Fixation of the mesh is an important step in hernia repair . We started with sutures , staples , metallic tacks , absorbable tacks and now self gripping meshes . Does it help in reducing the pain and recurrence .
Dear Dr Reddy,
All the data available in literature is from RCT of open Hernia repair with self gripping mesh vs sutures and most of the studies didn't show any improvement in chronic postoperative pain and recurrence but there is decreased early postoperative pain and operative time. We can assume similar result in laparoscopic hernia repair though need for randomized control trials comparing self gripping mesh with traditional mesh fixed with tacks can not be overstated.
http://www.ncbi.nlm.nih.gov/pubmed/23992854
http://www.ncbi.nlm.nih.gov/pubmed/25146918
Depending on which publications you read it is now understood that chronic pain is one of the less desired outcomes following mesh repair of groin hernias.
However in some series the incidence of chronic pain is far greater after laparoscopic mesh repair versus open mesh repair. This may not have so much to do with the actual fixation but more to do with the placement of large pieces of mesh. Of note the amount of mesh being used for laparoscopic repair is often greater than for open repair.
The problem which arises following laparoscopic repair is mesh slippage into the retroperitoneum and hence fixation of the mesh onto retroperitoneal nerves including the genitofemoral nerve. Mesh removal and neurectomy may be the only option in some cases-
http://www.ncbi.nlm.nih.gov/pubmed/19212190
In my personal experience, self gripping meshes for open inguinal hernia repair does not reduce post - herniorrhaphy pain compared my personal technique employing PHSe device, moreover, I have had more recurrences placing self gripping prosthetic devices in direct hernias, so I recommend to not use these prosthetic devices without placing some stitches to keep inside the mesh, in open repair.
Our experience is good as the procedure reduces the operation time without any visible disadvantages - so we use it as a standard. However hernia is not the key point of our activities.
Dear Dr. Prasanna, I started few months ago to use self gripping meshes in laparoscopic procedures with good results concerning operative times and postoperative pain...we need a longer observational period to evaluate the incidence of recurrence
As recurrence is low with both endoscopic and open mesh repair, evidence of reduced postoperative pain after endoscopic repair is a key reason for our choice of TEP as standard treatment for inguinal/femoral hernia.
Except in rare cases e.g. after open prostatectomy, in TEP repair we abandoned mesh fixation with tackers five years ago. In lieu of tacker fixation, in medial hernias > 1,5 cm (EHS classification M2+) and larger lateral hernias, we have since 2010 used the original Progrip mesh cut to 13 x 15 cm in about 300 cases. Technically, this is a little demanding, but the learning curve is steep. A selfgripping mesh that is easier to apply: the Lap-Progrip has been developed, but it is more expensive.
When applying a standard Progrip mesh in TEP where an intermediate fixation is deemed necessary, we avoid the potential pain by tackers. We also save the expence of the tacker, as the Progrip mesh is far cheaper than a standard mesh and a tacker - and equally, cheaper than glue.
Although we do not have validated data on pain or recurrence, the application of a standard Progrip mesh in TEP repair for inguinal hernia has been very satisfactory in our facility.
Like Dr Lambrecht, I do not routinely tack mesh during a TEP repair. For direct hernias I use PROLENE 6x5 inches and for indirects Parietex TECR1515 also 6xs5 inches. If the direct is larger than 3cm, I will use tacks but this is in less than 20% of patients. I disagree with Dr Verran that large mesh placed during a TEP is the cause of chronic pain. I think pain is related to fixation.
I routinely use preperitoneal ProGrip for umbilical hernias but not for TEP as I do not see the advantage. The path of an indirect hernia is oblique and deep ring simply needs to be occluded. Light weight mesh is OK. Covering large direct defects with lightweight mesh probably results in recurrence hence I favour the stiffer prolene mesh.
Belyansky I, Tsirline VB, Klima DA, Walters AL, Lincourt AE, Heniford TB
Prospective, Comparative study of postoperative quality of life in TEP, TAP, and Modified Lichtenstein Repairs. Ann Surg, 2011.
I use "standard" polypropylene mesh for open repair (Lichtenstein) and self gripping mesh for lap repair (TAPP)
NB The recent publication of the FinnMesh study which failed to prove that mesh fixed without sutures caused less inguinodynia than mesh fixed with sutures in Lichtenstein hernia repair.
Randomized Multicenter Trial Comparing Glue Fixation, Self-gripping Mesh and Suture Fixation of Mesh in Lichtenstein Hernia Repair.
Annals of Surgery 2015, 262 (5) 714-720
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