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Year : 2016  |  Volume : 35  |  Issue : 4  |  Page : 327-331

Tack fixation versus nonfixation of mesh in laparoscopic transabdominal preperitonaeal hernia repair

Department of General Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Submission25-Feb-2016
Date of Acceptance30-Apr-2016
Date of Web Publication28-Nov-2016

Correspondence Address:
Ahmed A Darwish
Department of General Surgery, Faculty of Medicine, Ain Shams University, Cairo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1110-1121.194729

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Context Laparoscopic transabdominal preperitoneal (TAPP) repair of inguinal hernia is traditionally performed by fixing the mesh to the abdominal wall by spiral tacks. However, mesh fixation might not be necessary as there is little space for the mesh to migrate; besides, tack fixation predisposes to postoperative pain.
Aim The present study aimed to compare mesh fixation versus nonfixation regarding postoperative pain and recurrence rates.
Settings and design This study was a prospective, controlled, randomized study.
Patients and methods In total, 60 patients with inguinal hernias were divided into two equal groups, were compared regarding mesh fixation versus nonfixation by TAPP technique, and followed-up for up to 12 months for postoperative complications, pain, and recurrence.
Statistical analysis Continuous variables are expressed as means and SDs. Categorical variables are expressed as frequencies and percentages.
Results There was significant reduction in postoperative pain and chronic pain in patients without mesh fixation in comparison with patients with mesh fixation and early return to work. There was no significant difference between the two groups regarding postoperative complications and recurrence rates.
Conclusion Mesh nonfixation reduces the incidence of postoperative pain and chronic pain in patients undergoing TAPP repair without increase in postoperative complications or recurrence rates.

Keywords: laparoscopic hernia repair, mesh nonfixation, postoperative pain, transabdominal preperitoneal

How to cite this article:
Darwish AA, Hegab AA. Tack fixation versus nonfixation of mesh in laparoscopic transabdominal preperitonaeal hernia repair. Egypt J Surg 2016;35:327-31

How to cite this URL:
Darwish AA, Hegab AA. Tack fixation versus nonfixation of mesh in laparoscopic transabdominal preperitonaeal hernia repair. Egypt J Surg [serial online] 2016 [cited 2020 Jun 4];35:327-31. Available from: http://www.ejs.eg.net/text.asp?2016/35/4/327/194729

  Introduction Top

Laparoscopic repair of inguinal hernia was first described by Ger et al. [1].

Nowadays, laparoscopic inguinal hernia repair is performed with placement of a mesh into the preperitoneal space. It can be carried out by transabdominal preperitoneal (TAPP) approach or by totally extraperitoneal (TEP) approach. The TAPP approach was first reported by Arregui et al. [2]. It involves laparoscopic access into the peritoneal cavity to place a mesh in the preperitoneal space after reduction of the hernia sac. The TEP hernia repair was first described by McKernan and Laws [3]. This approach requires preperitoneal dissection and placement of a mesh in the preperitoneal space TEP without entering the abdominal cavity [4].

However, mesh fixation is thought to help in increasing postoperative pain and the risk of nerve injury, with the most commonly injured nerves being the femoral branch of the genitofemoral nerve and the lateral cutaneous nerve of the thigh [5].

The factors causing postoperative pain include inguinal nerve irritation by the mesh or tacks, inflammatory reactions around the mesh, or simply fibrosis in the inguinal region incorporating the inguinal nerves. It may also be caused by local tissue inflammatory reactions against the foreign material, bioincompatibility, and reduction in abdominal wall compliance. Nonfixation of the mesh can reduce pain; however, it is theoretically a predisposing factor for hernia recurrence due to the risk of mesh displacement [6].

The aim of this study was to compare the effect of mesh fixation and nonfixation on postoperative pain and recurrence rates in patients undergoing TAPP inguinal hernia repair.

