Does surgical approach have a role in inguinal hernia mesh removal? At the 2021 annual meeting of the Americas Hernia Society (abstract 50176), researchers of a new study sought to answer this question.

The study led by Desmond Huynh, MD, a PGY-4 general surgery resident at Cedars-Sinai Medical Center, in Los Angeles, included 113 patients, 39 of whom had open, 23 of whom had laparoscopic and 51 of whom had robotic mesh removal. The approach was based on initial mesh placement. Mesh that was placed anteriorly in an open fashion was removed via the open technique, and preperitoneal mesh was removed either laparoscopically or robotically.

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Patients were evaluated two weeks after removal, and long-term follow-up occurred at a mean of 2.5 years. The patients in the three cohorts were well balanced in terms of comorbidities and indications for mesh removal, which included foreign-body sensation, meshoma, reaction, neuralgia and infection.

Table. Operative Complications
	Open	Laparoscopic	Robotic	P Value
Intraoperative injury	4 (10%)	8 (39%)	8 (16%)	0.044
Minor vascular (inferior epigastric, gonadal)	4 (10%)	4 (17%)	7 (14%)	NS
Major vascular (external iliac)	0 (0%)	3 (13%)	1 (2%)	0.019
Nerve	0	1 (4.3%)	0	NS
Organ	0	0	0	NS
NS, nonsignificant

The operative time was longest with the robotic approach (226 minutes), followed by open (181 minutes) and laparoscopic procedures (169 minutes). There was a significantly different rate of intraoperative injury and major vascular injury among the three approaches, with the laparoscopic group having the highest rate of injury (Table). The mean blood loss was 77 mL in open, 96 mL in laparoscopic and 52 mL in robotic procedures, with significant variance. There was no difference in postoperative complications among approaches. There was no difference in pain scores among groups at two-week and long-term follow-up with a mean of 2.5 years. There was a significant improvement in pain scores in all patients after mesh removal. There was no difference in pain score improvement among the approaches.

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The authors concluded that all mesh removal approaches were effective in treating chronic postoperative inguinal pain after inguinal hernia repair. The three groups were equally affected by treating postoperative chronic inguinal pain, yielding durable improvement. There was significant variance among the groups with regard to operative time, rate of injury and blood loss, with post hoc analysis suggesting that a robotic approach may confer some advantage, Dr. Huynh said. However, these observed differences were small.

“Based on [what the authors say], open repair is always going to be the procedure of choice for meshes that were placed anteriorly. In these cases, open removal was as good as robotic,” said Kamal Itani, MD, the chief of surgery at VA Boston Health Care System, a professor of surgery at Boston University and a faculty member at Harvard Medical School, who was not involved with the study. “It then becomes a comparison between the laparoscopic and robotic approach for posteriorly placed meshes. Although the surgery was longer with the robot, there were less complications with the robotic approach compared to laparoscopic. The numbers are too small, and possible confounders too many to reach solid conclusions. However, [this study] could be hypothesis-generating for a larger prospective multicenter study looking at laparoscopic versus robotic explantation of meshes in patients that had posteriorly placed mesh.”

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Dr. Huynh noted that mesh removal is safe and effective for treating chronic postoperative inguinal pain in the right patients, regardless of the approach taken. “Due to the reoperative setting and distorted anatomy, these cases should be approached judiciously by surgeons who are practiced in it,” Dr. Huynh said. “Based on our group’s own experience and trends in this data set, we prefer a robotic approach when appropriate. However, we continue to regularly employ the open and laparoscopic techniques when necessary.”