Hernia Mesh Fixation

Abstract

Hernia mesh fixation is an integral part of both inguinal and ventral hernia surgical repair, allowing the mesh to cover the hernia defect until the mesh-tissue fusion process is complete. There are a variety of mesh fixation methods, materials, and devices currently available. The use of mesh fixation is considered a balance between the benefit of mesh fixation or the strength of fixation to keep the mesh in place versus the adverse effect of fixing the mesh. However, there is no consensus or evidence regarding the most effective mesh fixation. This chapter will enlighten surgeons on mesh fixation, especially those who wish to implement their knowledge of hernia management.

1. Introduction

Following the recent guideline, mesh-based hernia repair is considered the standard treatment for both inguinal hernias [1, 2, 3, 4, 5] and ventral hernia [4, 6, 7]. Mesh is used to reinforce the inguinal floor and can be approached using both open and laparoscopic techniques. Transabdominal preperitoneal repair (TAPP) and totally extraperitoneal repair (TEP) are commonly utilized for laparoscopic approaches, whereas Lichtenstein’s hernia repair is typically utilized for an open approach. For the ventral hernia or incisional hernia, mesh is used to reinforce the hernia defect through the open or laparoscopic approach.

The purpose of the mesh used is to cover the hernia defect; subsequently, a mesh-tissue integration process will be developed. Mesh fixation is a technique used to retain the mesh in position until the mesh-tissue integration process is complete or about 2–3 weeks after surgery [8]. Presently, the mesh fixation methods are utilized in clinical practice and can be categorized as no mesh fixation or mesh fixation with a different kind of material and device such as suture, tacker, glue, or self-gripping mesh, which have different uses for both inguinal and ventral hernias. Mesh fixation is useful for keeping the mesh in position and closing the hernia defect; however, it may have adverse effects, including local tissue trauma [9], nerve injury due to entrapment [10], erosion [11], meshoma formation [12, 13], tack hernias [14], chronic pain [12, 15, 16], and infection [17].

In this chapter, we will provide updated evidence regarding various mesh fixation methods, materials, and devices for inguinal and ventral hernia repair.

2. Technique for keeping mesh in place

In clinical practice, the techniques for keeping mesh in place can be categorized as no mesh fixation and mesh fixation. No mesh fixation is the method used for laparoscopic inguinal hernias, as reported both in TEP [18, 19, 20] and TAPP [21, 22, 23]. At the end of the surgical procedure, expelling the air allows the peritoneum to attach to the mesh, while intra-abdominal pressure causes the extraperitoneal space to naturally close and constrict, allowing the mesh to be fixed in position. However, mesh fixation is still required in ventral hernia repair.

The current evidence from a recent meta-analysis comparing no mesh fixation versus mesh fixation demonstrated that no mesh fixation in laparoscopic inguinal hernia repair does not increase the risk of mesh displacement contributing to hernia recurrence [24, 25, 26], while reducing chronic groin pain and operative time is advantageous [24, 26].

However, recent guidelines for inguinal hernia repair [1, 5] still recommend mesh fixations in patients with large direct hernias (M3-EHS classification).

3. Mesh fixation methods

There is no distinct classification of mesh fixation methods. The terms “permanent versus non-permanent fixation“ and “atraumatic fixation“ are used in the most recent guideline [1]. However, this chapter will classify mesh fixation methods as either penetrating or non-penetrating (atraumatic) because the term can be used to designate mesh fixation mechanisms.

3.1 Penetrating mesh fixation

Penetrating mesh fixation is a method for attaching mesh to local tissue by permeating it. It includes sutures and tack. There are two types of tacks: permanent and absorbable.

3.1.1 Suture

The original Lichtenstein’s inguinal hernia repair described used non-absorbable monofilament sutures for fixing mesh [27]. However, the study using delayed-absorbable monofilament sutures demonstrated a decreasing risk of postoperative inguinal pain and paresthesia (Table 1), [28].

Name	Type	Loss of tensile strength	Complete absorption	Tissue reactivity
Polydioxanone (PDS)	Delayed-absorbable monofilament	Slow (45% by 3 weeks)	180 days	Minimal
Polyglyconate (Maxon)	Delayed-absorbable monofilament	Slow (31% by 6 weeks)	180 days	Minimal
Nylon (Ethilon, Dermalon)	Non-absorbable monofilament	30% at 2 years	NA	Minimal
Polybutester (Novafil)	Non-absorbable monofilament	Negligible	NA	Minimal
Polypropylene (Prolene)	Non-absorbable monofilament	Negligible	NA	Minimal

Table 1.

The characteristic of a common hernia repair suture.

3.1.2 Tack

Tack is a synthetic mesh fixation that can be subdivided by the materials into non-absorbable and absorbable tacks, and now the design of the launcher can be subdivided into an articulating and a non-articulating applier (Table 2).

Table 2.

The characteristic of a tacker.

PEEK: polyetheretherketone, PLG: polydioxanone and l(−)-lactide/glycolide copolymer, PGLA: poly(glycolide-co-l-lactide), PLA: poly(d,l)-lactide.

There are two varieties of tacker applicator shafts: straight and articulating (Figure 1). An articulating applicator has a significant benefit, as it allows the fired tacker to be at a perpendicular angle to the attachment point, resulting in a tighter fixation. This feature makes it more suitable for ventral hernias rather than inguinal hernias.

