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 Table of Contents  
Year : 2019  |  Volume : 52  |  Issue : 6  |  Page : 212-220

Comparison of mesh fixation and nonfixation in laparoscopic transabdominal preperitoneal repair of inguinal hernia

Department of Surgery, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission29-Jan-2019
Date of Decision21-Apr-2019
Date of Acceptance23-Jul-2019
Date of Web Publication05-Dec-2019

Correspondence Address:
Dr. Zakaria Sharbu
Department of Surgery, Medical School, Isfahan University of Medical Sciences, Isfahan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/fjs.fjs_15_19

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Introduction: Application of preperitoneal mesh method in the treatment of inguinal hernia can be regarded as one of the successful methods in this regard. However, the impact of mesh fixation or nonfixation on the recurrence of hernia and the incidence of its complications have not been thoroughly investigated.The present study aimed at comparing the effect of mesh fixation and nonfixation on transabdominal preperitoneal (TAPP) laparoscopy for inguinal hernia repair.
Materials and Methods: In this study, eighty patients with inguinal hernia underwent TAPP laparoscopy with mesh fixation (n = 41) and nonfixation (n = 39). Mesh was fixed using a suture in Group A and nonfixed in Group B. Then, the duration of operation, length of in-hospital stay, complications and recurrence of hernia, and pain severity 1 day after the surgery, during discharge, at the 1st and 2nd weeks, and at 1 and 6 months after the surgery were compared between the two groups.
Results: The length of in-hospital stay and return to work in Group B was statistically significantly lower than that of Group A (P < 0.05). Neuralgia and urinary retention were statistically significantly higher in Group A as compared with Group B (P < 0.05). There were no and 5.1% hernial recurrence in Group A and Group B, respectively (P > 0.05). The level of pain was generally higher in Group A and was statistically significant 1 and 2 weeks after the surgery (P < 0.05).
Conclusion: Mesh nonfixation causes less postoperative complications and pain in patients undergoing TAPP repair; however, in long-term follow-up, the level of chronic pain following the application of mesh fixation and non-fixation methods is not different.

Keywords: Fixation, inguinal hernia, mesh, transabdominal preperitoneal repair

How to cite this article:
Kalidarei B, Mahmoodieh M, Sharbu Z. Comparison of mesh fixation and nonfixation in laparoscopic transabdominal preperitoneal repair of inguinal hernia. Formos J Surg 2019;52:212-20

How to cite this URL:
Kalidarei B, Mahmoodieh M, Sharbu Z. Comparison of mesh fixation and nonfixation in laparoscopic transabdominal preperitoneal repair of inguinal hernia. Formos J Surg [serial online] 2019 [cited 2021 Jul 24];52:212-20. Available from: https://www.e-fjs.org/text.asp?2019/52/6/212/272315

  Introduction Top

The most common types of hernia are inguinal that accounts for 75% of all hernias.[1],[2] The prevalence rate of inguinal hernia is 15%–45% at different ages that requires surgical repair. In addition, the prevalence of indirect inguinal hernia is two to three times more than that of the direct inguinal hernia.[3] Overall, the risk of inguinal hernial incidence in the lifetime of males and females is 15% and <5%, respectively.[4] The incidence rate of hernia increases by age in men.[5] On the one hand, inguinal hernia leads to the development of discomfort, pain, and dysfunction in patients and, on the other hand, increases the risk of life-threatening potential complications. Therefore, recognition of the inguinal anatomy is essential for understanding its nature, and all hernias must undergo a surgical repair.[5] There are several different surgical methods for improving inguinal hernia. More traditional methods, on the basis of primary repair, were appropriately used in the past. However, today, with the production and provision of artificial meshes, repairing by mesh without hernial stretching is a gold standard in inguinal hernia surgery.[6],[7],[8],[9] Although open repair of inguinal hernia with mesh by Lichtenstein method has been recognized as an easy and safe method with a high success rate and a low recurrence rate, laparoscopic repair of the hernia is a newer preferred technique due to its effectiveness, remarkable improvements, and prevention of disease recurrence. Laparoscopic repair of inguinal hernia can be performed using transabdominal preperitoneal (TAPP) hernial repair or laparoscopic totally extraperitoneal (TEP). In TAPP, there is a better view of the inguinal anatomy, and it is possible to observe the back of the wall.[10],[11] This repair is done by the insertion of a mesh into the peritoneal space. By entering into the abdominal cavity, the dissection enters the peritoneal space, and it is repaired by placing the mesh after removing the sac from the herniated area.[10] Various studies have indicated that the factors in the prevention of inguinal hernia recurrence such as the development and improvement of surgical techniques, surgeon's skills in the proper implementation of hernial repair technique, inadequate dissection of peritoneal space, as well as the lack of appropriate coverage of wall using smaller mesh can lead to recurrence of inguinal hernia.[12]

