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Hello. So today we will talk about the Cochrane Systematic review mesh versus not mesh repair, foreign going away and femoral hernia that we were discussing this review. So why are you going to look at it? Is because the European Hernia Society they issue the guidelines that provide grade a recommendation that all adult male patient's with inguinal hernia should be operated on using a mesh technique, either with open little standard endoscopic in gonna hernia techniques. Um, however, mesh are quite costly, so it's gonna be a costly surgery, So it's require more money to use mesh than to do it with the future repair. Nearby. A little bit of the background. The aim of the hernia repair surgery is not only to fix the problem, but also to reduce the risk of recurrence and recurrently from primary hernia repair range from 0.5% to 15%. It depends on the hernias site, clinical circumstances like medical conditions and the type of the repair used. So in 2002, her neutral is collaboration, analyzed 58 randomized control trials, and they found that the use of the mesh was superior to other techniques. Cans the issue. The guidelines so in particular, the meth analogy is not a fewer recurrencies of the hernia and less post operative pain when using rash. Compared with all other techniques, however, non matched repairs are still very commonly performed worldwide and in particular in low income countries. And hence an updated meta analysis of the current literature is requires to see whether there is anything that has changed methods. So the objective was to evaluate the benefits and harms of different inguinal and femoral hernia repair techniques in adults, and to specifically compare closure with mesh versus without mesh all participants aged 18 years and older, with clinically diagnosed in Gunnell or femoral hernia or both. Uh, we're eligible to participate, Um, and in those participants, as surgical management was indicated, they were only required to participate if a surgical measurement was indicated. So what type of studies were included in this systematic review? Parallel randomized control trials and cluster randomized control trials, a cluster are the ones that are the smaller size one. There, like a trial, are see team so investigating mesh compared to non match techniques for open or laparoscopic repair of or often gonna or femoral hernias. These were all included and research strategies of the search engines that were used, so the authors looked through. Co Crane Central Register of Control Trials. MEDLINE Embrace Web of Sciences It's International Clinical Trial Register platform reference list of included trials and articles. They looked through the books through the abstracts from the conferences, and they also brought to the authors. There were two groups. Mesh repair versus you to repair. So with mesh repair in growing or hernia repair, these are the approaches that we're allowed so open. Let's entertain approach laproscopic Trans abdominal preparatory, new and totally extra Pretty new approaches. So and which type of mesh reviews like either the commercial market, non absorbable mesh or observable biomesh, the both of them. And in femoral hernias again, open mesh or mesh plug repair laproscopic um, all the same things, uh, for the Balmoral hernias, too, for the future repair in inguinal hernia. So the tension bassini McQuay and show these approaches and tension. Free approaches were also included. Like these are the and Guarneri, and again, any type of commercial market, non observable or absorbable futures were used similar for femoral harness, too primary outcomes. They looked at the recurrence of the same hernia of the same one of a different, uh, surgical complications and mortality and secondary outcomes. Duration of surgical operation. Duration of post operative hospital state time required to return to activity of daily living number of operations where conversion from laproscopic to open is required. Hey, here's a lot of statistics So essentially binary data, Um, when measured with, UH, 95% confidence intervals using a risk ratio and then where possible, an absolute risk reduction was called calculated and the number needed to treat was calculated and the number needed to treat to harm was calculated to so continuous data was, uh was analyzed as the main difference if the same scale was used or alternatively, a standardized main difference was calculated. So the treatment effect was considered statistically significant if P value was less than 0.5 and they also performed an I t. T analysis where the missing data, um from the participants um, happened and they assume that this missing data is due to treatment. Failure for distribute also performed a subgroup and sensitivity analysis, too, performed everything overall out of 2006 studies. 