SAGES OSAP Journal Club Activity Worksheet
Article: Lightweight versus heavyweight mesh in laparoscopic inguinal hernia repair: a meta-analysis
For release: ASAP
TO BE COMPLETED BY DON SELZER, MD
1. Please indicate which practice gap this article serves to fill: (you may access the SAGES Practice Gap Bank at
http://sages.niazyselim.net/
X
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X
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
Clinical research related to: _Inguinal hernia_________________________________________
Basic science research: __________________________________________________________
Technology and technique: _Lightweight versus heavyweight mesh in inguinal hernia repair__
Education: ____________________________________________________________________
Other: _______________________________________________________________________
2. Please review the author disclosures. You need to determine if there are any conflicts of interest.
When do relationships create "conflicts of interest?" (SCS 2.1)
The ACCME considers financial relationships to create actual conflicts of interest in CME when individuals have both a financial
relationship with a commercial interest and the opportunity to affect the content of CME about the products or services of that
commercial interest.
A. Indicators of COI: Please check all that apply
X None
 Topic is related to the same products or services as company listed in the Financial Disclosure
 Brand names used in materials and bias is perceived
 Article does not provide a balanced discussion of treatment options/products/services
 Other (describe): ____________________________________________________________
B. What methods may be used to manage or resolve the conflict?
X




N/A
Changes to article (describe): ___________________________________________________
Addition of references to validate recommendations
Do not use article
Other: _____________________________________________________________________
TO BE COMPLETED BY JC REVIEWER: _____________________
3. Please indicate the ABMS/ACGME/IOM competency(ies) this article & the questions will address:


X
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Patient-centered Care
Work in Interdisciplinary Teams
Evidence-based Practice
Quality Improvement

Utilize Informatics
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X
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Patient Care
Medical Knowledge
Practice Based Learning and
Improvement
Interpersonal Skills and
Communication
Professionalism


