Mesh Fixation Methods in Groin Hernia Surgery

*Morena Burati, Alberto Scaini, Luca Andrea Fumagalli, Francesco Gabrielli and Marco Chiarelli*

#### **Abstract**

No unanimous consent has been reached by surgeons in terms of a method for mesh fixation in laparoscopic and open surgery for inguinal hernia repair. Many different methods of fixation are available, and the choice of which one to use is still based on surgeons' preferences. At present, tissue glues, sutures, and laparoscopic tacks are the most common fixating methods. In open technique, sutures have been the method of choice for their reduced costs and surgeons' habits. Nevertheless, tissue glues have been demonstrated to be effective and safe. Similarly, tacks can be considered the most common means of fixation in laparoscopic hernia repair, but they are connected to a higher risk of complication and morbidity. In this chapter, we present these types of mesh fixation, their characteristics and potential risks, and advantages of their use.

**Keywords:** inguinal hernia, mesh, fixation, fixation techniques, fibrin glue, cyanoacrylic glue, tacks, suture

#### **1. Introduction**

Inguinal hernia repair is one of the most common procedures in surgical practice. In the surgical repair of groin hernia, prosthetic meshes and their fixation have been subject to debate. In the last decades, synthetic meshes have become crucial in surgical treatment of inguinal hernia. Once positioned, meshes are designed to be integrated in local tissue by a fibrotic reaction that gradually incorporates them. Therefore, a good fixation is essential to secure the mesh in its correct position, while the integration process occurs.

The introduction of synthetic meshes and their proper fixation has reduced recurrence rates to below 5%. As a consequence, the most frequent postoperative morbidities have become mesh migration, chronic pain, infection, and seroma [1, 2]. In surgical practice the main challenge in mesh fixation consists in finding a good balance between the strength of fixation, in order to avoid recurrence and the risk of tissue trauma and nerve entrapment, leading to chronic pain.

At present, various fixation techniques and materials have been developed, but no unanimous consent has been reached on the "best" method of fixation. The choice is still based on surgeon's preferences and experience, and much still depends on local habits and personal beliefs.

**88**

*Techniques and Innovation in Hernia Surgery*

[1] Ohene-Yeboah M, Abantanga FA. Inguinal hernia disease in Africa: A common but neglected surgical condition. West African Journal of

[8] Zulu HG, Mewa Kinoo S, Singh B. Comparison of Lichtenstein inguinal hernia repair with the tension-free Desarda technique: a clinical audit and review of the literature. Tropical Doctor.

2016;**46**(3):125-129

Medicine. 2011;**30**(2):77-83

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2008;**14**(3):122-127

[2] Kingsnorth AN, Clarke MG, Shillcutt SD. Public Health and Policy Issues of Hernia Surgery in Africa. World Journal of Surgery. 2009;**33**(6):1188. DOI: 10.1007/

[3] Mgba JA, Tangnyin CP, Atah TN, Meva'a JB, Sosso MA. Cure des Hernies Inguinales en Tension -Free (Nouvelle technique en Bassini modifiée). Health Sciences and Diseases. 2016;**17**(4):83-87

[4] Desarda MP. No-mesh inguinal hernia repair with continuous

[5] Konate I. Primary unilateral uncomplicated inguinal hernia repair, which is the procedure most frequently, performed in operating theatres the world over? Situation of Africa. Hernia. Jun 2019;**23**(3):623-624. DOI: 10.1007/ s10029-019-01937-5. [Epub 9 May 2019]

absorbable sutures: A dream or reality? (A study of 229 patients). Saudi Journal of Gastroenterology: Official Journal of the Saudi Gastroenterology Association.

[6] Gorad K, Lohar H, Patil S, Tonape T, Gautam R. Modified Bassini's repair: Our experience in a rural hospital setup. Medical Journal of Dr. DY Patil University. 2013;**6**:378. DOI:

10.4103/0975-2870.118276

[7] Dieng M, Cissé M, Seck M,

Chirurgie. 2012;**11**(2):069-074

Diallo F, Touré A, Konaté I, et al. Cure des hernies inguinales simples de l'adulte par plastie avec l'aponévrose du grand oblique: Technique de Desarda. e-mémoires de l'Académie Nationale de

#### **2. Mesh fixation**

#### **2.1 Fixation methods**

The primary function of a fixation device is to keep the mesh in place until tissue ingrowth is completed. The interaction between mesh and tissue depends on the type of mesh; however, complete integration is usually achieved within 2–3 weeks after surgery. It is important to underline that shear strength is reached for 74% during the first 2 weeks. Until then, therefore, proper fixation is essential. Different types of fixation medium can be used in inguinal hernia surgery, the main ones being tissue glues, staples and tacks, and sutures.

#### *2.1.1 Tissue glues*

Tissue adhesives have been introduced in medical practice during the 1960s. Since then, they have been used in numerous procedures like skin closure, suture reinforcement, arteriovenous embolization, endoscopic treatment of ulcers and varices, and fixation of meshes in abdominal wall defect repair.

Two types of tissue adhesive for mesh fixation are available in surgical practice:

#### *2.1.1.1 Fibrin glues (Tisseel®, Tissucol®, and Evicel®)*

It is made of four components: human purified fibrinogen, bovine atropine solution, human thrombin, and calcium chloride. Alongside its hemostatic action, the fibrinogen component gives the product tensile strength and adhesive properties. It also promotes fibroblast proliferation [3]. These are mixed at the time of fixation to duplicate the terminal coagulation reaction and generate polymerized fibrin [4]. Once applied to the mesh, 3 min may be required to complete the reaction [5].

#### *2.1.1.2 Cyanoacrylic tissue glues (Histoacryl®, Glubran®, and Glubran-2®)*

These glues are synthetic (n-butyl-cyanoacrylate) or hybrid tissue sealants. They are known for strong and rapid adhesive properties. Cyanoacrylic glues ensure high-degree and strong bonding to biologic tissues when compared with other adhesives. When they get in contact with blood or water contained in the tissue, they form a very tight cover, binding to the surface within 5–6 s [6]. Glubran-2 is the most recently produced tissue adhesive. Its peculiarity is a longer radical chain with a lower temperature of polymerization compared to Histoacryl®, which results in lower toxicity and fewer inflammatory reactions [7].

At present, there is no evidence in medical literature as to which glue may be considered better in mesh fixation during inguinal hernia repair. Nevertheless, it must be remarked that using glue for mesh fixation increases the costs of hernioplasty, if compared with sutures.

#### *2.1.2 Tacks*

Tack fixation has been performed since the introduction of laparoscopic inguinal and ventral hernia repair between the late 1980s and the early 1990s. In current practice, three types of tacks are commonly used, divided into two categories: absorbable and nonabsorbable.

**91**

*Mesh Fixation Methods in Groin Hernia Surgery DOI: http://dx.doi.org/10.5772/intechopen.89732*

*2.1.2.1 Helical titanium tacks (ProTack®)*

*2.1.2.2 Helical nontitanium tacks (PermaFix®)*

of titanium tacks is no longer advisable.

different time of strength loss due to degradation.

(Monocryl®) to a maximum of 4–5 weeks (PDS®).

permanent hollow tack with an atraumatic tip, 6.7 mm long [9].

*2.1.2.3 Absorbable tacks (AbsorbaTack®, PermaSorb®, and SorbaFix®)*

These tacks are made of polymers or copolymers (poly(D,L)-lactide or glycolide-co-L-lactide). They measure between 6.4 and 6.7 mm and adsorb in

Overall, tacks provide an excellent fixation strength, and they are also easy to apply. Nevertheless, their use is associated with significant morbidity. The penetration of the abdominal wall, in fact, may cause nerve and vessel entrapment. Also, tacks are themselves foreign bodies introduced in the abdomen, so they may cause inflammatory reactions. As a result, a significant number of patients suffer from pain and develop adhesion in the postoperative period. Moreover, cases of migration of titanium tacks have been described. At present, absorbable tacks are connected to lower inflammation rates, adhesion formation, and migration so the use

Sutures commonly used in hernia repair are divided into two: absorbable and nonabsorbable, each characterized by a different degree of tension generated and a

*polyglycolic acid (Dexon®), polyglyconate (Maxon®), and polydioxanone* 

Their loss of strength has been classified and varies from a minimum of 1 week

*2.1.3.1 Absorbable sutures (poliglecaprone (Monocryl®), polyglactin (Vicryl®),* 

*2.1.3.2 Nonabsorbable sutures (polypropylene (Prolene®) and polyamide* 

These sutures are designed to retain most of their strength indefinitely. International medical literature offers evidence that both absorbable and nonabsorbable sutures seem to provide enough strength and tension to prevent recurrence. International randomized trials do not seem to highlight significant difference between the two types of sutures in terms of postoperative complications.

the mesh [8].

12–16 months [9].

*2.1.3 Sutures*

*(PDS®))*

*(Nylon))*

It is a laparoscopic device, which places a helical coil into the fascia and muscle of the anterior abdominal wall. The tack itself has a helical shape, measures 4 mm in length and 3 mm in width, and penetrates approximately 3–4 mm into these tissues. To be placed correctly, tacks must be placed 1–1.5 cm apart, along the periphery of

These tacks are made of polyacetal, a molded, polymer-based material. It is a

*Mesh Fixation Methods in Groin Hernia Surgery DOI: http://dx.doi.org/10.5772/intechopen.89732*

*Techniques and Innovation in Hernia Surgery*

being tissue glues, staples and tacks, and sutures.

varices, and fixation of meshes in abdominal wall defect repair.

*2.1.1.1 Fibrin glues (Tisseel®, Tissucol®, and Evicel®)*

The primary function of a fixation device is to keep the mesh in place until tissue ingrowth is completed. The interaction between mesh and tissue depends on the type of mesh; however, complete integration is usually achieved within 2–3 weeks after surgery. It is important to underline that shear strength is reached for 74% during the first 2 weeks. Until then, therefore, proper fixation is essential. Different types of fixation medium can be used in inguinal hernia surgery, the main ones

Tissue adhesives have been introduced in medical practice during the 1960s. Since then, they have been used in numerous procedures like skin closure, suture reinforcement, arteriovenous embolization, endoscopic treatment of ulcers and

Two types of tissue adhesive for mesh fixation are available in surgical practice:

It is made of four components: human purified fibrinogen, bovine atropine solution, human thrombin, and calcium chloride. Alongside its hemostatic action, the fibrinogen component gives the product tensile strength and adhesive properties. It also promotes fibroblast proliferation [3]. These are mixed at the time of fixation to duplicate the terminal coagulation reaction and generate polymerized fibrin [4]. Once applied to the mesh, 3 min may be required to complete the

*2.1.1.2 Cyanoacrylic tissue glues (Histoacryl®, Glubran®, and Glubran-2®)*

results in lower toxicity and fewer inflammatory reactions [7].

plasty, if compared with sutures.

absorbable and nonabsorbable.

