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ORIGINAL ARTICLE

Total Extraperitoneal Laparoscopic Inguinal Hernia Repair Without Mesh Fixation
Prospective Study With 1-Year Follow-up Results
Evangelos Messaris, MD, PhD; Guy Nicastri, MD; Stanley J. Dudrick, MD

Objective: To determine the outcomes of patients undergoing total extraperitoneal inguinal hernia repair without fixation of the mesh. Design: Prospective cohort. Setting:Community teaching hospital. Patients: A total of 274 consecutive patients were included in the study group. Interventions: All operations were performed by the same surgeon with the patients under general anesthesia in an outpatient setting. A preformed polyester mesh (Parietex; Covidien, Mansfield, Massachusetts) was used in all cases without any fixation. Main Outcome Measures: All patients wereprospectively followed up at 2 weeks, 1 month, and 1 year after surgery. Operative morbidity, chronic pain, and hernia recurrence were recorded.

Results: Two hundred seventy-four consecutive pa-

tients underwent 311 total extraperitoneal inguinal hernia repairs. No conversions were made to open hernia repairs. No recurrences were found at the 12-month follow-up visit. There were 19 inguinalseromas (6.1%) identified at 2 weeks, but only 7 (1.9%) remained at 1 month, and none at 1 year. No wound infections, scrotal hematomas, or other perioperative complications were reported. Two hundred thirty-six patients used fewer than the 30 prescribed tablets for pain control, while 23 patients requested a refill, 12 of whom had seromas (P .01). At 12 months, no patient was taking pain reliefmedication; however, 8 patients reported occasional discomfort in the groin, and 1 patient reported occasional umbilical discomfort.
Conclusion: This single general surgeon experience sup-

ports total extraperitoneal inguinal hernia repair without mesh fixation as a safe, effective procedure with low morbidity and no evidence of recurrence at the 1-year follow-up visit. Arch Surg.2010;145(4):334-338 associated with intra-abdominal access, which was required for the transabdominal preperitoneal approach.4 The TEP method allows access to the preperitoneal space and avoids the need for a peritoneal incision.3 In an extraperitoneal laparoscopic repair, access to the preperitoneal space is achieved with a dissecting balloon, a laparoscope, or blunt dissection and/or carbon dioxide dissection,while the dissection is visualized from the extraperitoneal cavity. A mesh prosthesis is inserted into the preperitoneal space. Many technical variations exist in fixation (tacks, staples, or fibrin glue) or nonfixation methods and mesh configuration.5-9 The mechanisms of inguinal hernia recurrence after laparoscopic repair have been

Author Affiliations: Departments of Surgery, Rhode IslandHospital (Dr Messaris) and Memorial Hospital (Dr Nicastri), The Warren Alpert Medical School, Brown University, Providence, Rhode Island, and Saint Mary’s Hospital, Waterbury, Connecticut (Dr Dudrick).

HE LAPAROSCOPIC APproach for inguinal hernia repair was first reported by Ger,1 who performed a high ligation of the sac without mesh placement. In the early 1990s, a variety of transabdominallaparoscopic approaches were reported, with the transabdominal preperitoneal approach and the intraperitoneal onlay mesh techniques being the most common.2 Because of reports of high recurrence rates, the intraperitoneal onlay mesh technique quickly fell out of favor. In 1993, McKernan and Laws3 described the laparoscopic total extraperitoneal (TEP) approach. Total extraperitoneal repair was developedbecause of concern for possible complications

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(REPRINTED) ARCH SURG/ VOL 145 (NO. 4), APR 2010 334

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studied by many investigators and are related mostly to technique.10-13 As techniques have improved and surgeons have gained experience, recurrence rates...