Outcomes after Hernioplasty Utilising Low Cost Mesh in Low and Middle Income Countries: A Systematic Review

Abstract

Inguinal hernias are a source of significant morbidity and mortality in low and middle income countries (LMICs). Best practice for inguinal hernia repair (IHR) is hernioplasty but the cost of surgical mesh required limits its use in LMICs. Clinicians in LMICs have attempted to increase access to hernioplasty by seeking out cheaper alternatives to surgical mesh. Low cost mesh (LCM) includes mosquito netting, resterilised surgical mesh and other indigenous products. The use of LCM in inguinal hernioplasty in LMICs has been well described in the literature and two recent limited systematic reviews of mosquito net hernioplasty found equivalent postoperative surgical outcomes. The objective of this review was to build on extant reviews by conducting a broader search across a wider set of databases and grey literature sources, including all LCM alternatives and considering outcomes such as patient and surgeon preference, sterility and recurrence alongside a more granular assessment of complication rates. The review aimed to assist clinicians in LMICs in their decision-making regarding use of LCM, in particular, identifying potential areas for improvement of practice with regards to sterility and mesh choice. Electronic bibliographic databases, grey literature databases and trial registers were searched for randomised or quasi-randomised controlled trials, comparing surgical mesh vs low cost mesh in adult patients undergoing elective inguinal hernioplasty or emergent inguinal hernioplasty without bowel resection in LMICs, published in any language from 2000 to present date. Two independent reviewers conducted the literature search, title/abstract and full text screening, assessed methodological quality using the Cochrane Risk of Bias 2 tool and extracted data using a custom extraction tool. Synthesis involved pooling for statistical meta-analysis with either random-effects or fixed-effects model as appropriate, and where this was not possible, a narrative presentation of findings was reported. 11 RCTs with 1306 participants were identified. There was little to no evidence of an effect for low cost mesh vs surgical mesh on the assessed outcomes: recurrence RR 1.44 (95CI: 0.23 to 9.04, low certainty), chronic pain RR 0.68 (95CI: 0.24 to 1.92, low certainty), superficial infection RR 0.84 (95CI: 0.46 to 1.54, low certainty), deep infection (95CI: 0.12 to 71.15, very low certainty), explantation RR 2.93 (95CI: 0.31 to 27.71, very low certainty), seroma RR 1.06 (95CI: 0.53 to 2.11, moderate certainty), haematoma RR 1.01 (95CI: 0.69 to 1.49, moderate certainty), postoperative pain MD 0.07 lower (95CI: 0.27 lower to 0.14 higher, high certainty). The use of LCM in hernioplasty in LMICs delivers outcomes that are not significantly different to hernioplasty with surgical mesh. This systematic review identified that for the best assessed outcomes of chronic pain, superficial and deep infection rates, seroma and haematoma formation, mesh explantation and hernia recurrence, there was no significant difference in outcomes between surgical mesh and LCM. Based on this review, the use of LCM in hernioplasty in LMICs can be recommended as a safe alternative, with the caveats of satisfactory sterilisation and adequately trained service providers.