In addition, nonfixation of mesh theoretically may lead to recurrence although it has not been evidently confirmed.[8],[13],[14],[15] In addition, it seems that using mesh leads to an increase in the pain level after surgery in patients and increases the risk of damages. Thus, mesh nonfixation may lead to reduced level of pain in patients; however, probability of mesh migration may also lead to an increased rate of recurrence in this regard.[15],[16]

Postoperative groin pain would be developed and increased following the removal of staples and direct nerve injury. Moreover, the use of permanent fixation devices increases the costs and has been shown to be associated with postoperative groin pain, which reduces after the removal of tacks.[17],[18]

As few studies have been conducted to evaluate the postoperative complications following mesh fixation and nonfixation, application of laparoscopic surgery is still the subject of controversy.

The aim of this study was to evaluate the incidence rate of complications such as urinary retention, seroma, wound infection, and recurrence of hernia, after applying two methods of fixed and nonfixed TAPP in an Iranian population during 6 months after operation. In addition, this study evaluated the patients' pain level and made attempts to report more accurate results by distinguishing the direct and indirect types of hernia.

  Materials and Methods Top

The present randomized clinical trial with parallel groups has been registered with the code of IRCT20190204042618N4. The study population comprised all the patients admitted for laparoscopic inguinal hernial repair surgery in Al Zahra Hospital during April 2017–March 2018. Considering the confidence level of 95%, test power of 80%, error level of 0.035, and the results of previous studies regarding the complication incidence rate of 6.7% and 13% following the fixation and nonfixation methods, respectively,[19] approximately 43 patients were considered to be in each group. Therefore, simple random sampling technique was used to select 86 patients that agreed to participate in the study. Patients within the age range of 18–50 years, those with inguinal hernia, those with no history of inguinal hernial repair surgery, and those with laparotomy and strangulated or incarcerated hernia participated in the study.

Patients were excluded from the study in case of cancellation of the surgery for any reason or occurrence of unwanted complications during the surgery resulting in serious complications or death, as well as nonreferral of the patient in postoperative follow-up for any reasons or patients' dissatisfaction to continue the study. Out of all participants, two participants in the mesh fixation group and four participants in the mesh nonfixation group were excluded from the study [Figure 1].
Figure 1: Consort flow diagram

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Following the approval of the Ethics Committee of Isfahan University of Medical Sciences (IR.MUI.REC.1396.083) and obtaining written consent form, the patients were randomly assigned to two groups of 43 using random allocation software.

At the beginning of the study, the patients' demographic characteristics including age, gender, weight, education, hernia type, hernia side (unilateral and bilateral), and underlying diseases were recorded.

Then, the patients with inguinal hernia requiring surgery underwent inguinal hernia repair using mesh by laparoscopic TAPP repair technique.

Surgical technique

All the patients in the present study were exposed to general anesthesia. Carbon dioxide pressure set at 14 mmHg was used to establish pneumoperitoneum during the surgery. The next step was placing a 10-mm trocar at the umbilicus. Then, one 5-mm trocar and one 10-mm trocar were laterally inserted on the left and right sides, respectively. Next, identification of hernial sac was performed followed by making an incision in the peritoneum. A harmonic scalpel (Ethicon, Johnson and Johnson Co., Somerville, New Jersey, USA) was used to extend the incision from above the anterosuperior iliac spine to the lateral leaflet of the medial umbilical ligament. Then, the upward and downward dissections of the peritoneum flaps from the spermatic cord structures were performed [Figure 2].
Figure 2: Elevation of peritoneal flaps

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The size of the sac was decreased, and then, a 10 cm × 15 cm-mesh (Prolene Mesh; Ethicon, Johnson and Johnson Co.) was placed. It must be mentioned that covering the region of the inferior epigastric vessels, the internal ring, and the medial compartment was taken into consideration in the process of inserting the mesh to prevent the risk of possible recurrences [Figure 3].
Figure 3: Insertion of mesh to cover areas medial and lateral to the inferior epigastric vessels

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All meshes had the same size of 10 cm × 15 cm. The suture or spiral tacks (ProTack; Covidien–Medtronic, Minneapolis, USA) were used to fix the mesh into the Cooper's ligament, medial and lateral to the epigastric vessels in the mesh fixation group. It must be noted that tacks in the triangle of doom and pain were avoided. The mesh was not fixed in the mesh nonfixation group. Continuous absorbable sutures (Vicryl 3/0) were used to close the peritoneum [Figure 4].
Figure 4: Peritoneum after closure by Vicryl 3/0

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Mesh was fixed using suture in one group and not fixed in the other one. All patients underwent surgery under the supervision of the same surgical team, and mesh with similar type and size was used. In addition, equipment including laparoscopic system common to both groups was used in all operations.