These glues are synthetic (n-butyl-cyanoacrylate) or hybrid tissue sealants. They are known for strong and rapid adhesive properties. Cyanoacrylic glues ensure high-degree and strong bonding to biologic tissues when compared with other adhesives. When they get in contact with blood or water contained in the tissue, they form a very tight cover, binding to the surface within 5–6 s [6]. Glubran-2 is the most recently produced tissue adhesive. Its peculiarity is a longer radical chain with a lower temperature of polymerization compared to Histoacryl®, which

At present, there is no evidence in medical literature as to which glue may be considered better in mesh fixation during inguinal hernia repair. Nevertheless, it must be remarked that using glue for mesh fixation increases the costs of hernio-

Tack fixation has been performed since the introduction of laparoscopic inguinal and ventral hernia repair between the late 1980s and the early 1990s. In current practice, three types of tacks are commonly used, divided into two categories:

**2. Mesh fixation**

*2.1.1 Tissue glues*

reaction [5].

**2.1 Fixation methods**

**90**

*2.1.2 Tacks*

#### *2.1.2.1 Helical titanium tacks (ProTack®)*

It is a laparoscopic device, which places a helical coil into the fascia and muscle of the anterior abdominal wall. The tack itself has a helical shape, measures 4 mm in length and 3 mm in width, and penetrates approximately 3–4 mm into these tissues. To be placed correctly, tacks must be placed 1–1.5 cm apart, along the periphery of the mesh [8].

#### *2.1.2.2 Helical nontitanium tacks (PermaFix®)*

These tacks are made of polyacetal, a molded, polymer-based material. It is a permanent hollow tack with an atraumatic tip, 6.7 mm long [9].

#### *2.1.2.3 Absorbable tacks (AbsorbaTack®, PermaSorb®, and SorbaFix®)*

These tacks are made of polymers or copolymers (poly(D,L)-lactide or glycolide-co-L-lactide). They measure between 6.4 and 6.7 mm and adsorb in 12–16 months [9].

Overall, tacks provide an excellent fixation strength, and they are also easy to apply. Nevertheless, their use is associated with significant morbidity. The penetration of the abdominal wall, in fact, may cause nerve and vessel entrapment. Also, tacks are themselves foreign bodies introduced in the abdomen, so they may cause inflammatory reactions. As a result, a significant number of patients suffer from pain and develop adhesion in the postoperative period. Moreover, cases of migration of titanium tacks have been described. At present, absorbable tacks are connected to lower inflammation rates, adhesion formation, and migration so the use of titanium tacks is no longer advisable.

#### *2.1.3 Sutures*

Sutures commonly used in hernia repair are divided into two: absorbable and nonabsorbable, each characterized by a different degree of tension generated and a different time of strength loss due to degradation.

#### *2.1.3.1 Absorbable sutures (poliglecaprone (Monocryl®), polyglactin (Vicryl®), polyglycolic acid (Dexon®), polyglyconate (Maxon®), and polydioxanone (PDS®))*

Their loss of strength has been classified and varies from a minimum of 1 week (Monocryl®) to a maximum of 4–5 weeks (PDS®).

#### *2.1.3.2 Nonabsorbable sutures (polypropylene (Prolene®) and polyamide (Nylon))*

These sutures are designed to retain most of their strength indefinitely. International medical literature offers evidence that both absorbable and nonabsorbable sutures seem to provide enough strength and tension to prevent recurrence. International randomized trials do not seem to highlight significant difference between the two types of sutures in terms of postoperative complications.

Nevertheless, nonabsorbable suture seems to be connected to a higher incidence of postoperative pain due to entrapment of a nerve by suture or mesh [10].

#### **2.2 Mesh fixation and surgical techniques**

As mentioned above, several mesh fixation methods exist, including tacks, staples, self-fixing, fibrin sealants, synthetic glues, and sutures. Which method to choose to secure a mesh during surgical hernia repair depends on many factors such as personal beliefs, local habits and "dogmas," type of the hernia, and size of the defect but, most of all, on surgical technique.

Two approaches to repair inguinal hernia are common practice in surgery: the open approach, usually the Lichtenstein technique, and the laparoscopic approach, meaning both preperitoneal and extraperitoneal repair.

#### *2.2.1 Open technique*

Groin hernioplasty is the most common operation in general surgery. Due to its lower costs, shorter operating times, and reduced complication risks, the open Lichtenstein technique is performed more frequently. Lichtenstein hernia repair, in fact, is simple, safe, and easy to learn, with very good results in terms of morbidity and a very low recurrence rate.

Both sutures (absorbable and nonabsorbable) and glues (fibrin and cyanoacrylic) can be used to seal the mesh to the abdominal wall.

According to standard operating technique, once the mesh is placed and adjusted, the upper edge is kept in place with two or three sutures, one to the rectus sheath and the others to the internal oblique aponeurosis. Also the lower lateral edges of each of the two tails of the mesh are fixed to the inguinal ligament, leaving enough space for the passage of the spermatic cord.

The use of tissue adhesive to secure the mesh has become an internationally accepted practice in the last few decades. In the sutureless technique, the mesh is fixated by using fibrin or cyanoacrylic glue, whose components get mixed during the operation. Once activated, the glue is poured beneath the mesh, covering the whole Hesselbach's triangle. The mesh is placed above the glue and pressed against the inguinal floor for about 2 min [11].

Suture mesh fixation in inguinal hernia repair represents the main source of complications, possibly leading to inflammation and surgical site infection (SSI), hematoma, nerve entrapment, and chronic pain.

A 2014 systematic review including 12 articles by Sanders et al. [12] found an infection rate between 0 and 3.5%, and no significant difference in terms of SSIs incidence was detected between the groups. Anyway, there is no study specifying the depth of infection, whether it was deep or superficial. This could lead to improper conclusions, being a deep infection more related to the presence of the mesh.

Pain is a very important outcome after surgical repair of groin hernia. Pain is defined as acute, when it occurs in the first week after the operation, and chronic, when it lasts beyond 3 months after surgery. Two RCTs, recently published in medical literature, have demonstrated a significant lower incidence of acute pain after using fibrin sealant (p < 0.001) [13] and cyanoacrylic glue (p < 0.003) [14] compared to suture fixation.

A recent meta-analyses, including 13 RCTs comparing glue versus suture mesh fixation in Lichtenstein inguinal hernia repair [15, 16], showed a lower incidence of early acute pain (p = 0.03) and hematoma in the glue fixation group. On the other hand, chronic pain is one of the main issues after hernioplasty, and sutureless

**93**

*Mesh Fixation Methods in Groin Hernia Surgery DOI: http://dx.doi.org/10.5772/intechopen.89732*

often have been excluded.

*2.2.2 Laparoscopic technique*

glues and sutures.

hemostatic properties [20].

terms of SSIs rates could be registered.

symptoms like numbness and discomfort after 1 year.

large (MII or LII types, EHS classification).

glues, and sutures can all be used to fixate the mesh.

standard" technique has been established [19].

rates after different fixation methods, have been produced.

techniques were introduced in surgery in an attempt to reduce its incidence, without affecting recurrence rates. According to the international guidelines for groin hernia management, the incidence of chronic pain ranges from 0 to 36.3% [17]. In particular, 14.7% is for sutures, 7.6% for cyanoacrylic glues, and 3.7% for fibrin glues. Three international RCTs suggest that the use of fibrin or cyanoacrylic glue can reduce pain if compared to suture [10, 12]. In particular, the TIMELI international trial demonstrated that fibrin glue was connected to the reduction of chronic

Among the possible complications, recurrence is possibly the one that concerns surgeons the most. According to Sanders et al.'s review, recurrence rate is 1.3%. There was no significant difference between fixation methods in any of the RCTs, although long-term recurrence rates have not been determined and large hernias

Concluding, in open inguinal hernia repair, no differences in recurrence or surgical site infection between different mesh fixation methods have been reported in literature, while sutureless fixation may reduce the onset of acute and chronic pain. Therefore, according to HerniaSurge Group consensus, glue fixation in the Lichtenstein technique can be performed in direct or indirect hernias less than 3 cm

At present, the two most common laparoscopic techniques for hernia repair are the transabdominal preperitoneal repair (TAPP) and the total extraperitoneal repair (TEP). Both techniques involve the placement of a mesh in the preperitoneal space that must cover all potential hernia sites. The mesh in the preperitoneal space is subject to intra-abdominal forces and may be easily displaced before fibrosis seals it to the inguinal canal. In particular, the medial edge of the mesh is most susceptible to displacement, leading to inevitable recurrence if the medial part of the inguinal canal gets exposed. This underlines the importance of fixation [18]. Tacks,

Arguably, the most popular technique among surgeons is the use of tacks. However, it is known that using tacks and staples to secure the mesh can lead to complications, such as chronic pain. During the mesh fixation, in fact, it is really important not to place any tack or staple below the iliopubic tract, avoiding the triangle of pain. Lateral fixation should also be avoided, to prevent inadvertent damage to the nerves. Also misplaced tacks are described in literature to be responsible for nerve irritation and injury. The alternatives of the use of tacks are tissue

Sutures usually require expertise and longer operating times. Both absorbable and nonabsorbable sutures may be used to fixate mesh to the abdominal wall. Sutures are usually applied transfascially after reduction of intraperitoneal pressure. Suture type, quantity, and placement vary among surgeons and no "gold

Tissue glues have been introduced in laparoscopic hernia repair to reduce morbidity, such as pain and hematoma, thanks to their atraumatic application and their

Several studies, including meta-analyses and RCTs, comparing complication

Complications after TEP repair, using tacks against glue, have been analyzed in a recent review by Kaul et al. [21]. The authors included in the study four RCTs for a total of 664 procedures. According to their results, no significant difference in

#### *Mesh Fixation Methods in Groin Hernia Surgery DOI: http://dx.doi.org/10.5772/intechopen.89732*

*Techniques and Innovation in Hernia Surgery*

**2.2 Mesh fixation and surgical techniques**

defect but, most of all, on surgical technique.

*2.2.1 Open technique*

and a very low recurrence rate.

meaning both preperitoneal and extraperitoneal repair.

rylic) can be used to seal the mesh to the abdominal wall.

enough space for the passage of the spermatic cord.

hematoma, nerve entrapment, and chronic pain.

the inguinal floor for about 2 min [11].

