The Effect of Tack Fixation Methods on Outcomes in Laparoscopic Ventral Hernia Repair

Introduction

Ventral and incisional hernias are common problems encountered by general surgeons. An estimated 350,000 to 500,000 ventral hernias are repaired yearly ¹ at a cost of ∼$3.4 billion health care dollars per year. ² Many surgical techniques have been described to repair ventral/incisional hernias with the goal of minimizing recurrence rates, wound morbidity, and complications.

One method described to repair ventral/incisional hernias uses a laparoscopic approach, first described by Leblanc and Booth ³ and popularized by Heniford et al. in a published experience of 850 laparoscopic ventral hernia repairs with low recurrence and complication rates. ⁴ With early laparoscopic ventral hernia repair, transfascial sutures were used as the primary method of mesh fixation. This approach has since been challenged. ⁵ Morales-Conde et al. demonstrated that placing a double row of tacks without sutures (the so-called “double-crown” technique) was a safe alternative to transfascial sutures with similar recurrence rates and decreased pain at the 40-month follow-up. ⁶ Since this time, there has been ongoing controversy about the optimal mesh fixation method in laparoscopic ventral hernia repair. Although there is good evidence supporting the tack-only fixation approach, there are little comparative outcome data of using absorbable and permanent tacks. The purpose of this article is to compare absorbable and permanent tacks in laparoscopic ventral hernia repair.

Materials and Methods

This study is a retrospective review using data from the Americas Hernia Society Quality Collaborative (AHSQC) database, as accessed on June 30, 2017. The groups compared were permanent tacks and absorbable tacks.

Propensity score matching was used to strengthen the retrospective nature of the study and to ensure comparison between similar populations. Variables such as patient age, gender, race, wound status, hernia size, smoking, body mass index, American Society of Anesthesiologist (ASA) class, and concomitant procedures were matched before data analysis. The primary outcomes measured were hernia recurrence, hospital length of stay, surgical site infection (SSI), surgical site occurrence (SSO), Promis^® Pain Intensity score, and HerQLes quality-of-life score. Secondary outcomes included all other surgical complications. These data points were followed to 30 days, 6 months, 1 year, and 2 years.

The Promis pain intensity scoring is a standardized and validated system that asks several questions concerning a patient's pain, such as when it occurs, how often, and how debilitating it is. Subjective responses are assigned numerical values.

The HerQLes survey is also known as the Hernia-Related Quality-of-Life survey and was specifically designed and validated for use in postoperative hernia patients. The questions are more targeted to the patient's functional status and take into account the patient's pain at the surgical site as well as the surgery's impact on physical restriction and cosmetic discomfort.

The AHSQC database was queried on June 30, 2017, and the initial inclusion criteria were all patients who had surgery, who were 18 years of age or older. This yielded 11,579 patients. Applying exclusion criteria of laparoscopic ventral hernia repair with mesh and tack-only fixation reduced the cohort to 432 patients. This group was further divided into 272 patients who underwent fixation with only absorbable tacks and 160 who were repaired with only permanent tacks. Propensity score matching resulted in 160 patients in each group. In the absorbable tack group, these patients were operated on by 26 surgeons across 25 sites. In the permanent tack group, there were 15 surgeons across 9 sites.

Results

There were 320 total patients included for analysis, with 160 patients in each study group. There were no significant differences in demographics, comorbidities, or hernia characteristics among the groups (Table 1). For primary outcome measures, there were no significant differences in length of stay, hernia recurrence rate, or SSI (P > .05) (Table 2). There were significant differences in the rates of seroma formation and overall SSO with the permanent tack group having higher rates compared with the absorbable group (P = .003 and P < .001, respectively) (Table 2). However, the intervention rate was not increased in the permanent tack group compared to the absorbable tack group (P > .05) (Table 2). There were also no significant difference between the groups in pain or quality of life (Tables 3 and 4).

Discussion

Since the advent of the double-crown mesh fixation technique, fewer surgeons have used transfascial sutures alone, and many have switched to using a combination of sutures and tacks. A randomized clinical trial published in 2013 by Muysoms et al. ⁷ demonstrated in 76 patients randomized to either sutures and tacks or a double row of tacks that there was no difference in recurrence rates up to the 24-month follow-up. The double-crown technique was found to decrease intraoperative time and decrease pain in the immediate postoperative period as well as at the 3-month follow-up. ⁷

Laparoscopic ventral hernia repair mesh fixation methods have been the subject of multiple studies with no conclusive evidence supporting one particular approach. Wassenaar et al. completed a randomized controlled trial using three fixation methods (absorbable sutures with tacks, nonabsorbable sutures with tacks, and the double-crown technique) in 199 patients undergoing elective ventral hernia repair and did not show any method to be superior in terms of quality of life or postoperative pain with up to the 3 month follow-up. ⁸

As the volume of data has increased, there have been several large retrospective reviews, including one in 2011 that individually compared transfascial sutures, tacks, and staples to assess which had a lower recurrence rate. There was no statistical difference in recurrence rates, but transfascial sutures alone were found to be associated with higher infection rates. ⁹

In another retrospective literature review, the optimal fixation technique was questioned by statistically analyzing 25 series, which included a suture and tack group, a tack-alone group, and a suture-alone group. None of these fixation methods proved superior to the others in terms of hernia recurrence or postoperative pain with a minimum of 12 months of follow-up. ¹⁰

Numerous studies have attempted to demonstrate the superiority of one fixation technique over another. While several studies have shown small significant differences, and some have claimed superiority, there is no consensus at this time. One of the limitations of most of these studies is poor postoperative follow-up, which is usually limited to only a few months.

Data were used from the AHSQC, which is the largest data set in the Americas. The aim of this study was to query the database and compare outcomes between permanent and absorbable tacks when employing tack-only fixation for laparoscopic ventral hernia repair. Based on these data, we identified a statistically significant difference in one primary outcome, SSO. The SSO rate in the permanent tack group (n = 28, 18%) was statistically higher than the absorbable tack group (n = 8, 5%). However, there was no increase in need for intervention. All other measured outcomes showed no significant difference between the groups. The increase in SSO is likely explained by the higher seroma rate. In these data, the seromas are considered SSO.

One of the limitations of our study is the lack of long-term follow-up, a common problem among many studies, especially as it relates to hernia recurrence. Information regarding follow-up in our data consisted of completed Promis Pain Intensity score and HerQLes scoring assessments. Referencing both assessments, median follow-up was 30 days and maximum follow-up was 2 years. Although we found no meaningful difference in 30-day outcomes between permanent and absorbable tacks, the long-term recurrence rates will require further study. There has been some evidence from large population-based studies/hernia registries that permanent tacks may have a lower recurrence rate. ¹¹

Using data accessed through the AHSQC, we were not able to demonstrate that one tack material is superior to the other. Further studies are needed to gather conclusive evidence regarding long-term outcomes. The fixation method used should be at the discretion of the surgeon, considering factors such as individual training, preference, operative time, and overall cost effectiveness.

Conclusion

Data available through the AHSQC were reviewed to determine if there is a significant difference between absorbable and permanent tacks when used in tack-only laparoscopic mesh repair of ventral hernias. We noted a statistically significant increase in SSO in the permanent tack group, likely due to the increased rate of seroma formation in this group. Since the increase in SSO rate did not lead to an increased intervention rate, the clinical significance of this finding is questionable. Therefore, in using tack-only fixation for ventral hernia repair, both absorbable and permanent tacks appear to be acceptable.