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Fortelny. Mini-invasive Surg 2021;5:16 https://dx.doi.org/10.20517/2574-1225.2021.21 Page 3 of 11

[1]
triangle of doom and pain, for penetrating fixation modules .

[5]
Since Reinpold's anatomical study , we know that the entry points of the genital and femoral branch of the
genitofemoral nerve have a great variability and can lie above the ilio-pubic tract. This widens both the
triangle of doom and the triangle of pain. This also significantly increases the risk of nerve injury when
using penetrating fixation models. Similarly, the varied course of the ilio-hypogastric nerve, which can also
be injured during traumatic mesh fixation in TEP and TAPP repair, must also be taken into account.

In conclusion, a significantly increased risk of injury must be calculated for traumatic mesh fixation
techniques, which leads to the fact that only atraumatic mesh fixation methods are recommended in the
international guidelines for the laparo-endoscopic treatment of inguinal hernias .
[6]

Is the use of resorbable tacker able to prevent chronic postoperative pain?
Initiated by the results of comparative studies on different mesh fixation devices, the hypothesis arose that
the re-absorbability of penetrating staples could solve the problem of nerve damage, starting from
neuropraxia to total dissection. By definition, the chronicity of pain appears after 3-6 months at the latest
and is compared to the resorption time of these fixation models of 6-8 months. Thus, this consideration was
based on lacking knowledge of the time course of a nerve injury and entrapment. Moreover, the
configuration of these resorbable staples was partly incompatible with regard to the size of the mesh pores
to be considered and the depth of penetration especially in laparoscopic incisional and ventral hernia repair.

In summary, the problem of penetrating fixation models is not solved by the absorbability of the material
used and makes no difference in outcome results such as postoperative pain and recurrence.
[7,8]

Seroma
The incidence of postoperative seroma formation in laparo-endoscopic inguinal hernia surgery is reported
in the literature to be between 3.0 and 8% for TAPP and between 0.5% and 12.3% for TEP. A clinical
association was reported with large hernia sacs in direct and indirect inguinal hernias but also with mesh
fixation . In a registry study by Köckerling et al. , the occurrence of seroma formation after TAPP
[10]
[9]
treatment was analyzed in relation to the type of fixation and the type of hernia. In the multivariate analysis,
adhesive fixation had a twofold risk of postoperative seroma formation compared to staple fixation and a 5-
fold risk compared to non-fixation. In relation to hernia defect, M3 (direct inguinal hernia, defect size ≥ 3
cm, EHS classification) had a 2.8-fold increased risk compared to M1 (direct inguinal hernia, defect size ≤
1.5 cm, EHS classification) inguinal hernia, and direct inguinal hernia had a 1.2-fold increased risk
compared to indirect inguinal hernia.

The closure of the direct inguinal hernia defect area of the type MIII inguinal hernia by means of inversion
of the dilated transversalis fascia within laparo-endoscopic hernia repair to avoid postoperative seroma
formation seems recommendable. The use of barbed suture material for this purpose seems to be suitable.
The results of a RCT by Zhu et al. showed a significantly reduced incidence and volume of seroma
[11]
formation without increasing the risk of recurrence, acute and chronic pain.

In another prospective study by Usmani et al. comparing direct defect closure in MII and MIII inguinal
[12]
hernias by barbed non-resorbable suture versus non-closure in TEP and TAPP repair demonstrated a
statistically significant reduction not only in seroma formation (12.6% vs. 6.4%, P = 0.045) but also in
recurrence (4.4% vs. 0.9%, P = 0.036) after a follow-up of at least 9 months.