Nevertheless, nonabsorbable suture seems to be connected to a higher incidence of

As mentioned above, several mesh fixation methods exist, including tacks, staples, self-fixing, fibrin sealants, synthetic glues, and sutures. Which method to choose to secure a mesh during surgical hernia repair depends on many factors such as personal beliefs, local habits and "dogmas," type of the hernia, and size of the

Two approaches to repair inguinal hernia are common practice in surgery: the open approach, usually the Lichtenstein technique, and the laparoscopic approach,

Groin hernioplasty is the most common operation in general surgery. Due to its lower costs, shorter operating times, and reduced complication risks, the open Lichtenstein technique is performed more frequently. Lichtenstein hernia repair, in fact, is simple, safe, and easy to learn, with very good results in terms of morbidity

Both sutures (absorbable and nonabsorbable) and glues (fibrin and cyanoac-

According to standard operating technique, once the mesh is placed and adjusted, the upper edge is kept in place with two or three sutures, one to the rectus sheath and the others to the internal oblique aponeurosis. Also the lower lateral edges of each of the two tails of the mesh are fixed to the inguinal ligament, leaving

The use of tissue adhesive to secure the mesh has become an internationally accepted practice in the last few decades. In the sutureless technique, the mesh is fixated by using fibrin or cyanoacrylic glue, whose components get mixed during the operation. Once activated, the glue is poured beneath the mesh, covering the whole Hesselbach's triangle. The mesh is placed above the glue and pressed against

Suture mesh fixation in inguinal hernia repair represents the main source of complications, possibly leading to inflammation and surgical site infection (SSI),

A 2014 systematic review including 12 articles by Sanders et al. [12] found an infection rate between 0 and 3.5%, and no significant difference in terms of SSIs incidence was detected between the groups. Anyway, there is no study specifying the depth of infection, whether it was deep or superficial. This could lead to improper conclusions, being a deep infection more related to the presence of

Pain is a very important outcome after surgical repair of groin hernia. Pain is defined as acute, when it occurs in the first week after the operation, and chronic, when it lasts beyond 3 months after surgery. Two RCTs, recently published in medical literature, have demonstrated a significant lower incidence of acute pain after using fibrin sealant (p < 0.001) [13] and cyanoacrylic glue (p < 0.003) [14]

A recent meta-analyses, including 13 RCTs comparing glue versus suture mesh fixation in Lichtenstein inguinal hernia repair [15, 16], showed a lower incidence of early acute pain (p = 0.03) and hematoma in the glue fixation group. On the other hand, chronic pain is one of the main issues after hernioplasty, and sutureless

postoperative pain due to entrapment of a nerve by suture or mesh [10].

**92**

the mesh.

compared to suture fixation.

techniques were introduced in surgery in an attempt to reduce its incidence, without affecting recurrence rates. According to the international guidelines for groin hernia management, the incidence of chronic pain ranges from 0 to 36.3% [17]. In particular, 14.7% is for sutures, 7.6% for cyanoacrylic glues, and 3.7% for fibrin glues. Three international RCTs suggest that the use of fibrin or cyanoacrylic glue can reduce pain if compared to suture [10, 12]. In particular, the TIMELI international trial demonstrated that fibrin glue was connected to the reduction of chronic symptoms like numbness and discomfort after 1 year.

Among the possible complications, recurrence is possibly the one that concerns surgeons the most. According to Sanders et al.'s review, recurrence rate is 1.3%. There was no significant difference between fixation methods in any of the RCTs, although long-term recurrence rates have not been determined and large hernias often have been excluded.

Concluding, in open inguinal hernia repair, no differences in recurrence or surgical site infection between different mesh fixation methods have been reported in literature, while sutureless fixation may reduce the onset of acute and chronic pain. Therefore, according to HerniaSurge Group consensus, glue fixation in the Lichtenstein technique can be performed in direct or indirect hernias less than 3 cm large (MII or LII types, EHS classification).

#### *2.2.2 Laparoscopic technique*

At present, the two most common laparoscopic techniques for hernia repair are the transabdominal preperitoneal repair (TAPP) and the total extraperitoneal repair (TEP). Both techniques involve the placement of a mesh in the preperitoneal space that must cover all potential hernia sites. The mesh in the preperitoneal space is subject to intra-abdominal forces and may be easily displaced before fibrosis seals it to the inguinal canal. In particular, the medial edge of the mesh is most susceptible to displacement, leading to inevitable recurrence if the medial part of the inguinal canal gets exposed. This underlines the importance of fixation [18]. Tacks, glues, and sutures can all be used to fixate the mesh.

Arguably, the most popular technique among surgeons is the use of tacks. However, it is known that using tacks and staples to secure the mesh can lead to complications, such as chronic pain. During the mesh fixation, in fact, it is really important not to place any tack or staple below the iliopubic tract, avoiding the triangle of pain. Lateral fixation should also be avoided, to prevent inadvertent damage to the nerves. Also misplaced tacks are described in literature to be responsible for nerve irritation and injury. The alternatives of the use of tacks are tissue glues and sutures.

Sutures usually require expertise and longer operating times. Both absorbable and nonabsorbable sutures may be used to fixate mesh to the abdominal wall. Sutures are usually applied transfascially after reduction of intraperitoneal pressure. Suture type, quantity, and placement vary among surgeons and no "gold standard" technique has been established [19].

Tissue glues have been introduced in laparoscopic hernia repair to reduce morbidity, such as pain and hematoma, thanks to their atraumatic application and their hemostatic properties [20].

Several studies, including meta-analyses and RCTs, comparing complication rates after different fixation methods, have been produced.

Complications after TEP repair, using tacks against glue, have been analyzed in a recent review by Kaul et al. [21]. The authors included in the study four RCTs for a total of 664 procedures. According to their results, no significant difference in terms of SSIs rates could be registered.

Acute pain after TEP was analyzed in a randomized prospective trial by Lau in [22]. The study concluded that, even if glue group consumed significantly less analgesics compared to staple group (p = 0.034), no significant difference has been registered in the postoperative pain score in the first week after surgery. On the other hand, Kaul et al.'s review reported a significant difference in terms of chronic pain incidence between the two groups (OR 3.25; 95% CI 1.62–6.49).

As already said, recurrence is a very important outcome when it comes to inguinal hernia repair. According to the two meta-analyses present in literature, there is no evidence of a significant difference in terms of recurrence, after using tissue sealants or tacks to fix the mesh [21, 23].

Similar results can be found in literature about TAPP technique. In a recent meta-analyses by Shah et al. [24], including five randomized controlled trials and five non-RCTs, no significant differences were found in terms of acute pain, SSIs, or recurrence. Nevertheless, patients who underwent TAPP hernia repair, using tissue sealant for mesh fixation, experienced significant less chronic pain (p = 0.005). Several RCTs published in the last decade have confirmed these findings [25–27].

Concluding, international RCTs and several meta-analyses have proven tissue glue to be as safe as tacks in terms of recurrence and SSI. In addition, chronic pain was significantly less represented when tissue adhesives were used for the fixation of the mesh. Therefore, according to international guidelines, to minimize the risk of acute postoperative pain, atraumatic fixation techniques (fibrin glue, cyanoacrylate) should be considered.

#### **3. Conclusions**

When it comes to mesh fixation, no unanimous consent about technique has ever been reached. Several types of fixation methods exist such as tacks, staples, self-fixing, fibrin sealants, glues, and sutures. The choice of which method to use strongly depends on the type of surgery and the type of defect but also (and often decisively) on surgeons' personal beliefs and local habits. In open technique both sutures and tissue adhesives have been proven equally safe in terms of recurrence and wound infection, but glues are connected to less chronic pain onset. Therefore, glue fixation in the Lichtenstein technique can be performed in MII or LII types (EHS classification) hernias.

Similarly, in the laparoscopic approach, tacks or glues can be used to secure the mesh showing similar recurrence rates. Again, adhesive fixation is connected to less morbidity in terms of chronic pain.

In conclusion, international RCTs and recent meta-analyses have confirmed tissue adhesives to be a valid alternative to traditional sutures and tacks. When it comes to the choice of which fixation procedure to perform in inguinal hernia repair, many authors advise the use of tissue sealants to minimize the risks of chronic pain, justifying the higher costs due to the use of expensive glues.

#### **Acknowledgements**

Morena Burati MD: project conception; acquisition; analysis; and interpretation of data and drafting of the work. Marco Chiarelli MD: project design; acquisition; interpretation of data; and revising of the work.

Alberto Scaini MD: project design; acquisition; and interpretation of data. Luca Andrea Fumagalli MD: project design; acquisition; and interpretation of data.

**95**

*Mesh Fixation Methods in Groin Hernia Surgery DOI: http://dx.doi.org/10.5772/intechopen.89732*

The authors do not have any conflict of interest.

revising of the work.

**Conflict of interest**

**Author details**

Morena Burati1

Italy

and Marco Chiarelli1

\*, Alberto Scaini1

2 University Milano-Bicocca, Milan, Italy

provided the original work is properly cited.

Francesco Gabrielli PhD: project design; acquisition; interpretation of data; and

, Luca Andrea Fumagalli1

1 Emergency and Robotic Surgery Department, A. Manzoni Hospital, Lecco, LC,

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

3 General Surgery Department, Istituti Clinici Zucchi, Monza, MB, Italy

\*Address all correspondence to: morena.burati@gmail.com

, Francesco Gabrielli2,3

*Mesh Fixation Methods in Groin Hernia Surgery DOI: http://dx.doi.org/10.5772/intechopen.89732*

Francesco Gabrielli PhD: project design; acquisition; interpretation of data; and revising of the work.

## **Conflict of interest**

*Techniques and Innovation in Hernia Surgery*

sealants or tacks to fix the mesh [21, 23].

late) should be considered.

(EHS classification) hernias.

**Acknowledgements**

morbidity in terms of chronic pain.

interpretation of data; and revising of the work.

**3. Conclusions**

Acute pain after TEP was analyzed in a randomized prospective trial by Lau in [22]. The study concluded that, even if glue group consumed significantly less analgesics compared to staple group (p = 0.034), no significant difference has been registered in the postoperative pain score in the first week after surgery. On the other hand, Kaul et al.'s review reported a significant difference in terms of chronic

As already said, recurrence is a very important outcome when it comes to inguinal hernia repair. According to the two meta-analyses present in literature, there is no evidence of a significant difference in terms of recurrence, after using tissue

Similar results can be found in literature about TAPP technique. In a recent meta-analyses by Shah et al. [24], including five randomized controlled trials and five non-RCTs, no significant differences were found in terms of acute pain, SSIs, or recurrence. Nevertheless, patients who underwent TAPP hernia repair, using tissue sealant for mesh fixation, experienced significant less chronic pain (p = 0.005). Several RCTs published in the last decade have confirmed these findings [25–27]. Concluding, international RCTs and several meta-analyses have proven tissue glue to be as safe as tacks in terms of recurrence and SSI. In addition, chronic pain was significantly less represented when tissue adhesives were used for the fixation of the mesh. Therefore, according to international guidelines, to minimize the risk of acute postoperative pain, atraumatic fixation techniques (fibrin glue, cyanoacry-

When it comes to mesh fixation, no unanimous consent about technique has ever been reached. Several types of fixation methods exist such as tacks, staples, self-fixing, fibrin sealants, glues, and sutures. The choice of which method to use strongly depends on the type of surgery and the type of defect but also (and often decisively) on surgeons' personal beliefs and local habits. In open technique both sutures and tissue adhesives have been proven equally safe in terms of recurrence and wound infection, but glues are connected to less chronic pain onset. Therefore, glue fixation in the Lichtenstein technique can be performed in MII or LII types

Similarly, in the laparoscopic approach, tacks or glues can be used to secure the mesh showing similar recurrence rates. Again, adhesive fixation is connected to less

In conclusion, international RCTs and recent meta-analyses have confirmed tissue adhesives to be a valid alternative to traditional sutures and tacks. When it comes to the choice of which fixation procedure to perform in inguinal hernia repair, many authors advise the use of tissue sealants to minimize the risks of chronic pain, justifying the higher costs due to the use of expensive glues.