  Patients and methods Top

This study was a comparative, prospective, randomized clinical trial. For this study, 60 male patients having primary unilateral inguinal hernias aged more than 18 years and not having any contraindication for general anesthesia or laparoscopic surgeries, scheduled for laparoscopic TAPP hernia repair, were included.

The present study took place from June 2012 to May 2015 with a minimum of 12 months of follow-up for each patient. The patients were randomly allocated by closed envelope into two groups (each containing 30 patients) with standardization of the surgical technique and the team that carried out the procedure. Among these 60 patients, 30 patients were operated upon with mesh fixation with spiral tacks (Protack; Covidien–Medtronic, Dublin, Republic of Ireland), and 30 patients were operated upon with no mesh fixation.

The patients were recruited from the outpatient clinic. Complete detailed history was obtained from all patients, and a complete physical examination was carried out, including scrotal ultrasound with duplex and abdominal ultrasound to eliminate any possible causes of recurrence. An informed consent was obtained from the patients for participation in this study according to the Ethical Committee of the Faculty of Medicine, Ain Shams University.

Surgical technique

All patients were subjected to general anesthesia. Pneumoperitoneum was established by carbon dioxide at 14 mmHg. A 10-mm trocar was then placed at the umbilicus. Next, one 10-mm trocar and one 5-mm trocar were inserted laterally on the right and left sides, respectively. The hernia sac was identified, and the peritoneum was incised from above the anterior superior iliac spine till the lateral leaflet of the medial umbilical ligament using a harmonic scalpel (Ethicon, Johnson and Johnson Co., Somerville, New Jersey, USA) ([Figure 1]). The peritoneum flaps were then dissected upwards and downwards from the spermatic cord structures ([Figure 2]). The sac was reduced, and then the mesh (Prolene Mesh; Ethicon, Johnson and Johnson Co.) was inserted of size 10×15 cm, taking into consideration the following aspects: to cover the region of the internal ring, the inferior epigastric vessels, and the medial compartment to guard against recurrences ([Figure 3]). All meshes were of the same size − 10×15 cm. In the mesh fixation group, the mesh was fixed by spiral tacks (Protack; Covidien–Medtronic) into the Cooper’s ligament, medial and lateral to the epigastric vessels with avoidance of tacks in the triangle of doom and triangle of pain ([Figure 4]). In the mesh nonfixation group, the mesh was not fixed ([Figure 5]). The peritoneum was closed by continuous absorbable sutures (vicryl 3/0) ([Figure 6]).
Figure 1 Opening of the peritoneum by a harmonic scalpel.

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Figure 2 Elevation of peritoneal flaps.

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Figure 3 Insertion of mesh to cover areas medial and lateral to the inferior epigastric vessels.

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Figure 4 Mesh is being fixed by spiral tacks.

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Figure 5 Starting closure of the peritoneum without mesh fixation.

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Figure 6 Peritoneum after closure by vicryl 3/0.

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The patients were followed-up in the postoperative period for any complications such as seroma formation, mesh infection, occurrence of obstructions or adhesions, and postoperative pain. The pain was scored according to Numeric Rating Scale where 0=no pain and 10=extremely painful. The pain is scored in the first 24 h postoperatively and after 1, 3, 6, and 12 months. The duration of hospital stay and the time required to return to normal physical activity were recorded. The patients were followed-up for 1 year for any signs of recurrence.

  Results Top

Patients’ demographics

All the patients were males, with a mean age of 37.133±9.558 years (range: 22–55 years) in the mesh fixation group (group A). In the mesh nonfixation group (group B), the mean age was 38.700±9.969 years (range: 21–55 years). The P value was 0.537 by t-test, which was statistically nonsignificant.

In group A (30 patients), six (20%) patients had direct hernias, whereas 24 (80%) patients had indirect hernias. In group B (30 patients), seven (23.3%) patients had direct hernias, whereas 23 (76.7%) patients had indirect hernias. The P value was 0.754 by χ2-test, which was statistically nonsignificant.

