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Page 2 of 11 Fortelny. Mini-invasive Surg 2021;5:16 https://dx.doi.org/10.20517/2574-1225.2021.21

mesh fixation has become more and more the focus of discussion. Initially, recurrence rates were the focus
of interest, but now the chronic pain rate, which is much higher in percentage terms, is assessed as a
measure of surgical success. The type of fixation is closely related to the occurrence of postoperative pain.
While penetrating fixation modules such as staplers and staple clips were common in the first era of TAPP
and TEP, adhesive techniques have become increasingly popular. This article deals with the background of
this development as well as the latest scientific published data and international guidelines and resulting tips
and tricks of mesh fixation in laparo-endoscopic inguinal hernia surgery.

Since the implementation of minimal invasive techniques in inguinal hernia repair by TAPP and TEP, the
discussion of mesh fixation is still controversially discussed. In the early 1990s, the standard mesh fixation
[3]
in laparo-endoscopic inguinal hernia repair was performed with staples and tacks . The use of these
penetrating devices was frequently complicated by injury of nerves and vessels and occasionally followed by
postoperative pain. Knowledge in terms of the anatomical areas of high risk for injuries to nerves and
vessels such as the triangle of doom and pain are well known, but due to the variability of the nerve courses
in the region of the inguinal region, a residual risk of injury in the context of a penetrating mesh fixation
cannot be ruled out.

In the last two decades, therefore, the mesh fixation techniques have been under discussion. New absorbable
fixation models as well as self-fixing meshes have been developed. The advantages of this atraumatic mesh
fixation have been investigated in numerous studies and can be found as an evidence-based
recommendation in today's guidelines for inguinal hernia care. The completely fixation-free mesh
implantation in the TEP technique has been practiced by many TEP surgeons for years because of the
extraperitoneal access and the fixation of the mesh resulting from the intraperitoneal pressure immediately
after decompression of the pneumoperitoneum. For the TAPP technique, however, there are only a few
clinical studies to date. The exact background of the advantages of atraumatic fixation techniques and also
fixation-free mesh implantation will be examined in this review.

Pain as main issue in inguinal hernia repair
The recurrence rates after laparo-endoscopic hernia repair have been found to be similar to those with the
open mesh techniques, especially with the standard Lichtenstein technique. However, the advantage of
lower pain incidence after TAPP and TEP compared to Lichtenstein repair became apparent very soon. In a
recently published meta-analysis and trial sequential analysis of primary unilateral uncomplicated inguinal
hernias comparing open versus laparo-endoscopic mesh repair, the current situation of postoperative pain
[4]
and recurrence was described at length and analyzed in detail . This study enrolled 12 randomized
controlled trials (RCT) with 3966 patients randomized to Lichtenstein repair (n = 1926) or laparoscopic
repair (n = 2040). No significant differences were detected in recurrence rates between the laparoscopic and
open groups [odds ratio (OR) 1.14, 95%CI: 0.51-2.55, P = 0.76]. Laparo-endoscopic repair was associated
with reduced rate of acute pain compared to open repair (mean difference 1.19, 95%CI: - 1.86 to - 0.51, P ≤
0.0006) as well as reduced chronic pain compared to open (OR 0.41, 95%CI: 0.30-0.56, P ≤ 0.00001). A trial
sequential analysis found that further studies are unlikely to demonstrate a statistically significant difference
between the two techniques. This meta-analysis concluded that laparo-endoscopic repair has a statistically
significant advantage in inguinal hernia repair in comparison to open mesh repair in terms of postoperative
pain, and it complies with the current Hernia Surge Guidelines.

Why traumatic mesh fixation in laparo-endoscopic inguinal hernia repair should be abandoned?
In the early 1990s, the laparoscopic techniques of TAPP and TEP were developed. In addition to the
discussion about mesh, questions with regard to size and fixation with a stapler or tacker were standard. The
only recommendation at that time was to avoid the region caudal to the ilio-pubic tract, known as the