Morena Burati MD: project conception; acquisition; analysis; and interpretation of data and drafting of the work. Marco Chiarelli MD: project design; acquisition;

Alberto Scaini MD: project design; acquisition; and interpretation of data. Luca Andrea Fumagalli MD: project design; acquisition; and interpretation of

pain incidence between the two groups (OR 3.25; 95% CI 1.62–6.49).

**94**

data.

The authors do not have any conflict of interest.

#### **Author details**

Morena Burati1 \*, Alberto Scaini1 , Luca Andrea Fumagalli1 , Francesco Gabrielli2,3 and Marco Chiarelli1

1 Emergency and Robotic Surgery Department, A. Manzoni Hospital, Lecco, LC, Italy

2 University Milano-Bicocca, Milan, Italy

3 General Surgery Department, Istituti Clinici Zucchi, Monza, MB, Italy

\*Address all correspondence to: morena.burati@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Hoyuela C et al. Randomized clinical trial of mesh fixation with glue or sutures for Lichtenstein hernia repair. The British Journal of Surgery. 2017;**104**(6):688-694

[2] Guttadauro A et al. 'All-in-one mesh' hernioplasty: A new procedure for primary inguinal hernia open repair. Asian Journal of Surgery. 2018;**41**(5):473-479

[3] Katkhouda N et al. Use of fibrin sealant for prosthetic mesh fixation in laparoscopic extraperitoneal inguinal hernia repair. Annals of Surgery. 2001;**233**(1):18-25

[4] Olmi S, Scaini A, Erba L, Bertolini A, Croce E. Laparoscopic repair of inguinal hernias using an intraperitoneal onlay mesh technique and a Parietex composite mesh fixed with fibrin glue (Tissucol). Personal technique and preliminary results. Surgical Endoscopy. 2007;**21**(11):1961-1964

[5] Campanelli G et al. Randomized, controlled, blinded trial of Tisseel/ Tissucol for mesh fixation in patients undergoing Lichtenstein technique for primary inguinal hernia repair: Results of the TIMELI trial. Annals of Surgery. 2012;**255**(4):650-657

[6] Ayyıldız SN, Ayyıldız A. Cyanoacrylic tissue glues: Biochemical properties and their usage in urology. Turkish Journal of Urology. 2017;**43**(1):14-24

[7] Montanaro L et al. Cytotoxicity, blood compatibility and antimicrobial activity of two cyanoacrylate glues for surgical use. Biomaterials. 2000;**22**(1):59-66

[8] LeBlanc KA. Tack hernia: A new entity. JSLS - Journal of the Society of Laparoendscopic Surgeons. 2003;**7**(4):383-387

[9] Reynvoet E, Berrevoet F. Pros and cons of tacking in laparoscopic hernia repair. Surgical Technology International. 2014;**25**:136-140

[10] Dobrin PB. Suture selection for hernia repair. In: Abdominal Wall Hernias. New York, NY: Springer New York; 2001. pp. 237-245

[11] Sun P, Cheng X, Hu Q, Zheng Q, Deng S, Sun Y. Mesh fixation with glue versus suture for chronic pain and recurrence in Lichtenstein inguinal hernioplasty. Cochrane Database of Systematic Reviews. 2017;**2**:2017

[12] Sanders DL, Waydia S. A systematic review of randomised control trials assessing mesh fixation in open inguinal hernia repair. Hernia. 2014;**18**(2):165-176

[13] Lionetti R, Neola B, Dilillo S, Bruzzese D, Ferulano GP. Sutureless hernioplasty with light-weight mesh and fibrin glue versus Lichtenstein procedure: A comparison of outcomes focusing on chronic postoperative pain. Hernia. 2012;**16**(2):127-131

[14] Nowobilski W, Dobosz M, Wojciechowicz T, Mionskowska L. Lichtenstein inguinal hernioplasty using butyl-2-cyanoacrylate versus sutures. Preliminary experience of a prospective randomized trial. European Surgical Research. 2004;**36**(6):367-370

[15] Lin H, Zhuang Z, Ma T, Sun X, Huang X, Li Y. A meta-analysis of randomized control trials assessing mesh fixation with glue versus suture in Lichtenstein inguinal hernia repair. Medicine (Baltimore). 2018;**97**(14):1-9

[16] Shen Y, Sun W, Chen J, Liu S, Wang M. NBCA medical adhesive (n-butyl-2-cyanoacrylate) versus suture for patch fixation in Lichtenstein inguinal herniorrhaphy: A

**97**

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[25] Brügger L, Bloesch M,

hernioplasty: A prospective,

of fibrin glue versus tacked fixation in laparoscopic groin hernia repair. Surgical Endoscopy.

2013;**27**(8):2727-2733

2014;**259**(3):432-437

Ipaktchi R, Kurmann A, Candinas D, Beldi G. Objective hypoesthesia and pain after transabdominal preperitoneal

randomized study comparing tissue adhesive versus spiral tacks. Surgical Endoscopy. 2012;**26**(4):1079-1085

[26] Tolver MA, Rosenberg J, Juul P, Bisgaard T. Randomized clinical trial

[27] Chan MS et al. Randomized doubleblinded prospective trial of fibrin sealant spray versus mechanical stapling in laparoscopic total extraperitoneal hernioplasty. Annals of Surgery.

randomized controlled trial. Surgery.

[17] Simons MP et al. International

management. Hernia. 2018;**22**(1):1-165

[18] Jacob BP, Ramshaw B. The SAGES Manual of Hernia Repair. Springer;

[19] Sucher JF, Klebuc M. Abdominal

Problems in Acute Care Surgery.

[20] Olmi S, Erba L, Bertolini A, Scaini A, Croce E. Fibrin glue for mesh fixation in laparoscopic transabdominal

preperitoneal (TAPP) hernia repair: Indications, technique, and outcomes. Surgical Endoscopy.

[21] Kaul A et al. Staple versus fibrin glue fixation in laparoscopic total extraperitoneal repair of inguinal hernia: A systematic review and meta-analysis. Surgical Endoscopy.

[22] Lau H. Fibrin sealant versus mechanical stapling for mesh fixation during endoscopic extraperitoneal inguinal hernioplasty. Annals of Surgery. 2005;**242**(5):670-675

[23] Sajid MS, Ladwa N, Kalra L, McFall M, Baig MK, Sains P. A metaanalysis examining the use of tacker mesh fixation versus glue mesh

fixation in laparoscopic inguinal hernia repair. American Journal of Surgery.

Siriwardena AK, Sheen AJ. Mesh fixation at laparoscopic inguinal hernia repair: A meta-analysis comparing tissue glue and tack fixation. World Journal of Surgery.

2006;**20**(12):1846-1850

2012;**26**(5):1269-1278

2013;**206**(1):103-111

[24] Shah NS, Fullwood C,

2015;**38**(10):2558-2570

guidelines for groin hernia

wall hernias. Common

2013;**55**(2018):421-440

2012;**151**(4):550-555

2013

*Mesh Fixation Methods in Groin Hernia Surgery DOI: http://dx.doi.org/10.5772/intechopen.89732*

randomized controlled trial. Surgery. 2012;**151**(4):550-555

[17] Simons MP et al. International guidelines for groin hernia management. Hernia. 2018;**22**(1):1-165

[18] Jacob BP, Ramshaw B. The SAGES Manual of Hernia Repair. Springer; 2013

[19] Sucher JF, Klebuc M. Abdominal wall hernias. Common Problems in Acute Care Surgery. 2013;**55**(2018):421-440

[20] Olmi S, Erba L, Bertolini A, Scaini A, Croce E. Fibrin glue for mesh fixation in laparoscopic transabdominal preperitoneal (TAPP) hernia repair: Indications, technique, and outcomes. Surgical Endoscopy. 2006;**20**(12):1846-1850

[21] Kaul A et al. Staple versus fibrin glue fixation in laparoscopic total extraperitoneal repair of inguinal hernia: A systematic review and meta-analysis. Surgical Endoscopy. 2012;**26**(5):1269-1278

[22] Lau H. Fibrin sealant versus mechanical stapling for mesh fixation during endoscopic extraperitoneal inguinal hernioplasty. Annals of Surgery. 2005;**242**(5):670-675

[23] Sajid MS, Ladwa N, Kalra L, McFall M, Baig MK, Sains P. A metaanalysis examining the use of tacker mesh fixation versus glue mesh fixation in laparoscopic inguinal hernia repair. American Journal of Surgery. 2013;**206**(1):103-111

[24] Shah NS, Fullwood C, Siriwardena AK, Sheen AJ. Mesh fixation at laparoscopic inguinal hernia repair: A meta-analysis comparing tissue glue and tack fixation. World Journal of Surgery. 2015;**38**(10):2558-2570

[25] Brügger L, Bloesch M, Ipaktchi R, Kurmann A, Candinas D, Beldi G. Objective hypoesthesia and pain after transabdominal preperitoneal hernioplasty: A prospective, randomized study comparing tissue adhesive versus spiral tacks. Surgical Endoscopy. 2012;**26**(4):1079-1085

[26] Tolver MA, Rosenberg J, Juul P, Bisgaard T. Randomized clinical trial of fibrin glue versus tacked fixation in laparoscopic groin hernia repair. Surgical Endoscopy. 2013;**27**(8):2727-2733

[27] Chan MS et al. Randomized doubleblinded prospective trial of fibrin sealant spray versus mechanical stapling in laparoscopic total extraperitoneal hernioplasty. Annals of Surgery. 2014;**259**(3):432-437

**96**

*Techniques and Innovation in Hernia Surgery*

[1] Hoyuela C et al. Randomized clinical trial of mesh fixation with glue or sutures for Lichtenstein hernia repair. The British Journal of Surgery.

[9] Reynvoet E, Berrevoet F. Pros and cons of tacking in laparoscopic hernia repair. Surgical Technology International. 2014;**25**:136-140

[10] Dobrin PB. Suture selection for hernia repair. In: Abdominal Wall Hernias. New York, NY: Springer New York; 2001. pp. 237-245

[11] Sun P, Cheng X, Hu Q, Zheng Q, Deng S, Sun Y. Mesh fixation with glue versus suture for chronic pain and recurrence in Lichtenstein inguinal hernioplasty. Cochrane Database of Systematic Reviews. 2017;**2**:2017

[12] Sanders DL, Waydia S. A systematic review of randomised control trials assessing mesh fixation in open inguinal hernia repair. Hernia.

[13] Lionetti R, Neola B, Dilillo S, Bruzzese D, Ferulano GP. Sutureless hernioplasty with light-weight mesh and fibrin glue versus Lichtenstein procedure: A comparison of outcomes focusing on chronic postoperative pain.

