. Publications mentioning mesh size were brought for further analysis. A mesh surface area of 90cm(2) was accepted as the threshold for defining the mesh as small or large. Also, a subgroup analysis for recurrence pooled proportion according to the mesh size, mesh type, and follow-up period was done. In total, 514 papers were obtained. There were no prospective or retrospective clinical studies comparing mesh size and clinical outcome. A total of 141 papers were duplicated in both databases. As a result, 373 papers were obtained. The full text was available in over 95% of papers. Only 41 (11.2%) papers discussed mesh size. In 29 studies, a mesh larger than 90cm(2) was used. The most frequently preferred commercial mesh size was 7.5×15cm. No papers mentioned the size of the mesh after trimming. There was no information about the relationship between mesh size and patient BMI. The pooled proportion in recurrence for small meshes was 0.0019 (95% confidence interval: 0.007-0.0036), favoring large meshes to decrease the chance of recurrence. Recurrence becomes more marked when follow-up period is longer than 1year (p<0.001). Heavy meshes also decreased recurrence (p=0.015). This systematic review demonstrates that the size of the mesh used in Lichtenstein hernia repair is rarely discussed in clinical studies. Papers that discuss mesh size appear to reflect a trend to comply with the latest recommendations to use larger mesh. Standard heavy meshes decrease the recurrence in hernia repair. Even though there is no evidence, it seems that large meshes decrease recurrence rates.