Evaluation of Bilateral Laparoscopic Repair of Groin Hernias With One Large Self-fixating Mesh (ProGripTM) in a Prospective Cohort Study

1. INTRODUCTION

Evidence in groin hernia repair showed a significant reduction in recurrence rates since the introduction of mesh repair. Hence all current guidelines state that in surgical treatment of groin hernias in adults a mesh should be used.

In laparoscopic groin hernia repair a mesh is positioned in the preperitoneal plane. Two techniques are commonly used. A transabdominal technique (TransAbdominal PrePeritoneal - TAPP), in which the preperitoneal plane is dissected throughout the abdomen, with a closure of the peritoneum after positioning of the mesh, and a preperitoneal technique (Totally ExtraPeritoneal - TEP) in which the peritoneum remains intact.

Fixation of the mesh was originally performed by penetrating fixation, using staples or tackers. Alternative fixation with glue, self-fixating meshes or no mesh fixation at all, have been proposed to avoid the postoperative pain related to the penetrating fixation. Several studies were not able to show significant differences in recurrence rates between the different mesh fixation techniques. In general, sufficient overlap seems more important than fixation of the mesh. However, current guidelines state that tacker or suture fixation of the mesh for groin hernia should be avoided.

Concerns are often raised about large medial hernias (EHS classification: M3) because the medial overlap of the mesh beyond the hernia defect is small. An overlap of less than 2-3 cm may lead to protrusion of the mesh in the hernia opening, and this risk is increased in large direct hernias. In general, the larger the hernia opening, the more overlapping there should be. Observational studies have shown a higher recurrence rate in the repair of direct (i.e. medial) hernias. In a recent consensus statement, Poelman et al. stated that diverse types of inguinal hernias (direct vs. indirect, large vs. small) should be distinguished and treated in a different way. Despite the fact that randomized trials did not differentiate between large or small hernias, they state that the use of a heavy weight mesh, mesh fixation or larger mesh size should be considered in case of large medial hernias.