Hernia. 2012;**16**(2):127-131

[14] Nowobilski W, Dobosz M, Wojciechowicz T, Mionskowska L. Lichtenstein inguinal hernioplasty using butyl-2-cyanoacrylate versus sutures. Preliminary experience of a prospective randomized trial. European Surgical Research. 2004;**36**(6):367-370

[15] Lin H, Zhuang Z, Ma T, Sun X, Huang X, Li Y. A meta-analysis of randomized control trials assessing mesh fixation with glue versus suture in Lichtenstein inguinal hernia repair. Medicine (Baltimore). 2018;**97**(14):1-9

Liu S, Wang M. NBCA medical adhesive (n-butyl-2-cyanoacrylate) versus suture for patch fixation in

Lichtenstein inguinal herniorrhaphy: A

[16] Shen Y, Sun W, Chen J,

2014;**18**(2):165-176

[2] Guttadauro A et al. 'All-in-one mesh' hernioplasty: A new procedure for primary inguinal hernia open repair. Asian Journal of Surgery.

[3] Katkhouda N et al. Use of fibrin sealant for prosthetic mesh fixation in laparoscopic extraperitoneal inguinal hernia repair. Annals of Surgery.

[4] Olmi S, Scaini A, Erba L, Bertolini A, Croce E. Laparoscopic repair of inguinal

hernias using an intraperitoneal onlay mesh technique and a Parietex composite mesh fixed with fibrin glue (Tissucol). Personal technique and preliminary results. Surgical Endoscopy.

[5] Campanelli G et al. Randomized, controlled, blinded trial of Tisseel/ Tissucol for mesh fixation in patients undergoing Lichtenstein technique for primary inguinal hernia repair: Results of the TIMELI trial. Annals of Surgery.

2017;**104**(6):688-694

**References**

2018;**41**(5):473-479

2001;**233**(1):18-25

2007;**21**(11):1961-1964

2012;**255**(4):650-657

2017;**43**(1):14-24

2000;**22**(1):59-66

2003;**7**(4):383-387

[6] Ayyıldız SN, Ayyıldız A.

properties and their usage in

Cyanoacrylic tissue glues: Biochemical

urology. Turkish Journal of Urology.

[7] Montanaro L et al. Cytotoxicity, blood compatibility and antimicrobial activity of two cyanoacrylate glues for surgical use. Biomaterials.

[8] LeBlanc KA. Tack hernia: A new entity. JSLS - Journal of the Society of Laparoendscopic Surgeons.

**99**

**Chapter 8**

**Abstract**

and lower the recurrent rate.

**1. Introduction**

of contamination [2].

the surgical site [4].

pain and bleeding after surgery [5].

New Laparoscopic Surgery in

Laparoscopic inguinal herniorrhaphy has become widely accepted as an effective

Surgery to treat various diseases has been recorded back to middle ages. For two centuries, large incisions were necessary to perform abdominal surgical procedures. Although effective, several known morbidities were related to this method, including postoperative pain, wound infection, incisional hernia, and prolonged hospitalization [1]. The present surgical site infection rate is 15–25%, depending on the level

Laparoscopic surgery was introduced in 1983 by Lukichev and 1985 by Muhe who performed laparoscopic cholecystectomy. Their cumbersome techniques did not receive the attention they probably deserved. Interests were started to grow after Mouret in 1987 reported the first acknowledged laparoscopic cholecystectomy by means of four trocars [3]. Since then, operative laparoscopy has advanced progressively. Several operative procedures have been performed by this new approach. Due to its minimal invasiveness to abdominal wall, laparoscopic surgery is also called minimally invasive surgery. Laparoscopic procedures can be performed using small incisions of around 0.5–1.5 cm that can be made far away from

One of the main advantages of laparoscopic surgery over traditional open surgery is it often requires a shorter hospital stay than traditional open surgery. Procedure such as appendectomy or cholecystectomy is commonly stay at the hospital for only one night after surgery. This is due to patients are experiencing less

Another important advantage of laparoscopic surgery is that as the incision wound is so much smaller than open surgery, post-surgical scarring is significantly

alternative to the treatment of hernias with the anterior approach. It has success rates identical to those of the conventional method and quickens recovery by decreasing time until return to work or physical activities. With the introduction of single incision laparoscopic surgery (SILS), there has been an exponential increase in the number of SILS hernia repair. It probably represents the single most exciting innovation in laparoscopic surgery of the last 2 decades. The main premise of SILS is the use of completely blunt ports, which will negate the risks of bowel and vascular injuries, less wound, less postoperative pain, cosmetically more favorable

Inguinal Hernia Repair

*Reno Rudiman and Andika August Winata*

**Keywords:** inguinal hernia, laparoscopic, TAPP, TEP, SILS

#### **Chapter 8**

## New Laparoscopic Surgery in Inguinal Hernia Repair

*Reno Rudiman and Andika August Winata*

#### **Abstract**

Laparoscopic inguinal herniorrhaphy has become widely accepted as an effective alternative to the treatment of hernias with the anterior approach. It has success rates identical to those of the conventional method and quickens recovery by decreasing time until return to work or physical activities. With the introduction of single incision laparoscopic surgery (SILS), there has been an exponential increase in the number of SILS hernia repair. It probably represents the single most exciting innovation in laparoscopic surgery of the last 2 decades. The main premise of SILS is the use of completely blunt ports, which will negate the risks of bowel and vascular injuries, less wound, less postoperative pain, cosmetically more favorable and lower the recurrent rate.

**Keywords:** inguinal hernia, laparoscopic, TAPP, TEP, SILS

#### **1. Introduction**

Surgery to treat various diseases has been recorded back to middle ages. For two centuries, large incisions were necessary to perform abdominal surgical procedures. Although effective, several known morbidities were related to this method, including postoperative pain, wound infection, incisional hernia, and prolonged hospitalization [1]. The present surgical site infection rate is 15–25%, depending on the level of contamination [2].

Laparoscopic surgery was introduced in 1983 by Lukichev and 1985 by Muhe who performed laparoscopic cholecystectomy. Their cumbersome techniques did not receive the attention they probably deserved. Interests were started to grow after Mouret in 1987 reported the first acknowledged laparoscopic cholecystectomy by means of four trocars [3]. Since then, operative laparoscopy has advanced progressively. Several operative procedures have been performed by this new approach. Due to its minimal invasiveness to abdominal wall, laparoscopic surgery is also called minimally invasive surgery. Laparoscopic procedures can be performed using small incisions of around 0.5–1.5 cm that can be made far away from the surgical site [4].

One of the main advantages of laparoscopic surgery over traditional open surgery is it often requires a shorter hospital stay than traditional open surgery. Procedure such as appendectomy or cholecystectomy is commonly stay at the hospital for only one night after surgery. This is due to patients are experiencing less pain and bleeding after surgery [5].

Another important advantage of laparoscopic surgery is that as the incision wound is so much smaller than open surgery, post-surgical scarring is significantly reduced. Cosmetically, it is more desirable to most patients. Risks of keloid forming are therefore significantly reduced as well [6].

In conventional laparoscopic surgery, three to four small incisions are made. In a more complex procedure such as large bowel resection or bariatric (obesity) surgery, up to six incisions can be made, allowing more instruments to be used to assist organ resection [4, 7–9]. Obviously, the more wounds are made, the more pain it will eventually be caused to the patients. On the contrary, less wound signifies less pain. This brings about the concept of single incision laparoscopic surgery [10, 11].

#### **2. Laparoscopic hernia repair**

Transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair are the most common laparoscopic inguinal hernia repair techniques, since the early of 1990s [6]. In TAPP, the peritoneal cavity is explored by the surgeon and then a mesh is placed through a peritoneal incision over possible hernia sites. TEP is different as the peritoneal cavity is not penetrated and mesh is employed to seal the hernia from outside of the peritoneum [8]. Both techniques try to diminish the hernia and hernia sac within the abdomen and then place a 10 × 15 cm mesh just deep to the abdominal wall [12].

The more superior surgical approach and technique for inguinal hernia repair is still widely argued. TAPP laparoscopic inguinal hernia repair improved clinical outcome and associated with a better quality of patient's life in numerous study [13]. The advantages of this approach are capability to inspect abdominal cavity, excellent exposure and enabling bilateral repair if necessary. The disadvantages are the possibility of intraperitoneal structures injury, adhesion formation and possibility of late bowel obstruction [14] (**Figures 1** and **2**).

Peritoneal integrity preservation is the main reason for TEP laparoscopic inguinal hernia repair is preferred to the TAPP repair. However, the peculiarity of anatomy and working area restriction in general made it to be more difficult [15]. In TEP, the surgeon is able to create a space just deep to the abdominal muscles without entering the peritoneal cavity and minimizing adhesion formation [14, 16].

It has been more than 20 years since TAPP and TEP were introduced to clinical routine [17]. TEP is considered to be more difficult than TAPP but may have fewer complications [8].

Rhambia et al. in 2016 also conducted a comparative study between these techniques; they found that there is no significant difference between them in the

**101**

*New Laparoscopic Surgery in Inguinal Hernia Repair DOI: http://dx.doi.org/10.5772/intechopen.89028*

surgery in this research [18].

erative complications [17].

**2.1 SILS in hernia repair**

through a single incision [23].

almost "scarless" [10, 21, 25, 26].

difference [8].

**Figure 2.**

*Peritoneum is closed.*

variable of duration of surgery, serious adverse event, persisting post-operative pain, hematoma, seroma, persisting numbness, hernia recurrence, port site of hernia and length of hospital stay. TEP gave the patients less pain after 24 hours of

Former research by McCormack revealed that TAPP has slightly increased the number of hernias developing close by and injuries to internal organs. TEP has been associated with more conversions to another type of surgery. These are widely consistent results. Comparing these two techniques, the number of vascular injuries and deep and mesh infections is infrequent and there were no overt

Apart from that, assuming a comparable patient group, identical indication and adequately experienced surgeons, similar results can be achieved with the TEP and TAPP technique. That is borne out by the comparable reoperation rate for postop-

An effective alternative to treat hernias is SILS that was introduced in 2007 after a port by Covidien was released. It is now probably represents the single most exciting innovation in laparoscopic surgery of the last 2 decades [19]. In hernia repair, SILS also accommodates TAPP or TEP to repair the defect. Early outcomes of this novel technique show it to be feasible, safe and with potentially better cosmetic outcome [20]. With this technique, the surgeon operates exclusively through a single entry point, typically at the patient's umbilicus. Unlike a traditional multi-port laparoscopic approach, SILS leaves only a single small scar [10, 21, 22]. During the introduction years on SILS in 1997, enthusiasm was limited because of lack of technical support and poor equipment [3]. In 2005, Hirano et al. reintroduced the technique with some advancements compared to previous technique. Since then, the technology was progressing steadily. Among advancements created were articulating instruments, laparoscope adjustments, several trocars adjacent into each other

SILS is gaining popularity due to its advantages in minimizing the invasiveness of surgical incisions. With the reduced number of incisions, the associated possible wound morbidities will also be reduced. This includes the reduced risks of wound infection, pain, bleeding, organ injury, and port site hernia [24]. In addition, one important feature of SILS is since the wound is at umbilicus, it leaves a single small scar that is well-hidden, it is almost unseen when the wound is healed, thereby it is

**Figure 1.** *Positioning the mesh in inguinal area.*

*New Laparoscopic Surgery in Inguinal Hernia Repair DOI: http://dx.doi.org/10.5772/intechopen.89028*

**Figure 2.** *Peritoneum is closed.*

*Techniques and Innovation in Hernia Surgery*

**2. Laparoscopic hernia repair**

deep to the abdominal wall [12].

complications [8].

ity of late bowel obstruction [14] (**Figures 1** and **2**).

are therefore significantly reduced as well [6].

reduced. Cosmetically, it is more desirable to most patients. Risks of keloid forming

In conventional laparoscopic surgery, three to four small incisions are made. In a more complex procedure such as large bowel resection or bariatric (obesity) surgery, up to six incisions can be made, allowing more instruments to be used to assist organ resection [4, 7–9]. Obviously, the more wounds are made, the more pain it will eventually be caused to the patients. On the contrary, less wound signifies less pain. This brings about the concept of single incision laparoscopic surgery [10, 11].

Transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair are the most common laparoscopic inguinal hernia repair techniques, since the early of 1990s [6]. In TAPP, the peritoneal cavity is explored by the surgeon and then a mesh is placed through a peritoneal incision over possible hernia sites. TEP is different as the peritoneal cavity is not penetrated and mesh is employed to seal the hernia from outside of the peritoneum [8]. Both techniques try to diminish the hernia and hernia sac within the abdomen and then place a 10 × 15 cm mesh just

The more superior surgical approach and technique for inguinal hernia repair is still widely argued. TAPP laparoscopic inguinal hernia repair improved clinical outcome and associated with a better quality of patient's life in numerous study [13]. The advantages of this approach are capability to inspect abdominal cavity, excellent exposure and enabling bilateral repair if necessary. The disadvantages are the possibility of intraperitoneal structures injury, adhesion formation and possibil-

Peritoneal integrity preservation is the main reason for TEP laparoscopic inguinal hernia repair is preferred to the TAPP repair. However, the peculiarity of anatomy and working area restriction in general made it to be more difficult [15]. In TEP, the surgeon is able to create a space just deep to the abdominal muscles without

It has been more than 20 years since TAPP and TEP were introduced to clinical routine [17]. TEP is considered to be more difficult than TAPP but may have fewer

Rhambia et al. in 2016 also conducted a comparative study between these techniques; they found that there is no significant difference between them in the

entering the peritoneal cavity and minimizing adhesion formation [14, 16].

**100**

**Figure 1.**

*Positioning the mesh in inguinal area.*

variable of duration of surgery, serious adverse event, persisting post-operative pain, hematoma, seroma, persisting numbness, hernia recurrence, port site of hernia and length of hospital stay. TEP gave the patients less pain after 24 hours of surgery in this research [18].

Former research by McCormack revealed that TAPP has slightly increased the number of hernias developing close by and injuries to internal organs. TEP has been associated with more conversions to another type of surgery. These are widely consistent results. Comparing these two techniques, the number of vascular injuries and deep and mesh infections is infrequent and there were no overt difference [8].

Apart from that, assuming a comparable patient group, identical indication and adequately experienced surgeons, similar results can be achieved with the TEP and TAPP technique. That is borne out by the comparable reoperation rate for postoperative complications [17].

#### **2.1 SILS in hernia repair**

An effective alternative to treat hernias is SILS that was introduced in 2007 after a port by Covidien was released. It is now probably represents the single most exciting innovation in laparoscopic surgery of the last 2 decades [19]. In hernia repair, SILS also accommodates TAPP or TEP to repair the defect. Early outcomes of this novel technique show it to be feasible, safe and with potentially better cosmetic outcome [20].

With this technique, the surgeon operates exclusively through a single entry point, typically at the patient's umbilicus. Unlike a traditional multi-port laparoscopic approach, SILS leaves only a single small scar [10, 21, 22]. During the introduction years on SILS in 1997, enthusiasm was limited because of lack of technical support and poor equipment [3]. In 2005, Hirano et al. reintroduced the technique with some advancements compared to previous technique. Since then, the technology was progressing steadily. Among advancements created were articulating instruments, laparoscope adjustments, several trocars adjacent into each other through a single incision [23].

SILS is gaining popularity due to its advantages in minimizing the invasiveness of surgical incisions. With the reduced number of incisions, the associated possible wound morbidities will also be reduced. This includes the reduced risks of wound infection, pain, bleeding, organ injury, and port site hernia [24]. In addition, one important feature of SILS is since the wound is at umbilicus, it leaves a single small scar that is well-hidden, it is almost unseen when the wound is healed, thereby it is almost "scarless" [10, 21, 25, 26].

In general, SILS techniques take about the same amount of time to do as traditional laparoscopic surgeries. However, SILS is recognized as to be a more complicated procedure because it involves manipulating three articulating instruments through one access port [22, 27, 28]. SILS performed with a similar technique to the conventional laparoscopic through a single umbilical port. The SILS-Port was introduced through a single 2.0–3.0 cm transverse transumbilical skin and facial incision. After creation of pneumoperitoneum at pressure of 12 mmHg, two 5-mm working ports and a 10-mm camera port was inserted. The peritoneal flap was prepared. A mesh was placed, and the peritoneum was closed with standard laparoscopic instruments or tackers. After releasing the pneumoperitoneum, the umbilical fascia was routinely closed with polypropylene loop suture and the skin was sutured with 4-0 absorbable intradermic sutures [29].

From financial point of view, the use of a single-port device and the increased skills needed to perform, SILS is slightly more costly to conventional multi-port laparoscopic surgery [25–27]. Generally, the length of stay in the hospital is shorter and the need of medical assistance is lesser than traditional laparoscopic surgeries [30].

Although SILS offers benefits for patients undergoing abdominal surgery, not everyone is an applicant for the procedure. Obesity, severe adhesions, or scarring from previous surgeries are a few of the factors that would prohibit patients from getting the surgery [26]. Nonetheless, new technologies are evolving continuously [27].

#### *2.1.1 SILS versus conventional laparoscopic hernia repair*

A concordant evolution and improvement of the laparoscopic method has occurred when the advantages of minimally invasive surgical techniques are continuing to be defined. The less scar initiative has driven to a reduction in the number of port sites. Consequently, SILS is more popular and widely being used. As the findings show, repair of abdominal wall defects, specifically inguinal hernias, is feasible via SILS as well [31].

There are many studies comparing these two methods now. In Rajapandian et al. study, they assess the potential benefits of SILS without using specialized ports or instruments and compare the same with the conventional laparoscopic surgery in terms of operative time, post-operative pain, complications, cost and scars. They found that the mean duration of surgery was significantly longer in SILS for unilateral as well as bilateral hernia repair than its conventional counterpart. While the mean blood loss was comparable in either groups, various complications like vascular injury, peritoneal tear, cord and nerve injuries had not significant differences. In SILS, two patients were converted to conventional laparoscopy, but without any open conversion [26].

Ece et al. did a research from 148 patients, 88 underwent conventional laparoscopic repair and 60 underwent SILS repair. All SILS procedures were completed successfully without conversion conventional laparoscopic or open repair, and no additional port was required in both groups. There were no differences in operative time, length of hospital stay and VAS scores of patients 24 hours after the operation. No intraoperative major complications were observed such as vessel, intestine, or bladder injury. One patient in each group had a complaint of pain for longer than 3 months. Short-term complication rates were similar in each group. Several small seroma and hematomas were reported in both groups, and all of them were resolved with conservative treatment. Also, three patients treated with oral antibiotics for port site infection. Long-term complications such as mesh infection and recurrence were not detected in both the groups. Three patients in the SILS-TAPP group

**103**

outcome.

divided into:

1.Preoperative

2.Intraoperative

3.Postoperative

**3.1 Preoperative precautions**

*New Laparoscopic Surgery in Inguinal Hernia Repair DOI: http://dx.doi.org/10.5772/intechopen.89028*

conventional group [27].

sound, and elective mesh hernioplasty was performed [29].

experienced port site hernia. All of the port site hernias were confirmed by ultra-

Another research by Buckley in 2014 described a slightly different result. SILS for unilateral cases was significantly shorter statistically than for conventional one. For bilateral cases, the average operative times for both were similar. No conversions from SILS to conventional laparoscopic were performed. There were five conversions from SILS (3.88%) and three conversions from other group (3.95%) to open Kugel or Lichtenstein repairs, but the difference was not significant statistically. The recurrence rate during half year period follow up was 2.3% (3 of 129) for SILS and 1.4% (1 of 76) for conventional one. The chronic pain rate was 4.7% for SILS and 5.2% for other group. Both groups reported only one wound infection. Incisional hernia was rare (only one) in the SILS arm of the study, which occurred at the site of an umbilical hernia. There was no widely difference between the two cohorts in complication rate [31]. A systematic review by Sajid et al. analyzed from 15 comparative studies on 1651 patients evaluating the surgical outcomes of inguinal hernia repair using SILS versus conventional laparoscopic techniques. Recovery time after the surgery was significantly more rapid in SILS compared to the other procedure. Nonetheless, from the perspective of length of hospital stay, operative time both for unilateral and bilateral hernias, post-operative pain score, one-week pain score, hernia recurrence conversion and post-operative complications between two approaches showed an equality. The sub-group analysis of four included randomized, controlled trials showed similarities between outcomes following SILS and conventional laparoscopic procedure except slightly higher postoperative pain score in

SILS inguinal hernia repair offers better cosmetic results with slightly longer operative time compared to conventional laparoscopic inguinal hernia repair. However, this approach is technically demanding and should be reserved for experienced single incision hernia surgeons [32]. The invention of new surgical tools will

Even the complications in endoscopic inguinal hernia surgery are more dangerous and more frequent compared to those in open surgery; they could be avoided especially in experienced hands [33]. The complication rate for laparoscopic repair

Complications and the various precautions to be taken in hernia surgery can be

Patient with large hernias, obese patients and irreducible, obstructed hernias are best avoided. Strangulated hernia is an absolute contraindication. Elderly patients require a detailed work-up to assess cardiorespiratory status to ensure a safe

hopefully overcome the current obstacles in SILS in the future [27].

of inguinal hernia ranges from less than 3% to as high as 20% [34].

**3. Complication of laparoscopic hernia repair**

#### *New Laparoscopic Surgery in Inguinal Hernia Repair DOI: http://dx.doi.org/10.5772/intechopen.89028*

*Techniques and Innovation in Hernia Surgery*

surgeries [30].

feasible via SILS as well [31].

without any open conversion [26].

