Bilateral Laparoscopic Repair of Groin Hernias With One Large Self-fixating Mesh (ProGripTM)

1. INTRODUCTION Evidence in groin hernia repair showed a significant reduction in recurrence rates since the introduction of mesh repair. Hence all current guidelines state that in surgical treatment of groin hernias in adults a mesh should be used. In laparoscopic groin hernia repair a mesh is positioned in the preperitoneal plane. Two techniques are commonly used. A transabdominal technique (TransAbdominal PrePeritoneal - TAPP), in which the preperitoneal plane is dissected throughout the abdomen, with a closure of the peritoneum after positioning of the mesh, and a preperitoneal technique (Totally ExtraPeritoneal - TEP) in which the peritoneum remains intact. Fixation of the mesh was originally performed by penetrating fixation, using staples or tackers. Alternative fixation with glue, self-fixating meshes or no mesh fixation at all, have been proposed to avoid the postoperative pain related to the penetrating fixation. Several studies were not able to show significant differences in recurrence rates between the different mesh fixation techniques. In general, sufficient overlap seems more important than fixation of the mesh. However, current guidelines state that tacker or suture fixation of the mesh for groin hernia should be avoided. Concerns are often raised about large medial hernias (EHS classification: M3) because the medial overlap of the mesh beyond the hernia defect is small. An overlap of less than 2-3 cm may lead to protrusion of the mesh in the hernia opening, and this risk is increased in large direct hernias. In general, the larger the hernia opening, the more overlapping there should be. Observational studies have shown a higher recurrence rate in the repair of direct (i.e. medial) hernias. In a recent consensus statement, Poelman et al. stated that diverse types of inguinal hernias (direct vs. indirect, large vs. small) should be distinguished and treated in a different way. Despite the fact that randomized trials did not differentiate between large or small hernias, they state that the use of a heavy weight mesh, mesh fixation or larger mesh size should be considered in case of large medial hernias. In repair of bilateral inguinal hernias, current guidelines state that laparoscopic treatment is the preferable approach, without clear advantage of TEP over TAPP or vice-versa. During transabdominal (TAPP) repair, evaluation and subsequent treatment of a contralateral hernia can be performed without additional incision and/or trocar placement. Whether one large mesh or two separate meshes with sufficient overlap should be used, remains unclear. The IEHS guidelines state that both options can be used. However, the recurrences detected after the use of two separate meshes suggest the presence of weaker zone at the midline, despite the overlap. On the other hand, application of one large mesh seems to be technically more difficult. In laparoscopic groin hernia repair, the mesh is placed in the anatomical space between pubic bone and bladder. Any type of mesh might therefore potentially influence the urinary bladder function. Until now it is not clear if these urinary symptoms will be different in patients with one large mesh compared to those with two overlapping meshes.
2. AIM AND DESIGN OF THE STUDY Purpose of this study is the assessment urinary symptoms after bilateral repair using one large self-fixating mesh covering both groins in repair of bilateral inguinal hernias. Health outcomes are assessed using different questionaires with focus on urinary symptoms (with ICIQ-MLUTS score), the recurrence rate, postoperative pain measurement, and Quality of Life assessment with EuraHS-QoL and chronic pain monitoring for 12 months. A total of 100 male patients will be entered in the trial in AZ MARIA MIDDELARES, for which an inclusion period of 24 months is anticipated. Study inclusion will be based on clinical examination and/or ultrasonography. Informed Consent will be obtained pre-operatively.
3. OPERATIVE STANDARD PROCEDURES A bilateral laparoscopic groin hernia repair will be performed, using one large self-fixating mesh (ProGripTM). in transabdominal (TAPP) approach or in totally extra-peritoneal (TEP) approach on all patients.
4. FOLLOW-UP After receiving informed consent and planned surgery, patients will get invited for a standard clinical check-up (at 1 month en 12 months post-operatively) and for assessment of urinary symptoms using the ICIQ-MLUTS (International Consultation on Incontinence modular Questionnaire on Lower Urinary Tract Symptoms) at 1 month, 3 months en 12 months post-operatively. Recurrence rates will be based on clinical examination by the surgeon during follow-up. In case of uncertainty during clinical evaluation further investigation using ultrasonography and/or CT scan will be performed. Quality of Life, using the pre- and postoperative EuraHS-QoL score and postoperative pain using a VAS (Visual Analogue Scale) scale will be assessed during the clinical follow-up moments. Additional registration of pain medication used will be performed.
5. DATA COLLECTION AND ANALYSIS All data related to the surgical procedure, patient comorbidities and the post-operative course will be documented prospectively. Anonymized data of all patients will be collected in the online platform EuraHS (European Registry of Abdominal Wall Hernias), developed by the scientific working of European Hernia Society EHS under a specific study account.

A study specific CRF including the ICIQ-MLUTS, the EuraHS-QoL, the VAS (visual analog scale) and VRS (verbal rating scale will be provided by the trial secretariat and gathered by the study coordinator.