Pain level was measured in patients based on visual analog scale in 1 day after the surgery, at the time of discharge, at 1 and 2 weeks, and at 1 and 6 months after the surgery in both groups. In addition, early and late complications including seroma, urinary tract infection, wound infection, mesh infections, urinary retention, neuralgia, and relapse were evaluated at 1 week, 2 weeks, 1 month, and 6 months after the surgery.

Finally, the collected data were analyzed using SPSS software (version 22; SPSS Inc., Chicago, Ill., USA). Kolmogorov–Smirnov test to examine the normal distribution of data, parametric tests such as independent sample t-test and repeated-measures ANOVA, Chi-square test, and Fisher's exact test were used to analyze the data at the significance level of <0.05.

  Results Top

In the present study, the mesh fixation group (Group A) comprised 41 patients, 31 (75.6%) males and 10 (24.4%) females, with a mean age of 50.51 ± 10.23 years. Thirty-nine patients participated in the nonfixation group (Group B), 32 (83.1%) males and 7 (17.9%) females, with a mean age of 53.87 ± 8.37 years (P > 0.05). The patients in the two groups were identical in terms of hernia type, hernia involvement side, and the underlying diseases (P > 0.05) [Table 1].
Table 1: Patient characteristics

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The duration of surgery in Groups A and B was 73.8 ± 0.54 min and 70.2 ± 0.44 min, respectively. No statistically significant difference was observed between the two groups in this respect (P = 0.585). The mean length of in-hospital stay and return to work in Group B was 1.18 ± 0.48 and 6.90 ± 1.92 days, respectively, which was significantly lower than that of Group A, with mean values of 1.78 ± 0.73 and 8.79 ± 2.27 days, respectively (P< 0.05) [Table 2].
Table 2: Variables used to compare the two groups

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Furthermore, intraoperative and other complications such as seroma and neuralgia were not observed 1 week after the surgery. Moreover, mesh infections were not detected in any of the two groups in the long-term follow-up. In contrast, the early (1 week after the surgery) and late (2 weeks, 1 month, or 6 months after the surgery) complications in Group A were 34.1% of urinary retention, 7.3% of seroma, and 26.8% of neuralgia. The mentioned early and late complications in Group B included 12.8% of urinary retention, 5.1% of seroma, 2.6% of neuralgia, and 5.1% of recurrence. In terms of statistics, except for neuralgia and urinary retention, the incidence of other complications in the two groups did not reveal any statistically significant difference (P > 0.05) [Table 3]. In addition, the incidence evaluation of each of the mentioned complications considering the subclassifications of inguinal hernia showed that although the incidence rate of complications in the indirect hernia was higher than that of the direct hernia, there was no statistical significance in this regard (P > 0.05).
Table 3: Postoperative complication in the two groups

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The pain score of patients 1 day after the surgery was not statistically significantly different between the two groups (P = 0.241). However, the pain score at the time of release in Group A with a mean of 3.34 ± 2.26 was statistically significantly higher than that of Group B, with a mean of 3.34 ± 2.26 (P = 0.010). In addition, the mean of pain score in Group A was 2.76 ± 1.62 and 2.34 ± 1.37, at 1 and 2 weeks after the surgery, respectively, which was higher than that of Group B, with a mean score of 1.74 ± 1.50 and 1.41 ± 1.29, at 1 and 2 weeks after the surgery, respectively (P< 0.05). The pain score of the two groups showed no statistically significant difference at 1- and 6-month follow-up (P > 0.05) [Table 4]. The mean score of pain from the 1st day to 6 months after the surgery was slightly and nonsignificantly higher for patients with indirect hernia as compared to patients with direct hernia (P > 0.05).
Table 4: Mean comparison of postoperative and chronic pain between the two groups

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Finally, the pain score in Group A was higher than that of Group B; however, a statistically significant reduction was observed in the pain score of patients over the time (P< 0.001) [Figure 5].
Figure 5: Line chart of two groups' mean scores of postoperative and chronic pain

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  Discussion Top

In the current study, majority of patients with inguinal hernia were male in both groups. The number of patients with indirect hernia was more than those with direct hernia, but the two groups were identical in terms of age, gender, education, underlying diseases, subclassification of inguinal hernia, and side of hernia (P > 0.05).