Operative time

In group A, the mean operative time was 74.633±10.434 min (range: 55–92 min). In group B, the mean operative time was 72.533±8.341 min (range: 55–89 min). The P value was 0.393 by t-test, which was statistically nonsignificant.

Postoperative complications

In group A, two (6.7%) patients developed seroma, which was managed conservatively, whereas none of the patients developed infection, adhesion, or obstruction.

In group B, three (10%) patients developed seroma, which was managed conservatively, one (3.3%) patient developed mesh infection (which was managed conservatively with intravenous antibiotics), and none of the patients developed adhesions or intestinal obstruction.

The mean hospital stay for group A was 1.9±1.689 days and for group B 1.4±0.498 days.

The difference between the two groups regarding postoperative complications was statistically nonsignificant.

Postoperative pain, chronic pain, and return to work

The patients’ pain was evaluated using Numeric Rating Scale where 0=no pain and 10=extreme pain. The ranges then were divided into mild pain (1–3), moderate pain (4–6), and severe pain (7–10).

In group A, the first 24-h postoperative pain had a mean of 4.067±1.112, whereas in group B the value was 1.967±0.765.

With respect to the follow-up, the pain in group A after 1 week was 3.567±1.331, after 1 month 2.633±1.520, after 6 months 1.867±1.613, and after 12 months 1.233±1.501. The pain in group B after 1 week was 0.967±0.765, after 1 month 0.4±0.563, after 6 months 0.167±0.379, and after 12 months 0.033±0.183. There was a statistically significant decrease in postoperative pain and chronic pain in group B than in group A ([Figure 7]).
Figure 7 Graphic representation of the difference in postoperative and chronic pain between the two groups.

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The patients in group A returned to work after 7.867±2.662 days and in group B after 5.033±1.189 days.

The rate of recurrence within 1 year

The rate of recurrence in group A was 0% (no patients) and in group B 3.3% (one patient). This was considered statistically nonsignificant.

  Discussion Top

The laparoscopic approach has become an attractive alternative to open repair for inguinal hernia for many patients and surgeons. There is abundant literature that emphasizes that laparoscopic inguinal hernia repair provides excellent results [4].

In laparoscopic hernia repair, several anchoring techniques were used since the early 1990s, such as staples, tacks, and sutures, but any mechanical anchoring adds to the risk of inducing temporary or permanent pain or can even damage sensitive structures such as nerves and vessels [7].

The need for mesh fixation to prevent recurrence of hernias following laparoscopic preperitoneal inguinal hernia repair (TAPP) is controversial [8].

The aim of this study was to determine the effect of fixing a mesh versus nonfixation on the incidence of postoperative and chronic pain and the risk of hernia recurrence within 1 year.

There were no statistically significant differences between the two groups regarding age, type of hernia, operative time, and postoperative complications. Patients in the mesh nonfixation group had significant reduction in pain scores in the first 24 h postoperatively with mean±SD of 1.967±0.765 in comparison with the patients in the mesh fixation group with mean±SD of 4.067±1.112 and in the follow-up period after 1 week, 1, 6, and 12 months with mean±SD of 0.967±0.765, 0.4±0.563, 0.167±0.379, and 0.033±0.183, respectively, in comparison with patients in the mesh fixation group of 3.567±1.331, 2.633±1.520, 1.867±1.613, and 1.233±1.501. Most of the studies compared mesh fixation versus nonfixation during TEP hernia repair. In a meta-analysis carried out by Sajid et al. [6], five clinical trials by Koch et al. [8], Garg et al. [9], Li et al. [10], Moreno-Egea et al. [11], and Parshad et al. [12] were assessed comparing the postoperative pain and chronic pain using the TEP technique, similar to the study conducted by Koch et al. [8], which reported pain in the mesh fixation group to be 1.9±2.3 and in the mesh nonfixation group to be 1.1±1.6 in the postoperative period. Moreover, in the study conducted by Parshad et al. [12], the postoperative pain was 2.92±2.38 and 2.28±1.81, respectively, which was considered to have no statistical significance between the mesh fixation and nonfixation groups regarding pain with the TEP technique, whereas the studies carried out on the TAPP technique was concentrated on the recurrence rate, similar to the study carried out by Smith et al. [13] who concluded that there was no significant difference between mesh fixation and nonfixation regarding the recurrence rate as concluded by the present study where the recurrence rate was 0% in the mesh fixation group versus 3.3% in the mesh nonfixation group; however, they did not report the postoperative or chronic pain scores among the two groups.

