Minimally invasive hernia surgeries are a safe and widely used procedure. The comparison between total extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) shows no advantage for either procedure; both techniques are acceptable. Lightweight meshes show promising advantages, while biological meshes are a new approach; however, randomized controlled trials are lacking for these. Randomized controlled trials have demonstrated that mesh fixation is unfavorable for most hernias. However, an operative standard is still lacking.
Indication:
• Recurrent inguinal hernia after initial anterior procedure
• Bilateral inguinal hernia
• Primary inguinal hernia after appropriate counseling on alternative procedures
Contraindications:
• Previous lower abdominal surgeries, as these make the separation of the parietal peritoneum from the abdominal wall more difficult.
• Scrotal or incarcerated/irreducible hernias
Advantages compared to open mesh implantation (Lichtenstein):
• No difference in the average recurrence rate (2%)
• Chronic pain is less common
• Shorter recovery period
• No postoperative rest is necessary
Disadvantages compared to open mesh implantation (Lichtenstein):
• The surgeon's experience has a greater impact on the recurrence rate
• Higher costs
• General anesthesia
• Longer operation time
• Occurrence of major complications (nerve, bowel, vascular, and bladder injuries)
• Long learning curve
• Limited availability in specialized centers
Advantages compared to the TAPP technique:
• Injuries to intra-abdominal organs and adhesion formation can be avoided.
• Tendentially shorter hospital stay
Meshes
• At present, there is not enough clinical data to make clear recommendations for specific meshes on an evidence-based basis.
• Based on experimental data, we know that heavyweight meshes exhibit stronger scar formation and resulting shrinkage compared to lightweight meshes.
• In clinical comparative studies, short-term advantages of lightweight meshes are found, namely less seroma formation, less pain, and earlier return to daily activities.
Mesh fixation
• For the fixation of meshes in hernia surgery, in addition to sutures, various absorbable and non-absorbable tackers as well as tissue adhesives are available. According to the guidelines for minimally invasive inguinal hernia surgery (Bittner et al. 2011a), at evidence level 1B, the recurrence rate after TAPP or TEP is not higher if fixation is omitted, but only for defects up to 3 cm in diameter. If metal tackers are used for mesh fixation, a higher rate of acute or chronic groin pain must be expected. Fixation of the mesh with tissue adhesive is associated with a lower rate of acute and chronic groin pain, without increasing the recurrence rate.
• For defect sizes up to 3 cm, mesh fixation can be omitted in TAPP and TEP. If the defects are larger and fixation appears necessary, tissue adhesive fixation should be performed to reduce postoperative acute and chronic pain.
• Only for very large medial inguinal hernias and bilateral medial hernias or lateral scrotal hernias does the necessity of using tackers remain. In such cases, a larger mesh (12 × 17 cm) should be used.