In this regard, many previous studies also reported that the prevalence of inguinal hernia in men is 12–25 times higher than that in women.[20] Overall, the highest incidence rate of this disorder is observed in infancy and ages over 50.[2] In addition, the incidence rate of indirect inguinal hernia is 2–3 times higher than that of direct inguinal hernia.[3]

Furthermore, no statistically significant difference was observed between the two groups in terms of duration of surgery (P > 0.05), while length of in-hospital stay and return to work was statistically significantly higher in mesh fixation group (Group A) as compared to nonfixation group (Group B) (P< 0.05).

In accordance with the findings of the present study, there was no significant difference between the two groups with respect to the duration of surgery as reported by a number of recent studies with similar sample size.[1],[18],[21] However, the findings of some studies revealed a shorter duration of surgery in both mesh fixation and nonfixation groups.[22]

Moreover, many studies indicated that the length of in-hospital stay was significantly shorter in the nonfixation group,[18],[19] which may be due to recommendations regarding postponing the patients' discharge until obtaining the score of 24 in pain score measurements.

In addition, investigation of the early and late complications in the two groups showed that complications such as seroma, mesh infection, orchitis, and neuralgia have not been observed over the 1st week after the surgery. However, two cases of wound infections were reported in Group B 1 week after the surgery, whereas no case of wound infection was observed in Group A. In addition, three cases of seroma were observed in Group A, two of which occurred at the 2nd week and one case happened 1 month after the surgery. Two cases of seroma happened in Group B at the 2nd week after the surgery, which was not statistically significant (P > 0.05). However, the incidence rate of urinary retention in the 1st week after the surgery was statistically significantly higher in Group A as compared with Group B (P< 0.05). The incidence rate of neuralgia was also much more common in Group A in comparison with Group B (P< 0.05).

The findings of a meta-analysis revealed that there is no significant difference between the mesh fixation and nonfixation groups in the rates of postoperative complications.[22]

In Abd-Raboh et al.'s study, on comparing mesh fixation group versus nonfixation group in TEP hernioplasty for inguinal hernia, no difference was observed between the two groups regarding the surgery duration, postoperative complications, and length of in-hospital stay.[9]

In a review study, Sajid et al. also found that the rate risk of complications in the fixation group was 1.21 times higher than that of nonfixation group; however, the observed difference was not significant.[15] Moreover, no significant differences in the incidence rate of complications have been reported in many previous studies.[23],[24],[25]

The findings of the mentioned studies are not consistent with those of the current study as the complications were evaluated in this study in detail, and thus the rate of urinary retention and neuralgia complications showed significant difference between the two groups. In addition, most of the above-mentioned studies compared the incidence rate of complications in general. However, overall, it can be stated that the difference in the incidence rate of some complications was reported in this study, and the inconsistency with other studies can be related to the type of laparoscopic (TEP or TAPP) or mesh fixation technique, surgeon's skills, etc.

Consistent with the findings of the current study, Buyukasik et al. indicated that 17 patients in the fixation group and 5 patients in the nonfixation group had urinary retention in a 24-h follow-up, which showed a significant difference between the groups in this regard.[7]

In fact, it has been shown that urinary retention is not related to postoperative pain. Mulroy proposed a relationship between postoperative pain and urinary retention by expressing that the pain increases urinary retention by increasing the sympathetic tone.[26] Accordingly, the incidence rate of urinary retention during the first 24-h follow-up was significantly higher in the fixation group that was equivalent to later postoperative pain. Indeed, studies that found a difference in the level of postoperative pain have also pointed a difference in the incidence rate of urinary retention.[27],[28]

In this study, comparing the means of pain score of the groups after the surgery suggested that the level of pain at the 1st day after the surgery had no significant difference, while it was higher in Group A as compared with Group B at the time of release and 1 and 2 weeks after the surgery. The level of pain was reduced in both groups in 1- and 6-month follow-ups, and there was no significant difference between the groups in this respect. In fact, it can be stated that pain severity at the discharge time and at the 1st and 2nd weeks after the surgery was higher in patients with mesh fixation.