In general, SILS techniques take about the same amount of time to do as traditional laparoscopic surgeries. However, SILS is recognized as to be a more complicated procedure because it involves manipulating three articulating instruments through one access port [22, 27, 28]. SILS performed with a similar technique to the conventional laparoscopic through a single umbilical port. The SILS-Port was introduced through a single 2.0–3.0 cm transverse transumbilical skin and facial incision. After creation of pneumoperitoneum at pressure of 12 mmHg, two 5-mm working ports and a 10-mm camera port was inserted. The peritoneal flap was prepared. A mesh was placed, and the peritoneum was closed with standard laparoscopic instruments or tackers. After releasing the pneumoperitoneum, the umbilical fascia was routinely closed with polypropylene loop suture and the skin

From financial point of view, the use of a single-port device and the increased skills needed to perform, SILS is slightly more costly to conventional multi-port laparoscopic surgery [25–27]. Generally, the length of stay in the hospital is shorter and the need of medical assistance is lesser than traditional laparoscopic

Although SILS offers benefits for patients undergoing abdominal surgery, not everyone is an applicant for the procedure. Obesity, severe adhesions, or scarring from previous surgeries are a few of the factors that would prohibit patients from getting the surgery [26]. Nonetheless, new technologies are evolving continuously [27].

A concordant evolution and improvement of the laparoscopic method has occurred when the advantages of minimally invasive surgical techniques are continuing to be defined. The less scar initiative has driven to a reduction in the number of port sites. Consequently, SILS is more popular and widely being used. As the findings show, repair of abdominal wall defects, specifically inguinal hernias, is

There are many studies comparing these two methods now. In Rajapandian et al. study, they assess the potential benefits of SILS without using specialized ports or instruments and compare the same with the conventional laparoscopic surgery in terms of operative time, post-operative pain, complications, cost and scars. They found that the mean duration of surgery was significantly longer in SILS for unilateral as well as bilateral hernia repair than its conventional counterpart. While the mean blood loss was comparable in either groups, various complications like vascular injury, peritoneal tear, cord and nerve injuries had not significant differences. In SILS, two patients were converted to conventional laparoscopy, but

Ece et al. did a research from 148 patients, 88 underwent conventional laparoscopic repair and 60 underwent SILS repair. All SILS procedures were completed successfully without conversion conventional laparoscopic or open repair, and no additional port was required in both groups. There were no differences in operative time, length of hospital stay and VAS scores of patients 24 hours after the operation. No intraoperative major complications were observed such as vessel, intestine, or bladder injury. One patient in each group had a complaint of pain for longer than 3 months. Short-term complication rates were similar in each group. Several small seroma and hematomas were reported in both groups, and all of them were resolved with conservative treatment. Also, three patients treated with oral antibiotics for port site infection. Long-term complications such as mesh infection and recurrence were not detected in both the groups. Three patients in the SILS-TAPP group

was sutured with 4-0 absorbable intradermic sutures [29].

*2.1.1 SILS versus conventional laparoscopic hernia repair*

**102**

experienced port site hernia. All of the port site hernias were confirmed by ultrasound, and elective mesh hernioplasty was performed [29].

Another research by Buckley in 2014 described a slightly different result. SILS for unilateral cases was significantly shorter statistically than for conventional one. For bilateral cases, the average operative times for both were similar. No conversions from SILS to conventional laparoscopic were performed. There were five conversions from SILS (3.88%) and three conversions from other group (3.95%) to open Kugel or Lichtenstein repairs, but the difference was not significant statistically. The recurrence rate during half year period follow up was 2.3% (3 of 129) for SILS and 1.4% (1 of 76) for conventional one. The chronic pain rate was 4.7% for SILS and 5.2% for other group. Both groups reported only one wound infection. Incisional hernia was rare (only one) in the SILS arm of the study, which occurred at the site of an umbilical hernia. There was no widely difference between the two cohorts in complication rate [31].

A systematic review by Sajid et al. analyzed from 15 comparative studies on 1651 patients evaluating the surgical outcomes of inguinal hernia repair using SILS versus conventional laparoscopic techniques. Recovery time after the surgery was significantly more rapid in SILS compared to the other procedure. Nonetheless, from the perspective of length of hospital stay, operative time both for unilateral and bilateral hernias, post-operative pain score, one-week pain score, hernia recurrence conversion and post-operative complications between two approaches showed an equality. The sub-group analysis of four included randomized, controlled trials showed similarities between outcomes following SILS and conventional laparoscopic procedure except slightly higher postoperative pain score in conventional group [27].

SILS inguinal hernia repair offers better cosmetic results with slightly longer operative time compared to conventional laparoscopic inguinal hernia repair. However, this approach is technically demanding and should be reserved for experienced single incision hernia surgeons [32]. The invention of new surgical tools will hopefully overcome the current obstacles in SILS in the future [27].

#### **3. Complication of laparoscopic hernia repair**

Even the complications in endoscopic inguinal hernia surgery are more dangerous and more frequent compared to those in open surgery; they could be avoided especially in experienced hands [33]. The complication rate for laparoscopic repair of inguinal hernia ranges from less than 3% to as high as 20% [34].

Complications and the various precautions to be taken in hernia surgery can be divided into:


#### **3.1 Preoperative precautions**

Patient with large hernias, obese patients and irreducible, obstructed hernias are best avoided. Strangulated hernia is an absolute contraindication. Elderly patients require a detailed work-up to assess cardiorespiratory status to ensure a safe outcome.

#### **3.2 Intraoperative complication**

#### *3.2.1 Vascular injury*

The iliac vessels, inferior epigastric vessels, spermatic vessels, muscular branches, vessels over the pubic arch (including corona mortis vein) or other vessels in the region are susceptible to injury [33].

#### *3.2.2 Visceral injury*

The most common injury occurs is bladder injury. Emptying the bladder prior to an inguinal hernia repair is a must to prevent a trocar injury. It is desirable to catheterize the bladder. When urine is seen in the extraperitoneal space then the diagnosis of this bladder injury is evident. Repair with vicryl in two layers and insert a urinary catheter for 7–10 days are recommended [33].

Bowel injuries take place when trocar insertion or while dissecting hernia or utilizing an electrodiathermy. The incidence of bowel injuries is greatly reduced, but sadly not completely eliminated [35].

#### *3.2.3 Pneumoperitoneum*

It is a common occurrence in TEP. The patient is placed in Trendelenburg position and escalating the insufflation pressures to 15 mmHg helps. Insertion of a Veress needle at Palmer's point can be used if the problem still persists [33].

#### *3.2.4 Nerve injuries*

There are several nerves, viz., ilioinguinal nerve, iliohypogastric nerve, genito-femoral nerve with its medial and lateral branches (external spermatic nerve and lumboinguinal nerve) which are coursing in the myopectineal orifice of Fruchaud. These are prone to injury especially when a lateral dissection or mesh fixation is being performed. Patient might be suffering from a long-term pain and discomfort [36].

#### *3.2.5 Injury to cord structures*

The cord structures might be harmed while dissecting the hernial sac from it. It leads to an eventual fibrotic narrowing of the vas. In a young patient, a complete transection of the vas needs to be done. Finding the vas before releasing any structure near the deep ring or floor of the extraperitoneal space can help to avoid this injury. It should be done gentle and direct and not grasping vas deferens with forceps [33].

#### *3.2.6 Bowel obstruction*

A water-tight peritoneal closure should reduce the risk of postoperative intestinal obstruction. Laparoscopy is the procedure of choice to diagnose and treat this complication [37].

A risk reduction strategy is required to improve the clinical outcome and this must be adopted during the following surgical steps:

**105**

*New Laparoscopic Surgery in Inguinal Hernia Repair DOI: http://dx.doi.org/10.5772/intechopen.89028*

and alert in placing the trocar [33, 38].

2.Dissection of the hernial sac

3.Mesh placement and fixation

it can lead to a recurrence [33].

**3.3 Post-operative complication**

*3.3.1 Seroma/hematoma formation*

*3.3.2 Urinary retention*

*3.3.3 Neuralgias*

psoas [33].

next day morning [33, 43, 44].

*3.3.4 Testicular pain and swelling*

1.Placement of the trocar and working port

considered if any visceral injury is found [39].

tacks in the triangle of pain laterally [33, 39].

Identify and repair a pneumoperitoneum as a result of reckless insertion of the first trocar. If there any previous surgical scarring, a surgeon must be more attentive

The underlying intraperitoneal organs like bowel and bladder should not be damaged in trocar insertion process. In midline area, beware of the inferior epigastric vessels which cause copious bleeding. A laparotomy conversion might be

Identifying the correct anatomical landmarks is the next most decisive step, which is difficult for beginners. The first point is to recognize the pubic bone. After this, the rest of the landmarks can be discovered by putting this as reference point. Keep away the triangle of doom, which contains the iliac vessels and do not place

Choose the appropriate size of the mesh to prevent a later recurrence due to an eventual "shrinkage" of the prosthesis [40]. Slashing the mesh is hindered because

Several studies have recommended no fixation but have been found wanting.

It is a common complication after laparoscopic hernia surgery and the incidence

is within 5–25%. It resolves spontaneously around 4–6 weeks. A drain can be considered if there is an excessive bleeding or after extensive dissection [33].

The reported incidence for this complication is 1.3–5.8%, usually found in elderly patients with prostatism. Put a catheter before the surgery and remove the

The incidence is reported to be between 0.5 and 4.6% and intra peritoneal onlay mesh had the highest incidence [43]. The most commonly involved nerves are lateral cutaneous nerve of thigh, genitofemoral nerve and intermediate cutaneous nerve of thigh. This complication can be prevented by avoiding fixing the mesh lateral to the deep inguinal ring in the region of the triangle of pain, safe dissection of a large hernial sac and no dissection of fascia over the

Reported incidence is of 0.9–1.5%. Most are short-term. Orchitis was found

occasionally but testicular atrophy was not a complication [33, 43, 44].

Tissue glues are being used to secure the mesh in place [39, 41, 42].

*New Laparoscopic Surgery in Inguinal Hernia Repair DOI: http://dx.doi.org/10.5772/intechopen.89028*

*Techniques and Innovation in Hernia Surgery*

in the region are susceptible to injury [33].

but sadly not completely eliminated [35].

The iliac vessels, inferior epigastric vessels, spermatic vessels, muscular branches, vessels over the pubic arch (including corona mortis vein) or other vessels

The most common injury occurs is bladder injury. Emptying the bladder prior to an inguinal hernia repair is a must to prevent a trocar injury. It is desirable to catheterize the bladder. When urine is seen in the extraperitoneal space then the diagnosis of this bladder injury is evident. Repair with vicryl in two layers and

Bowel injuries take place when trocar insertion or while dissecting hernia or utilizing an electrodiathermy. The incidence of bowel injuries is greatly reduced,

It is a common occurrence in TEP. The patient is placed in Trendelenburg position and escalating the insufflation pressures to 15 mmHg helps. Insertion of a

There are several nerves, viz., ilioinguinal nerve, iliohypogastric nerve, genito-femoral nerve with its medial and lateral branches (external spermatic nerve and lumboinguinal nerve) which are coursing in the myopectineal orifice of Fruchaud. These are prone to injury especially when a lateral dissection or mesh fixation is being performed. Patient might be suffering from a long-term pain and

The cord structures might be harmed while dissecting the hernial sac from it. It leads to an eventual fibrotic narrowing of the vas. In a young patient, a complete transection of the vas needs to be done. Finding the vas before releasing any structure near the deep ring or floor of the extraperitoneal space can help to avoid this injury. It should be done gentle and direct and not grasping vas deferens with

A water-tight peritoneal closure should reduce the risk of postoperative intestinal obstruction. Laparoscopy is the procedure of choice to diagnose and treat this

A risk reduction strategy is required to improve the clinical outcome and this

must be adopted during the following surgical steps:

Veress needle at Palmer's point can be used if the problem still persists [33].

insert a urinary catheter for 7–10 days are recommended [33].

