The most essential aspect of inguinal hernia surgery is the postoperative recurrence rate. Mesh fixation is used frequently during laparoscopic hernia surgery to avoid mesh migration. There was no significant difference in the recurrence rate of TEP with or without mesh fixation, according to certain RCTs, meta-analyses, and systematic reviews [4–14]. According to the meta-analysis, the recurrence rate after mesh fixation repairs was 0.19% (1/540) compared to 0.55% after nonfixation repairs (3/546); no significant difference was detected between the two groups . We were concerned about recurrence via mesh migration when we implemented the nonfixation TEP at our institution. As a result, we chose SURGIMESH®XD, nonwoven material with high tissue adhesion and a form suitable to the architecture of the inguinal area. This is, to the best of our knowledge, the first report that makes use of this mesh. However, the potential of avoiding mesh fixation in situations of extensive hernias, bilateral hernias, or impaction remains debatable. It is up to the surgeon in actual practice, not clinical trials, to decide whether or not the mesh has to be repaired. All of the surgeons in this research were aware of the worldwide standards for inguinal hernia repair  and decided whether or not to repair the mesh. As a result, big hernias and bilateral hernias were deemed to be at high risk of recurrence, and mesh fixation was done in the majority of patients. Even after the nonfixation TEP was introduced; mesh fixation was done in 75 of 240 patients (31.3%) for the reasons stated above. The lone patient in this research who had a recurrence was very elderly (95-years-old) and had a low-performance status (ECOG-PS3). His hernia was classified as L3 by the EHS. We hypothesized that the patient did not have adequate intraabdominal pressure to fix the mesh as a result of the lengthy period spent in bed, which may have resulted in mesh migration [17, 18]. We must use caution while treating patients with low PS. Because of the significant bias between the fixation and nonfixation groups, only the normal hernia was studied. As a consequence, no patient experienced recurrence following nonfixation TEP. As a result, based on our experience, it was assumed that if SURGIMESH®ฎXD was utilized for typical hernia cases, the mesh might be unfixed. Claus et al. investigated mesh movement in bilateral hernia repair and found that TEP with no mesh fixation is safe in bilateral inguinal surgery . Despite the small number of patients in the current investigation, no recurrence of bilateral hernias was found.
The most serious problem with hernia surgery, aside from recurrence rates, is postoperative groin discomfort caused by mesh fixation . Groin discomfort is difficult to measure since definitions and evaluation techniques are inconsistent. Previous research found a difference between fixation and nonfixation groups in persistent groin pain [8, 21]. The majority of patients in the fixation group who complained of groin discomfort said it was minor and had little impact on their everyday lives. Mesh fixation in TEP is generally unneeded in most situations, although it may cause severe discomfort in a few. In our study, three patients had persistent groin discomfort, all of whom were in the fixation group. One of the three was in so much agony that it was interfering with his everyday life that he underwent surgery more than six months following TEP. He experienced significant relief from groin discomfort when the tack was removed under local anesthesia. There is no need to be concerned about groin pain produced by tacking in the nonfixation group.
The final significant benefit is increased economic efficiency by lowering the cost of the tack applicator. The tacking device used at our institute cost around $385. It has also been claimed that the reduced use of analgesics due to less postoperative discomfort caused by no tacking may have led to cost savings [4, 5, 8].
Previous research has indicated that the nonfixation group has lower urine retention rates, shorter operating times, shorter hospital stays, and quicker return to work [10–14]. In our investigation, the nonfixation group had a considerably shorter surgery time. This was most likely owing to the time saved repairing the mesh; however, the explanation for the lack of change in bilateral hernia cases was unknown. Similarly, the explanation for the shorter hospital stay in the nonfixation group was unknown, but we speculated that it was probably owing to the fixation group’s more severe postoperative pain, albeit no such data were provided. Our research has some limitations. First, because this was retrospective research, the patient population was limited. As stated in the review articles , further high-quality prospective trials are required to show that tacking is unnecessary in TEP. Second, the number of main surgeons in this research was not limited. The procedures were carried out by young residents under the supervision of medical experts in many cases. Third, there were a lot of elderly people in our region, and the average patient age in our research was rather old. Some of them had died or were unable to be reached.
Finally, the absence of mesh fixation in TEP was deemed clinically appropriate for normal hernias (hernia orifice < 3 cm). In terms of form and substance, the mesh utilized in this study, SURGIMESH®ฎXD, was appropriate for the nonfixation TEP.