Many previous studies using TAPP or TEP technique indicated that fixation or nonfixation had no significant effect on the pain severity at the first 24 h after the surgery. The mentioned finding was in line with the findings of the present study. However, the patients had higher pain level in the fixation group as compared to the nonfixation group at 1 week, 6 months, 1 month, and 12 months after the surgery, while it should be noted that pain severity in patients was significantly reduced over time in all the previous studies as well as in the current study.[8],[12],[18],[19],[22]

It seems that using mesh leads to not only an increase in pain after surgery but also an increase of damage risk for organs of this area. The most commonly damaged nerves are the femoral branch of the genitofemoral nerve and the lateral cutaneous nerve of the thigh. Factors that cause postoperative pain in these patients include inguinal nerve stimulation using mesh and tucker, inflammatory reaction around the mesh, and formation of fibrous bone in the inguinal region that stimulates the inguinal nerve. Pain can also be due to local inflammatory reactions to foreign objects and reduction of abdominal wall compilation. Nonfixation of mesh may lead to pain reduction in patients; however, it may lead to an increased recurrence rate due to the probability of mesh displacement.[22],[29]

Finally, the complication that is the main concern of surgeons is hernial recurrence. In this study, there was no recurrence in the fixation group, whereas there was 5.1% recurrence in the nonfixation group (P > 0.05).

Consistent with the findings of the current study, many studies showed that the recurrence rate in mesh fixation group was higher than the reported rate for nonfixation group; however, there was no significant difference between the two groups in terms of recurrence rate.[9],[14],[19],[29]

Although some studies showed a significant mesh migration with nonfixation mesh,[30] some clinical studies revealed no increase in the hernial recurrence risk in the nonfixation group.[18],[22],[31] Moreover, studies showed no significant difference between different mesh types or methods of fixation regarding the hernial recurrence rate.[30],[32],[33]

The basis of preperitoneal mesh method is to repair the hernia without stretching. Using this method, the entire space of the peritoneal apex from the substrate to the outer edge of the anterolateral upper inguinal ligament and Poupart's ligament along the pectin line to the pubis on each side, the Hesselbach's triangle borders, and around the Cooper's ligament is entirely covered and empowered by the mesh. In this method, the hysteresis sac fastens at the highest point of the abdominal wall entrance, and the cord elements are placed by cutting the outside of the mesh. Thus, the possibility of recurrence of the hernia is minimized. The use of this space, especially in the case of recurrent hernias, is a very good solution for minimizing the recurrence rate of hernia.[34] In patients who have intra-abdominal pressure for any reasons such as frequent coughing, chronic constipation, or heavy object removal, the recurrence rate of hernia is increased. In addition, the use of inappropriate mesh size, tissue ischemia, infection, stretch of the repair site, mesh migration and overdissection, malnutrition, immune deficiency, diabetes, use of steroids, and smoking can be regarded as other important factors associated with recurrence.[34],[35]

It should be noted that several factors such as higher body mass index (BMI), surgeon's skill, hernia type (direct and indirect), bilateral or unilateral hernia, mesh fixation method, mesh type, and longer follow-up can be influential in evaluating the results of hernia repair. One type of mesh was used in the present study, and the results of comparing the incidence of complications and other factors did not differ significantly between the groups with direct and indirect hernias. Moreover, individuals with high BMI were not included, and all the surgeries were performed by one skilled surgeon. Therefore, in this study, it was tried to control the confounding factors even though the results showed a difference between the two methods of fixed or nonfixed mesh.

However, it is suggested that future studies assess the effect of different types of mesh or different meshing methods on the incidence rate of recurrence. Moreover, the surgeon's skill and the patient's BMI can be evaluated as effective factors in this regard. In addition, as the TAPP method was used in the present study, considering the preference of many surgeons for using TEP instead of TAPP due to its lower rate of complications, it is suggested to conduct a similar study using the TEP method. Moreover, studies examining the outcome of these two methods (TEP and TAPP) with fixed and nonfixed mesh can be informative.

  Conclusion Top

According to the findings of the current study, the length of in-hospital stay in the fixation group was more than that of the nonfixation group. Regarding the occurrence of complications, only neuralgia and urinary retention showed significant difference between the two groups; however, the other complications were not significantly different between the two groups. In addition, there was no hernial recurrence in the fixation group; however, it occurred only in the two cases of the nonfixation group. Finally, the severity of pain in the mesh fixation group was more than that of the nonfixation group, the severity of pain was significantly decreased in both groups 6 months after the surgery, and there was no significant difference between the groups in this respect.


The authors would like to acknowledge the support of the Research Deputy of Isfahan Medical School.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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

  [Table 1], [Table 2], [Table 3], [Table 4]


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