Surgical Science, 2013, 4, 516-519
Published Online November 2013 (
Open Access SS
Transabdominal Pre-Peritoneal Mesh for Inguinal Hernia
Repair with External Fixation versus Mesh Stapling
Mohamed Abdelhamid*, Ahmed Mohamed Sadat, Ayman Refaat Abdelhaseeb,
Tamer Mohamed Nabil, Mohamed Salah Abdelbasset, Amro Mohamed Ali Bechet,
Hesham Ahmed Nafady, Kalid Ahmed Shawky
Faculty of Medicine, Bani Swif University, Bani Swif, Egypt
Email: *
Received June 1, 2013; revised July 1, 2013; accepted July 10, 2013
Copyright © 2013 Mohamed Abdelhamid et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: It is unknown whether stapling the mesh affects recurrence rate, incidence of neuralgia, and port-site her-
nia. We chose to fix it to the ex terior redu cing port size, co st and pain, at the same comparing th is with traditional mesh
stapling. Methods: We conducted a prospective trial for laparoscopic TAPP inguinal hernia repair on 120 patients in
which we fixed the mesh to the anterior abdominal wall using either two prolene threads that passed to the exterior and
tied in place or traditional mesh stapling. Results: The operative time is ranged from 35 to 70 minutes for external fixa-
tion, 30 to 60 minutes for mesh stapling, and 4 to 51 months for follow-up, and no recurrence occurred in both groups
during the procedure. Two cases with post TAPP pain in mesh stapling patients are discussed with reduction of the cost
and port size in external fixation patients. Conclusion: It is not necessary to secure the mesh during laparoscopic TAPP
inguinal hernia repair from the interior and it is fixed only to the exterior allowing a reduction in size of the ports and
considerable reduction in cost with elimination of TAPP associated post operative pain.
Keywords: Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair; Mesh Prosthesis Fixation;
1. Introduction
3500 years ago, Egyptian physicians reported the man-
agement of hernia by conservative means including the
snuggly fitting bandage for reduction and support. For
100 years, the Bassini-type repair for inguinal hernia was
the standard method. The Lichtenstein “tension free”
mesh repair replaced it on the grounds of much lower
recurrence rates, <5% vs. ~15%. However, all open pro-
cedures have significant long-term discomfort rates of up
to 53%. Laparoscopic repair has become a genuine op-
tion in the last 15 years and offers low recurrence (<1%)
and minimal long-term discomfort. However, it has not
been widely taken up [1]. Laparoscopic inguinal hernia
repair (LIHR) has comparable results to open hernia re-
pair (OHR).
Many studies have shown that LIHR gives similar re-
sults in terms of recurrence as compared with OHR but
with the added advantage of less chance of post operative
pain, wound infection and early return to activity [2].
Following the laparoscopic revolution, laparoscopic her-
nia repair has become one of commoner laparoscopic
operations. Several studies have demonstrated a definite
advantage over open repair with regard to reduced post-
operative pain [3-5] and earlier return to work and nor-
mal activities [6-8]. It is unknown at present what the
best method is among mesh implantation, central incision,
reconstructing the deep inguinal ring, or a non-incised
mesh implant in laparoscopic hernia surgery [9]. No in-
fluence on postoperative complaints or complications
could be demonstrated by different mesh fashioning and
fixation alternatives [10]. Cost has been a major point of
criticism against the laparoscopic approach, particularly
in term of disposable items of which a stapling device is
the most expensive [11]. That is why we tried to find out
a way that can eliminate the use of expensive devices to
reduce the cost without affecting the outcome.
2. Patients
This work was conducted at Al Hayat Hospital Jeddah,
*Corresponding a uthor.
KSA, Bani Swif University Hospital and Bani Swif
Health Insurance Hospital between September 2008 and
August 2012. Included in the study were 120 patients
with unilateral inguinal hernia, both direct and indirect.
Both bilateral and recurrent hernia were excluded from
the study. There were 42 patients with direct inguinal
hernia, 65 patients with indirect inguinal hernia and only
13 with pantaloon hernia.
3. Methods
3.1. Anesthesia
General endotracheal anesth esia is used.
3.2. The Technique
A pneumoperitoneum is created using a Verres needle
and an intra-abdominal pressure of 15 mm Hg is main-
tained. The 10 mm trocar in infra-umbilical position is
inserted. The telescope is then inserted and the intraab-
dominal cavity explored. Two 5 mm trocars are inserted
lateral to each rectus muscle, at the same level as the
umbilical trocar.
3.2.1. S tep 1: Creating th e Pe r itoneal Flap
The repair is initiated. The laparo scope is pointed toward
the afflicted inguinal canal. The peritoneal defect or her-
nia is identified. The other inguinal canal is inspected. If
an asymptomatic hernia sac is found on the other side, it
is excluded from the study. The Lateral Umbilical Liga-
ment is located as well as the Inferior Epigastric Artery
and Vein. A peritoneal incision is made using the En-
doShear*instrument connected to an electocautery source.
The incision is extended from the lateral aspect of the
inguinal region to the Lateral Umbilical Ligament as
high as possible to maximize the exposure of the region.
3.2.2. S tep 2: Exp osing the In g uinal S tructures
Coopers Ligament is exposed as well as the Inferior
Epigastric Vessels and the Spermatic Cord. It is essential
to expose the uncovered abdominal wall meticulously
(without peritoneum) and remove all fatty layers.