25 were included in this review and here are the names of it in this flow. Diagram of the studies. A total of 6293 participants, 3289 versus 3004 were included in the analysis, so they were both from a high and from a low income countries. So the countries included for France, Lebanon, Ireland, Germany, India, Egypt, Belgium, Turkey, Uganda, USA, Japan's within Mexico, UK, China, New Zealand's and Poland. So all across the shop, these were the risk of bias of all of the 25 includes studies overall, looks like 50 50 right, 50% low risk, 50% middle or not enough information to judge the risk and only a few dots are on the high risk. So which is pretty good, I guess somebody of the findings. So this is a difficult slide to have a look, but this is devolved from somebody of the results so overall regarding her knee recurrence, those with non mesh repair her foreign 100 her knee recurrencies those with the mesh repair had two in 100 so twice a little surgical complications so neurovascular or recent injury was happened more in the non mass repair. So one infection happen more in the mesh repair wouldn't be. Hazen's happened more in a non mass repair, but it's pretty similar, and mortality didn't happen anywhere. And if you look at the certainty of evidence so the hernia currents were judged as moderate, neurovascular visceral injury is high and the rest as low. The surgical complication were judged as low according to the certainty of evidence released by Great, so duration of the surgery, um, in non mass repair retrench between 10 to 94 minutes and in mass repair. It was lower, but the evidence is very low duration of the post operative stay in the non mesh repair. So the post operative stage ranged between half day to 7.5 days, and in the mesh repair it was lower. But again, the evidence is law. Time to return to full activity of daily living. So in a non mesh, it changes between 2.62 26 and again in the mesh repair. It was lower, but the evidence is low, and conversion from laproscopic to open actually didn't happen. now discussion. Overall measure intervention provided a statistically significant reduction in her knee recurrence. But the reliability of this finding was downgraded to moderate because of the lack of blinding. So I guess majority of the studies didn't blind the assessors and participants. So neurovascular and visceral injuries and post operative urinary retention, we're less likely in the mesh group. So non mesh interventions were found to have a lower rate of Ciroma and post operative wound swelling. So it means that the prestige ick mask has more reaction to it. Um, the non mesh repairs also were found to have a slightly lower rate of wound infections in hematoma, which also makes, I guess, a little bit of sense. Um, all of these post operative complications the moderate to high grade of evidence. So but unfortunately, apart from your vascular missile injury and union retention, um, the difference are of minimal clinical significance. There have been no clear conclusion reached regarding post operative and chronic pain analysis because it's very subjective and different studies you different methods of pain analysis. So that's why even the evidence with that great it as a low quality majority of the side. His favorite meals repair, but it can be really a subjective and really biased mesh. Repairs had a shorter operative time, however again, the evidence quality was downgraded too low because its imprecision and there have been a lot of heterogeneity. Post operative hospital stay was reduced in the mesh group by only half the day. And it's unlikely to be significant because majority of the consultants or in different countries, I guess, for grounds, happened differently. So it's really hard to draw conclusions from that. And cost analysis was not performed because there was a lot of confounding variations and confounding factors and heterogeneous knighted to perform this analysis. Overall, the quality of included studies was good, considering the nature of the intervention where blinding would be hard to achieve. Um, and there are several limitations. One of them was that, um some of the studies were not written in English and do the cost of the translation. They weren't translated, um, by the assessors, but they were rather translated by the employer of Coke Rain. I don't think it's likely to influence any results, though, so discussion point, it's like a conclusion slide. So meshing guy in Gunnell hernia repairs may be associated with better outcomes and non mesh repairs in the elective setting, which is important. So in the elective setting, non mesh repairs remain viable alternative depending on health service circumstances again. So although mesh repairs were superior, they weren't superior by by large amount. The average effect on operative time, hospital stay and return to daily activities in is uncertain due to wide variation between the results of the studies. Additional cost of a mesh in the surgical repair, whilst possibly nullified by the shorter operative times and associated cost in the high income countries, remain insignificant and prohibitive cost in low income countries. So in low income countries, majority of them can't afford to have a mass repair. And there was not enough information to provide conclusion getting post oppressive pain and mortality outcomes. Thank you. That was it.