  Conclusion Top

The TAPP hernia repair is considered to be preferred by many surgeons, and the mesh can be placed without fixation with marked reduction in the incidence of postoperative pain and chronic pain due to nerve injury or trapping without significant increase in the recurrence rates.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Ger R, Monroe K, Duvivier R, Mishrick A. Management of indirect inguinal hernias by laparoscopic closure of the neck of the sac. Am J Surg 1990; 159:370–373.  Back to cited text no. 1
Arregui ME, Davis CJ, Yucel O, Nagan RF. Laparoscopic mesh repair of inguinal hernia using a preperitoneal approach: a preliminary report. Surg Laparosc Endosc 1992; 2:53–58.  Back to cited text no. 2
McKernan JB, Laws HL. Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc 1993; 7:26–28.  Back to cited text no. 3
Mathavan VK, Arregui ME. Fixation versus no fixation in laparoscopic TEP and TAPP. In: Jacob BP, Ramshaw B, editors. The Sages manual of hernia repair. New York, NY: Springer; 2013. 203–212.  Back to cited text no. 4
Lantis JC II, Schwaitzberg SD. Tack entrapment of the ilioinguinal nerve during laparoscopic hernia repair. J Laparoendosc Adv Surg Tech A 1999; 9:285–289.  Back to cited text no. 5
Sajid MS, Ladwa N, Kalra L, Hutson K, Sains P, Baig MK. A meta-analysis examining the use of tacker fixation versus no-fixation of mesh in laparoscopic inguinal hernia repair. Int J Surg 2012; 10:224–231.  Back to cited text no. 6
Morrison JE Jr, Jacobs VR. Laparoscopic preperitoneal inguinal hernia repair using preformed polyester mesh without fixation: prospective study with 1-year follow-up results in a rural setting. Surg Laparosc Endosc Percutan Tech 2008; 18:33–39.  Back to cited text no. 7
Koch CA, Greenlee SM, Larson DR, Harrington JR, Farley DR. Randomized prospective study of totally extraperitoneal inguinal hernia repair: fixation versus no fixation of mesh. JSLS 2006; 10:457–460.  Back to cited text no. 8
Garg P, Nair S, Shereef M, Thakur JD, Nain N, Menon GR, Ismail M Mesh fixation compared to nonfixation in total extraperitoneal inguinal hernia repair: a randomized controlled trial in a rural center in India. Surg Endosc 2011; 25:3300–3306.  Back to cited text no. 9
Li JW, Zheng MH, Li HQ, Zhang H, Hu WG, Wang ML. A randomized controlled clinical trial comparing stapling with non-stapling of mesh in laparoscopic total extraperitoneal inguinal hernioplasty. Chin J Gen Surg 2007; 22:440–442.  Back to cited text no. 10
Moreno-Egea A, Torralba Martínez JA, Morales Cuenca G, Aguayo Albasini JL. Randomized clinical trial of fixation vs nonfixation of mesh in total extraperitoneal inguinal hernioplasty. Arch Surg 2004; 139:1376–1379.  Back to cited text no. 11
Parshad R, Kumar R, Hazrah P, Bal S. A randomized comparison of the early outcome of stapled and unstapled techniques of laparoscopic total extraperitoneal inguinal hernia repair. JSLS 2005; 9:403–407.  Back to cited text no. 12
Smith AI, Royston CM, Sedman PC. Stapled and nonstapled laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair. A prospective randomized trial. Surg Endosc 1999; 13:804–806.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

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