X


4. Will this activity change knowledge and/or competence?
X Knowledge (knowing about something)
 Competence (knowing “how to” do something)*
*If you mark competence, the questions asked must be case-based or scenario-based in order to measure this.
Systems Based Practice
Professional Standing
Commitment to Lifelong Learning
Cognitive Expertise
Evaluation of Performance in Practice
5. Please write 4 multiple choice questions with 4 answers, 1 of which is correct – do not use “all of the above.”
Identify which answer is correct. Then write a brief explanation regarding why the correct choice was correct and why
each of the other choices was incorrect. See the Question Writing Guide for suggestions!
Question 1
The article included comparision of outcomes of which of the following operations for inguinal
hernia repair? (TAPP = Trans-abdominal preperitoneal); (TEP = Totally extraperitoneal)
a.
b.
c.
d.
e.
TAPP Vs TEP repair with mesh <50 g/m2 and mesh >50 g/m2
TAPP & TEP repair Vs Open inguinal hernia repair with mesh <50 g/m2 and mesh >50 g/m2
TAPP & TEP repair with mesh <50 g/m2 and mesh >50 g/m2
TAPP Vs Open inguinal hernia repair with mesh <50 g/m2 and mesh >50 g/m2
TEP Vs Open inguinal hernia repair with mesh <50 g/m2 and mesh >50 g/m2
Question 2
In the article presented by Currie et al, the authors compared outcomes after laparoscopic
inguinal hernia repair using lightweight versus heavyweight mesh. Which of the following
statements is TRUE given the available evidence?
a.
b.
c.
d.
Lightweight mesh is associated with significantly less development of chronic pain
Outcomes are not affected by increased surgical experience
More recurrences are seen using lightweight mesh after open hernia repair
Mesh weight does not affect primary or secondary outcomes of laparoscopic inguinal hernia
repair
e. Seroma formation is more commonly seen with heavyweight mesh
Question 3
Metanalysis offers some advantages in compensating for quality issues of pooled studies. In
this study, correcting for which of the following will most likely guide the surgeon in selection
of the mesh weight for laparoscopic inguinal hernia repair?
a.
b.
c.
d.
e.
Non-uniform reporting of clinical parameter
Variability of clinical factors
Size of the trials
Duration of follow up
Frequency of occurrence of events of interest
Question 4
In this met-analysis presented by Currie et al, the recurrence risk and chronic pain outcomes
between lightweight and heavyweight mesh are affected by which of the following?
a.
b.
c.
d.
e.
Type of hernia
Type of repair (TAP Vs TEPP)
Age of patient
Type of mesh fixation
None of the above
Answers with explanation
Question 1
The article included comparision of outcomes of which of the following operations for inguinal
hernia repair? (TAPP = Trans-abdominal preperitoneal); (TEP = Totally extraperitoneal)
a. TAPP Vs TEP repair with mesh <50 g/m2 and mesh >50 g/m2
The definition of light weight mesh was <50 g/m2, both TAPP & TEP techniques were pooled into one
composite group “tension-free laparoscopic mesh repair group for analysis, comparison were made
between heavyweight mesh and lightweight mesh, not between the different laparoscopic approach of
repair
b. TAPP & TEP repair Vs Open inguinal hernia repair with mesh <50 g/m2 and mesh >50 g/m2
Studies of open Lichtenstein repair comparing the use of lightweight Vs heavyweight mesh were
discussed but the comparison was not between the laparoscopic and open approach
c. TAPP & TEP repair with mesh <50 g/m2 and mesh >50 g/m2
The studies included in this analysis were controlled trials in which patients underwent laparoscopic
mesh repair of inguinal hernia either with heavyweight or lightweight mesh
d. TAPP Vs Open inguinal hernia repair with mesh <50 g/m2 and mesh >50 g/m2
Studies of open Lichtenstein repair comparing the use of lightweight Vs heavyweight mesh were
discussed but the comparison was not between the laparoscopic and open approach
e. TEP Vs Open inguinal hernia repair with mesh <50 g/m2 and mesh >50 g/m2
Studies of open Lichtenstein repair comparing the use of lightweight Vs heavyweight mesh were
discussed but the comparison was not between the laparoscopic and open approach
Question 2
In the article presented by Currie et al, the authors compared outcomes after laparoscopic
inguinal hernia repair using lightweight versus heavyweight mesh. Which of the following
statements is TRUE given the available evidence?
a. Lightweight mesh is associated with significantly less development of chronic pain
Chronic pain was defined as pain persisting after 1 yr. Six studies reported chronic pain as an
outcome and there was no significant statistical difference in the development of chronic pain
b. Outcomes are not affected by increased surgical experience
Restropective audit Khan et al was undertaken in a cross-over fashion. The improvement noted may
be secondary to increased surgical experience
c. More recurrences are seen using lightweight mesh after open hernia repair
Prospective randomized study found no significant difference in recurrence rate after 3 years
d. Mesh weight does not affect primary or secondary outcomes of laparoscopic inguinal hernia
repair
This review has demonstrated in the available RCTs, that lightweight and heavyweight mesh appear
to have similar outcomes
e. Seroma formation is more commonly seen with heavyweight mesh
Seven trials reported the development of seroma but there was no significant effect of lightweight or
heavyweight mesh on seroma formation
Question 3
Metanalysis offers some advantages in compensating for quality issues of pooled studies. In
this study, correcting for which of the following will most likely guide the surgeon in selection
of the mesh weight for laparoscopic inguinal hernia repair?
a. Non-uniform reporting of clinical parameter
While pooled analysis is comprehensive, this listed factor is one of the variable factors may still
adversely affect the study
b. Variability of clinical factors
While pooled analysis is comprehensive, this listed factor is one of the variable factors may still
adversely affect the study
c. Size of the trials
While pooled analysis is comprehensive, this listed factor is one of the variable factors may still
adversely affect the study
d. Duration of follow up
Type 2 error may prevent detection of actual difference, longer follow up may correct for this effect and
limitation, and provide additional data for analysis of any potential benefit of the type of mesh used.
Type 2 error is failing to reject the null hypothesis when it is false, the probability of a Type 2 error
cannot generally be computed because it depends on the population mean which is unknown
e. Frequency of occurrence of events of interest
While pooled analysis is comprehensive, this listed factor is one of the variable factors may still
adversely affect the study
Question 4
In this met-analysis presented by Currie et al, the recurrence risk and chronic pain outcomes
between lightweight and heavyweight mesh are affected by which of the following?
a. Type of hernia
Both mesh options result in similar long term and short term postoperative outcomes, these factors listed
have all been accounted for by use of controlled trials
b. Type of repair (TAP Vs TEPP)
Both mesh options result in similar long term and short term postoperative outcomes, these factors
listed have all been accounted for by use of controlled trials
c. Age of patient
Both mesh options result in similar long term and short term postoperative outcomes, these factors
listed have all been accounted for by use of controlled trials
d. Type of mesh fixation
Both mesh options result in similar long term and short term postoperative outcomes, these factors
listed have all been accounted for by use of controlled trials
e. None of the above
This review has demonstrated that lightweight and heavyweight meshes appear to have similar
outcomes
6. Please include 4 references (at least 1 per question above).
1. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, McQuay HJ 1996) Assessing the
quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17:1–12
2. Karthikesalingam A, Markar SR, Holt PJ, Praseedom RK (2010) Meta-analysis of randomized controlled
trials comparing laparoscopic with open mesh repair of recurrent inguinal hernia. Br J Surg 97:4–11
3. Khan LR, Liong S, de Beaux AC, Kumar S, Nixon SJ (2010) Lightweight mesh improves functional outcome in
laparoscopic totally extra-peritoneal inguinal hernia repair. Hernia 14:39–45
4. Bringman S, Wollert S, Osterberg J, Smedberg S, Granlund H, Heikkinen TJ (2006) Three-year results of a
randomized clinical trial of lightweight or standard polypropylene mesh in Lichtenstein repair of primary
inguinal hernia. Br J Surg 93:1056–1059
7. Please write a learning objective for this activity that describes a change in knowledge or competence.
At the conclusion of this activity, the learner will be able to ….
Describe the differences between heavyweight and lightweight mesh and how they affect inguinal hernia repair.
Please return to Yumi Hori – via email: yumi@sages.org
JC form version 8/22/2011