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Page 6 of 11 Fortelny. Mini-invasive Surg 2021;5:16 https://dx.doi.org/10.20517/2574-1225.2021.21

Since the evidence regarding the benefit using self-fixating meshes in laparo-endoscopic inguinal hernia
repair is too little, no conclusions or recommendations can be derived at present.

Is there a need for mesh fixation in TEP or TAPP?
Finally, the main topic of this paper is the discussion of non-fixation of mesh in laparo-endoscopic inguinal
hernia surgery.

[15]
The first study in terms of non-fixation in TEP repair in an experimental setting by Katkhouda et al.
demonstrated the risk of mesh movement. Despite this finding and an increased potential risk of early
recurrence derived from it, the non-fixation in TEP technique, for the difference of TAPP, has been
thematized very early. The obvious reason for this was the specific technique of implanting the mesh in a
pocket that made it unlikely that the mesh would slip after the pneumoperitoneum was depressurized. On
the other hand, the advantage of not fixing the meshes is associated with a significantly reduced risk of
[10]
seroma occurrence .
[39]
In a study by Claus specifically focused on mesh displacement in the absence of fixation in TEP repair,
only a minimal displacement was found. The comparison of radiologically controlled mesh movement after
bilateral versus unilateral TEP repair showed 30 days postoperatively a median of 1.9 and 1.8 cm (P = 0.78),
respectively. With this aspect of potential, albeit minor mesh displacement, care must be taken to ensure
adequate size and defect overlap, especially in large direct inguinal hernias.

In 1999, Ferzli et al. published the first study comparing tacker versus non-fixation in TEP repair without
[40]
significant differences in recurrence or complication rates after a 12-month follow-up.

Since then, several studies [41-46] and meta-analyses [47-49] of TEP procedures with non-fixation were published.
The conclusion of these were that outcomes after non-fixation in TEP repair are comparable to fixation and
not associated with higher recurrence rates. However, the various meta-analyses had a certain bias due to
the inclusion of RCTs with recurrent surgery, bilateral inguinal hernias, both sexes and exclusion of large
medial inguinal hernias. As there has been no RCT on primary unilateral inguinal hernias to date, an
evidence-based statement can only be drawn to a limited extent.

Based on the Swedish Hernia Registry, a study including 1110 male patients undergoing TEP repair
comparing permanent fixation versus non-fixation including glue fixation in terms of chronic pain detected
no significant difference . Going into detailed analyses, the rate of permanent fixation was significantly
[50]
higher in medial hernias compared to non-fixation and glue fixation (P < 0.003) as well as regarding the
defect size (P < 0.002). The distribution of unilateral inguinal to bilateral and recurrent inguinal hernias was
36, 64 and 9%, respectively. The use of heavy meshes were significantly more frequent in the fixation group
compared to non-fixation and glue-fixation (P < 0.015). In a subgroup-analysis, the use of glue fixation was
performed significantly more in medial hernia compared to non-fixation (P < 0.001). After a median follow-
up of 7.5 years, a total of 15 patients had an operation for recurrent hernia: 1.5% for fixation and 1.3% for
non-fixation and glue-fixation (P < 0.735). Looking to the sub-analysis of recurrences after medial hernia
repair, no significant difference was seen (0.7% after fixation vs. 1.7% after non-fixation and glue-fixation; P
< 0.669). In a multivariable analysis, the risk factor for chronic pain was a postoperative complication.

In summary, in this registry study of TEP repair in male patients, a low incidence of recurrence was
observed with no significant difference seen in non fixation, permanent and glue fixation. The conclusion of
this study suggests that non-fixation in TEP repair does not carry a risk of recurrence even in medial