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Inguinal hernias are one of the most common complaints that surgeons hear from patients on a daily basis. Controversy still surrounds whether laparoscopic or open repair is the ideal for inguinal hernias. Hernia repair can be done by two methods: Total extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) repairs1.
The transabdominal preperitoneal (TAPP) repair involves standard laparoscopy with access into the peritoneal cavity and placement of a large mesh along the anterior abdominal wall, thereby repairing the hernia posterior to the defect. This technique was the first laparoscopic hernia repair to be performed2.
In TAPP procedure, the mesh must be fixed after its placement either by tacks (titanium or absorbable), sutures, staples, self-fixing meshes or other glues. There is no consensus on the best method of mesh fixation and the choice of options often depends on surgeons’ personal preference3.
Recently, the market/surgeon preference is turning toward absorbable spiral tacks. These tacks appear to cause less long-term complications than the titanium tacks and tend to reabsorb within one year (as described by the company for the AbsorbaTack). Tissue glues are also an acceptable mesh fixation method. No one fixation material has been shown to be the “ideal” method in the literature1.
Tackers are very popular fixation devices for inguinal hernia repairs as they are simple to use and prevent mesh migration, which is the most common cause for recurrence4, 5. However, one of the biggest issues with tacks is the risk of causing long-term pain after its use1.
The use of absorbable tacks appears to cause less long- term complications than the titanium tacks and tend to reabsorb within one year2.
Absorbable fixation devices have been developed to achieve sufficient tensile fixation strength with acceptable postoperative pain compared to conventional non absorbable devices. Yet, their efficiency has not been confirmed by randomized controlled clinical trials6.
Guidelines of EAES (European Association for Endoscopic Surgery and other interventional techniques) and the EHS (European Hernia Society) reported that, at present, there are no adequate clinical studies about the use of absorbable devices, and they could not make any recommendation7.
2. Objectives:
In the present study we are comparing the outcome of absorbable versus non-absorbable tacks as mesh fixation devices in patients undergoing laparoscopic transabdominal inguinal hernia repair (TAPP) in regard to postoperative chronic groin pain and recurrence.
3. Patients and methods:
This study was conducted in Eldemerdash Hospital, Ain Shams University and Badr hospital, Helwan university between June 2015 and June 2018. The study included 30 male patients suffering from bilateral inguinal hernia who were candidate for laparoscopic transabdominal preperitoneal repair (TAPP). Patients were enrolled into two groups by random selection; the first group (group A) included 15 males who underwent TAPP using non-absorbable tacks (NAT) while the second group (group B) included 15 males who underwent TAPP using absorbable tacks (AT).
Inclusion criteria included patients aged 20-60 years, patients who had bilateral inguinal hernia with American Society of Anesthesiology Scores (ASA) I and II patients and signed informed consent.
Exclusion criteria included patients with history of previous abdominal operations, recurrent hernia, irreducibility, ASA III and IV, BMI ? 35, patients with COPD, emergency presentation, large scrotal hernia, contraindications to general anesthesia and patients who refused to participate in the study. Cases that underwent conversion were excluded from the study.
Smokers were advised to stop smoking at least one month before the operation. Any predisposing factor for hernia was treated preoperatively.
3.1. Surgical technique:
Patients were instructed to void before surgery, which rendered bladder catheterization unnecessary. A single preoperative dose of parenteral 3rd generation cephalosporin was administered on anesthesia induction. General anesthesia was administered routinely.
Patients were put in a supine head down leg up position with both arms tucked. Bilateral compression stockings were applied. The table was tilted opposite the side of the hernia. The anesthesia monitor is placed as far toward the head of the table as possible. A single video monitor was placed at the foot of the bed, directly facing the patient’s head, with the surgeon standing by the patient’s shoulder on the opposite side of the hernia, the assistant surgeon standing opposite the surgeon and the nurse standing on the ipsilateral side. In case of bilateral inguinal hernias, we started by the side of the larger, more symptomatic hernia. The skin is prepared and draped so as to allow exposure of the entire lower abdomen, the genital region, and the upper thighs because manipulation of the hernial sac and the scrotum may be necessary.
A pneumoperitoneum was established using a Veress needle in the left subcostal area. Three trocars were used. One 10-mm trocar was placed at the epigastrium just below the sternum on the abdominal wall to obtain adequate distance from the hernia orifice. A 30° endoscope was inserted through this 10 mm trocar. Other trocars; one 5 mm and one 10-mm were inserted under direct visualization at the level of umbilicus just lateral to the lateral border of rectus muscle.
Diagnostic laparoscopy was first done. Identification of the median and medial umbilical ligaments, bladder, inferior epigastric vessels and hernial defects whether direct or indirect or both. Marking of the site of peritoneal incision was done from anterior superior iliac spine to medial umbilical ligament. The incision was sufficiently above the hernia defect to allow dissection of 2 to 3 cm of normal fascia to provide sufficient mesh overlap after mesh placement.
Peritoneal flap elevation was done beginning at the lateral edge of the medial umbilical ligament and extending in a subfascial plane 8 to 10 cm laterally till the anterior superior iliac spine. The intra-abdominal pressure in this phase helps to divide the peritoneum from the underlying abdominal wall.
After developing the peritoneal flap in the avascular plane between the peritoneum and the transversalis fascia, dissection was done to reach the pubic symphysis, Cooper’s ligament, iliopubic tract, cord structures, inferior epigastric vessels, and hernia spaces followed by dissection of the sac from the cord structures.
The most crucial step in TAPP procedure is the accurate preparation of the external borders of the peritoneal flap. This allows the mesh to be perfectly positioned on the inguinal area, medially, laterally, and in femoral and obturator areas. We used two separate peritoneal incisions for each side.
Careful identification of the femoral branch of the genitofemoral nerve and lateral cutaneous nerve of the thigh was done to avoid their injury (Triangle of Pain). For direct hernia gentle reduction of sac from the preperitoneal fat using gentle traction was done. While indirect sacs were mobilized from the cord structures and then reduced into the peritoneal cavity. A larger hernia sac that was difficult to mobilize from the cord without undue trauma to the vas deferens or vasculature to the testicle was divided just distal to the internal ring, leaving the distal sac in situ within the inguinal canal. After dissection was done, the mesh was placed and fixed using either non-absorbable tacks (Group A) or absorbable tacks (Group B), we used 3-5 tacks to fix the mesh for every side and another 3-5 tacks to close the peritoneum. In our study we used the ProTack® by Covidien as nonabsorbable tacks (figure 1) and AbsorbaTack® by Covidien as absorbable tacks (figure 2).

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