3.2.3. St ep 3: Dis se ct ing the Hernia Sac
The inguinal hernia sac should be dissected carefully
from the Spermatic Cord. Particular care should be taken
not to dissect lateral and inferior to Cooper’s ligament, as
the Iliac Artery and Vein will enter the femoral canal at
this site.
3.2.4. Step 4: Insert ing and An choring th e Mesh
To 60 patients the mesh was stapled against the posterior
surface of the anterior abdominal wall using automatic
gun stapler, for the other 60 patients before inserting the
mesh, its middle bilaterally is anchored to two prolene
threads that are tied with the knots towards the back
(Figures 1 and 2), to be facing the abdominal wall when
it is pulled using the port closure device, which is intro-
duced obliquely twice, first just medial to the anterior iliac
spine, second lateral to midline (Figure 3), pulled (Fig-
ure 4) then tied in place. We used 8 × 12 cm mesh to
cover the myopectineal orifice applied onlay on cord
Figure 1. Lateral thread.
Figure 2. Medial thread.
Figure 3. Port closure device opened.
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Figure 4. Pulling the lateral thread.
3.2.5. St ep 5: Clos i ng the Peritoneu m
It is closed while reducing the pressure with vicryl 2/0.
For post operative pain relief, injection diclofenac so-
dium 75 mg i.m. will be given post-operatively in the
recovery room to all patients. Pain will be recorded at 1,
6, 24 hours after operation, at the time of discharge on a
Visual Analogue Scale (VAS) with end points labeled as
no pain and worst possible pain on a scale of 10. (Visual
analogue scale No pain Worst possible pain 0 1 2 3 4 5 6
7 8 9 10).
4. Results
All these patients underwent TAPP repairs. There were
no visceral and vascular injuries with zero conversions to
open surgery. The time of surgery ranged from 35 min-
utes to 70 minutes from the first incision until the last
suture in the external fixation group of patients, on the
stapled mesh group of patients ranged from 30 - 60 min-
utes. We followed patients until December 2012, so it
ranged from 4 months until 51 months. During this pe-
riod we did not enc ounter any recurrences.
Regarding pain no single patient required extra anal-
gesic until discharge from the hospital except two pa-
tients in the stapled mesh group of patients who com-
plaint of groin pain and was in need for more analgesics.
The port sizes are reduced in external fixation group of
patients with con siderable reduction in the cost. The out-
let puncture with the prolene thread sho wed no infection,
no reaction at all until it is pulled and cut.
5. Discussion
Laparoscopic hernia repair was first described by Ger in
1990, who placed a simple mesh plug in the defect [12].
Laparoscopic inguinal hernia repair (LIHR) has compa-
rable results to open hernia repair (OHR). Many studies
have shown that LIHR gives similar results in terms of
recurrence as OHR but with the added advantage of re-
duced post operative, pain, wound infection and early
return to activity [13]. Several laparoscopic procedures
have successfully passed the stage of feasibility assess-
ment and are currently under scrutiny with regard to in-
dications. Laparoscopic repair of inguinal hernia is a
typical example of such investigations [14]. Mechanisms
of recurrence may be related to technical difficulties and
the use of inadequate mesh size and positioning [15]. A
model that takes into account the additional equipment
cost and time cost related to laparoscopic surgery, as
patients return to work earlier. Unfortunately, this analy-
sis showed that an early return to work does not offset
the additional costs associated with laparoscopic hernia
repair [16]. Reliable laparoscopic fixation of meshes
prior to their fibrous incorporation is intended to mini-
mize recurrences following transabdominal preperitoneal
hernia (TAPP) [17]. It is not necessary to secure the
mesh during laparoscopic TAPP inguinal hernia repair
from the interior and fix it only to the exterior [18]. By
all criteria of success—recurrence, recovery, long term
symptoms and economics—laparoscopic inguinal hernia
repair in the way we are doing is the winner. The end
result on both groups nearly the same except that the
operative time is longer in the external fixation group of
patients. Two patients in the stapled mesh group of pa-
tients got groin pain with no such pain in external fixa-
tion of the mesh favoring the use of external fixation In
external fixation group of patients we omitted the use of
the disposable 12 mm trocar and the use of any hernia
tucker which are the most expensive parts in the cost of
TAPP hernia repair. Olmi et al. [19] stated that their ex-
perience demonstrates that fibrin glue (Tissocol) is an
effective method for mesh fixation during TAPP, yet our
method has the advantage of being fixed well. Kapiris et
al. [20] stated that TAPP repair is a technically demand-
ing laparoscopic technique, but once mastered, is safe
and effective with a high degree of patient satisfaction.
Stapling the mesh is not necessary in most cases, thus
resulting in a remarkably low cost. Again external fixa-
tion of the mesh is superior as it is associated with fixa-
tion and at the same time low cost. The issue of mesh
fixation in laparoscopic repair of inguinal hernia repairs
remains unsolved. The need for fixing the mesh arises
from the fear of increasing recurrence rates. However,
specific complications have emerged as a result of mesh
fixation and in our study we got two patients with post
TAPP groin pain. Avoid stapling of the mesh helps in
decreasing complications and operative costs without
affecting recurrence rates.
6. Conclusion
It is not necessary to secure the mesh during laparoscopic
TAPP inguinal hernia repair from the interior and it is
fixed only to the exterior allowing a reduction in size of
the ports and con s iderable reduction in cost with less post
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TAPP pain with mild increase in operative time.
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