Figure 1.

Articulating mesh fixation device.

3.2 Non-penetrating (atraumatic) mesh fixation

3.2.1 Glue

Glue has been used for mesh fixation in both open and laparoscopic approaches, as it does not injure the tissue. It can be divided into fibrin glue and synthetic glue.

3.2.1.1 Fibrin glue

Fibrin glue, also known as Tisseel® or Tissucol® (Baxter Healthcare) and Evicel® (Ethicon), is a biological hemostatic agent comprised of fibrinogen and thrombin. Then activated by calcium chloride when it is added, the fibrin glue transforms into a fibrin fiber matrix, and the reaction may require 3 min to complete [29]. This not only affects hemostasis but also has strength enough to fix the mesh.

3.2.1.2 Synthetic glue

The synthetic adhesive cyanoacrylate glue is composed of n-butyl-cyanoacrylate. Histoacryl® (B-Braun), LiquiBand Fix8 (Advanced Medical Solutions), and Glubran 2® (GEM) are utilized, when available.

Polymerization occurs promptly in the presence of ionic substances like water, blood, or tissue fluids. There is a requirement for 30–45 s. The polymerized form shows excellent tensile strength and is highly effective for securing mesh.

3.2.2 Self-gripping mesh

Self-gripping mesh, ProGrip™, is a polyester monofilament mesh with a polylactic acid (PLA) microgrip or microhook. The portion of a microgrip can secure local tissue without requiring additional fixation.

4. Clinical application and evidence

4.1 Inguinal hernia

4.1.1 Open inguinal hernia repair

Open inguinal hernia repair has a mesh fixation method that involves suturing with non-absorbable monofilament sutures or the original Lichtenstein‘s hernia repair. While glue, self-gripping mesh, and suturing with absorbable monofilament sutures were used as alternative methods.

The effects of absorbable versus non-absorbable monofilament suture for open inguinal hernia mesh fixation were examined in a comparative study. The study evaluated the impact of delayed absorbable monofilament suture, Polyglecaprone (2-0), compared to non-absorbable monofilament suture, Polypropylene (2-0). The results indicated that the group treated with delayed absorbable sutures experienced significantly less pain after 6 months [28]. However, it is important to note that these findings were not mentioned in the recent guidelines [1].

The comparison between glue and non-absorbable monofilament suture for open inguinal hernia mesh fixation has been investigated in various study designs, such as randomized controlled trials, systematic reviews, meta-analyses [30, 31, 32], and umbrella reviews [33]. The findings consistently indicate that glue is superior to non-absorbable monofilament suture in reducing short- and medium-term postoperative pain, as well as chronic groin pain [33].

A comparison between self-gripping mesh and non-absorbable monofilament suture for open inguinal hernia mesh fixation revealed that self-gripping mesh resulted in a reduction in operative time. However, there was no significant difference observed in terms of recurrence prevention or postoperative pain [31, 33, 34, 35].

4.1.2 Laparoscopic inguinal hernia repair

The conventional method for mesh fixation in laparoscopic inguinal hernia repair involves the use of titanium or metallic tacks. However, alternative mesh fixation methods, such as glue, self-gripping mesh, and non-absorbable tacks, have been reported in clinical practice.

A study reported that a new design for the tacker mesh fixation device includes an articulation feature, allowing surgeons to adjust the angle of the device for proper mesh fixation. Adjusting the angle to align with the mesh fixation point results in a better average fixation force compared to a non-articulated mesh fixation device [36].

In an in vitro study, it was discovered that fibrin glue provided stronger mesh fixation compared to absorbable tacks. The study involved placing the mesh on a stake and measuring the force required to detach the mesh from the stake. The applied force for the tacks was found to be 6.40 ± 1.50 N, while for the glue, it was 15.34 ± 3.93 N, indicating a significant difference between the two methods [37].

Finally, the evidence suggests that glue is beneficial compared to other methods in terms of reducing postoperative pain, but there is no significant difference observed in hernia recurrence (Table 3) [33, 35, 38].

Outcome	Suggestive of mesh fixation
Hernia recurrence prevention	All techniques
Chronic groin pain prevention	Glue
Shortening of operating time	Glue, SGM
Early return to daily activities	Glue
Postoperative complication prevention	All techniques

Table 3.

The summarized evidence for inguinal hernia mesh fixation [33].

SGM, self-gripping mesh.

4.2 Ventral hernia

The mesh fixation methods used for primary and incisional ventral hernias are similar to those employed for inguinal hernias. These methods include sutures, non-absorbable and absorbable tacks, self-gripping mesh (for open ventral hernias only), and glue. Evidence from several systematic reviews and meta-analyses indicates that there are no significant differences among these methods in terms of outcomes such as hernia recurrence and chronic pain. Therefore, the choice of method may depend on the surgeon‘s expertise [39, 40, 41, 42, 43].

5. Conclusions

The available mesh fixation techniques include sutures, tacks, self-gripping mesh, and tissue adhesive, which can be applied both openly and laparoscopically. There is no consensus for this part; the selection to be used depends on the surgeon. Mesh fixation techniques have been demonstrated to be equally safe in terms of recurrence; however, tissue adhesives are associated with a lower incidence of chronic pain.

Conflict of interest

The authors declare no conflict of interest.