**3.2 Intraoperative complication**

*3.2.1 Vascular injury*

*3.2.2 Visceral injury*

*3.2.3 Pneumoperitoneum*

*3.2.4 Nerve injuries*

discomfort [36].

forceps [33].

*3.2.6 Bowel obstruction*

complication [37].

*3.2.5 Injury to cord structures*

**104**

1.Placement of the trocar and working port

Identify and repair a pneumoperitoneum as a result of reckless insertion of the first trocar. If there any previous surgical scarring, a surgeon must be more attentive and alert in placing the trocar [33, 38].

The underlying intraperitoneal organs like bowel and bladder should not be damaged in trocar insertion process. In midline area, beware of the inferior epigastric vessels which cause copious bleeding. A laparotomy conversion might be considered if any visceral injury is found [39].

#### 2.Dissection of the hernial sac

Identifying the correct anatomical landmarks is the next most decisive step, which is difficult for beginners. The first point is to recognize the pubic bone. After this, the rest of the landmarks can be discovered by putting this as reference point. Keep away the triangle of doom, which contains the iliac vessels and do not place tacks in the triangle of pain laterally [33, 39].

#### 3.Mesh placement and fixation

Choose the appropriate size of the mesh to prevent a later recurrence due to an eventual "shrinkage" of the prosthesis [40]. Slashing the mesh is hindered because it can lead to a recurrence [33].

Several studies have recommended no fixation but have been found wanting. Tissue glues are being used to secure the mesh in place [39, 41, 42].

#### **3.3 Post-operative complication**

#### *3.3.1 Seroma/hematoma formation*

It is a common complication after laparoscopic hernia surgery and the incidence is within 5–25%. It resolves spontaneously around 4–6 weeks. A drain can be considered if there is an excessive bleeding or after extensive dissection [33].

#### *3.3.2 Urinary retention*

The reported incidence for this complication is 1.3–5.8%, usually found in elderly patients with prostatism. Put a catheter before the surgery and remove the next day morning [33, 43, 44].

#### *3.3.3 Neuralgias*

The incidence is reported to be between 0.5 and 4.6% and intra peritoneal onlay mesh had the highest incidence [43]. The most commonly involved nerves are lateral cutaneous nerve of thigh, genitofemoral nerve and intermediate cutaneous nerve of thigh. This complication can be prevented by avoiding fixing the mesh lateral to the deep inguinal ring in the region of the triangle of pain, safe dissection of a large hernial sac and no dissection of fascia over the psoas [33].

#### *3.3.4 Testicular pain and swelling*

Reported incidence is of 0.9–1.5%. Most are short-term. Orchitis was found occasionally but testicular atrophy was not a complication [33, 43, 44].

#### *3.3.5 Mesh infection and wound infection*

Wound infection rates are very low. Mesh infection is a very serious complication and care must be taken to maintain strict aseptic precautions during the entire procedure [33].

#### *3.3.6 Recurrence*

The risk of the need for repair for recurrent hernia following these initial hernia operations was lower for patients with open mesh repair and for patients with laparoscopic mesh repair [33, 45].

Laparoscopic has advantages in treating recurrent inguinal hernia including elimination of the missed hernia, identify a complex hernias, covering entire myopectineal orifice with mesh that buttressing the intrinsic collagen deficit so one of the cause of recurrent hernia could be overcome [14].

#### **4. Conclusion**

Laparoscopic inguinal hernia repair shows more benefits compared to open hernia repair. SILS inguinal hernia repair offers better cosmetic results; post-operative recovery time was significantly quicker and less painful. However, this approach is technically demanding and should be reserved for experienced single incision hernia surgeons. The invention of new surgical tools will hopefully overcome the current obstacles in SILS in the future.

#### **Acknowledgements**

We would also like to show our gratitude to the Grace Ika Yuwono of Western Sydney University for writing assistance and language editing.

**107**

**Author details**

Reno Rudiman1

West Java, Indonesia

and Andika August Winata<sup>2</sup>

\*Address all correspondence to: andhika.august@gmail.com

2 General Surgeon in Eka Hospital BSD, Indonesia

provided the original work is properly cited.

\*

1 Director of Digestive Surgery Department, Padjadjaran University, Bandung,

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*New Laparoscopic Surgery in Inguinal Hernia Repair DOI: http://dx.doi.org/10.5772/intechopen.89028*

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Appendices and nomenclature**


*New Laparoscopic Surgery in Inguinal Hernia Repair DOI: http://dx.doi.org/10.5772/intechopen.89028*

*Techniques and Innovation in Hernia Surgery*

*3.3.5 Mesh infection and wound infection*

laparoscopic mesh repair [33, 45].

current obstacles in SILS in the future.

of the cause of recurrent hernia could be overcome [14].

procedure [33].

*3.3.6 Recurrence*

**4. Conclusion**

**Acknowledgements**

**Conflict of interest**

Wound infection rates are very low. Mesh infection is a very serious complication and care must be taken to maintain strict aseptic precautions during the entire

The risk of the need for repair for recurrent hernia following these initial hernia

Laparoscopic inguinal hernia repair shows more benefits compared to open hernia repair. SILS inguinal hernia repair offers better cosmetic results; post-operative recovery time was significantly quicker and less painful. However, this approach is technically demanding and should be reserved for experienced single incision hernia surgeons. The invention of new surgical tools will hopefully overcome the

We would also like to show our gratitude to the Grace Ika Yuwono of Western

Sydney University for writing assistance and language editing.

The authors declare no conflict of interest.

SILS single incision laparoscopic surgery TAPP trans-abdominal pre-peritoneal

CDC The Centers for Disease Control

**Appendices and nomenclature**

TEP totally extra peritoneal

operations was lower for patients with open mesh repair and for patients with

Laparoscopic has advantages in treating recurrent inguinal hernia including elimination of the missed hernia, identify a complex hernias, covering entire myopectineal orifice with mesh that buttressing the intrinsic collagen deficit so one

**106**

#### **Author details**

Reno Rudiman1 and Andika August Winata<sup>2</sup> \*

1 Director of Digestive Surgery Department, Padjadjaran University, Bandung, West Java, Indonesia

2 General Surgeon in Eka Hospital BSD, Indonesia

\*Address all correspondence to: andhika.august@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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**111**

Section 4

Rare Hernias

Section 4 Rare Hernias

*Techniques and Innovation in Hernia Surgery*

abdominal surgery: Is it safe? A prospective study. Surgical endoscopy.

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operativen Medizen. 1999;**70**(8):876-887

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2006;**20**(3):473-476

Surgery. 2006;**2**:165-170

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multicenter trial. Annals of Surgery.

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herniorrhaphy. Results of a

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2016;**316**(15):1575-1582

1995;**221**(1):3-13

Sedman PC. Stapled and nonstapled laparoscopic transabdominal

preperitoneal (TAPP) inguinal hernia repair. A prospective randomized trial. Surgical Endoscopy. 1999;**13**(8):804-806

[32] Yang GP, Tung KL. A comparative

study of single incision versus conventional laparoscopic inguinal hernia repair. Hernia: The Journal of Hernias and Abdominal Wall Surgery.

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of Surgery. 1999;**230**(2):225-231

Vartanian S. Laparoscopic hernioplasty: Significant complications. Surgical Endoscopy. 1999;**13**(4):328-331

[36] Kraus MA. Nerve injury during laparoscopic inguinal hernia repair. Surgical Laparoscopy and Endoscopy.

[37] Cueto J, Vázquez JA, Solís MA, Valdéz G, Valencia S, Weber A. Bowel obstruction in the postoperative period of laparoscopic inguinal hernia repair (TAPP): Review of the literature. JSLS: Journal of the Society of Laparoendoscopic Surgeons.

[35] Felix EL, Harbertson N,

1993;**3**(4):342-345

1998;**2**(3):277-280

[38] Dulucq JL, Wintringer P, Mahajna A. Totally extraperitoneal (TEP) hernia repair after radical prostatectomy or previous lower

2015;**19**(3):401-405

[31] Buckley FP 3rd, Vassaur H, Monsivais S, Sharp NE, Jupiter D, Watson R, et al. Comparison of outcomes for single-incision laparoscopic inguinal herniorrhaphy and traditional three-port laparoscopic herniorrhaphy at a single institution. Surgical Endoscopy. 2014;**28**(1):30-35

**110**

**113**

**Chapter 9**

**Abstract**

*Ashanga Yatawatta*

modality of treatment.

**1. Introduction**

no supporting imaging facilities.

**2. Spigelian hernia**

Rare Presentations of Hernia

Rare types of hernias require the use of astute clinical judgment and high index of suspicion with supportive information obtained with cross sectional imaging. Having a clear understanding is important to the current surgeon as well as gynecologist. This chapter attempts to compile the common types of these rare hernias to discuss anatomical defects, imaging features and treatment options. Technical details of treatment are not offered for each type in detail due to limited scope of this text. The emphasis on clinical examination and judgment cannot be overstated and depending on cross sectional imaging alone for clinical diagnosis is discouraged. Introduction of minimally invasive surgery has changed the landscape for rare hernias with some new types being added—such as port site hernia—but mostly with less invasive treatment options being added to the armament. It is expected that laparoscopic hernia repair for these rare hernias will be soon the preferred

**Keywords:** spigelian hernia, obturator hernia, Richter hernia, Amyand hernia,

Hernia surgery is one the commonest procedure performed today. Although the vast majority of hernias are typical on presentation, there are rare types, which can confuse even the most experienced surgeons [1]. Having an understanding behind the anatomy, appearance on imaging and treatment principles are important for the contemporary surgeon, as the likelihood of coming across one would be the limiting factor during an average career [2]. Clinical features of each type tend to be subtle and frequently overlapping, therefore a clear understanding of clinical features as well as supporting imaging information in critical for accurate diagnosis and treatment planning. Important surgical history is embedded with most of these rare hernias as all of these were recognized, treated, and taught clinically in an era with

Spigelian hernia occurs due to a weakness of the spigelian fascia, which is the layer between rectus muscle and semilunar line [3]. The absence of a posterior rectus sheath is a contributing factor at this location and therefore mostly occurs below the arcuate line. Most of these are smaller than 2 cm and clinical findings may be obscured by the intact anterior rectus sheath, giving rise to the

De Garengeot hernia, Littre hernia, reduction en-masse of hernia, interparietal hernia, sciatic hernia, perineal hernia, parastomal hernia

#### **Chapter 9**
