Outcomes of staple fixation of mesh versus nonfixation in laparoscopic total extraperitoneal inguinal repair: A meta-analysis of randomized controlled trials

Background Staple fixation of mesh during laparoscopic total extraperitoneal (TEP) inguinal repair is thought to be necessary to prevent recurrence. However, mesh fixation may increase surgical complications and pain. Therefore, ameta-analysis of randomized controlled trials (RCTs) was conducted to compare the outcomes of nonfixation with fixation of mesh by metal tacks during TEP inguinal hernia repair. Methods The meta-analysis was conducted according to the Quality of Reporting of Meta-analyses (QUOROM) standards. The inclusion criteria were RCTs comparing stapled with unstapled mesh in TEP inguinal hernia repair. The primary outcome was incidence of recurrence, secondary outcomes were operative duration, postoperative pain score, number of analgesics consumed, in-hospital stay, time to return to normal activity, cost, and complications. Results Six trials were included with a total number of 932 patients (1086 hernias): the mesh was fixed in 463 (540 hernias) patients and not fixed in 469 (546 hernias). We found no difference between groups in the incidence of recurrence (OR = 2.01, 95% CI: 0.37-11.02), complications (OR = 0.73, 95% CI: 0.51-1.05), postoperative pain score [day 1 (p = 0.19), day 7 (p = 0.18) and month 1 (p = 0.47)] and number of analgesics consumed (WMD of -1.20, 95% CI: -3.08 to 0.68). The mean operative time (WMD of -3.86, 95% CI: -7.45 to -0.26) and hospital stay (WMD of -0.34, 95% CI: -0.50 to -0.18) were significantly higher in the mesh fixation group. Moreover, a net cost savings was realized for each hernia repair performed without stapled mesh. Conclusions Elimination of tack fixation of mesh in TEP inguinal hernia repair is associated with decreased operative cost and significantly reduce operative time and in-hospital stay, but no difference in the risk of hernia recurrence, complications, and postoperative pain. For more detailed evaluation, further well-structured trials with improved standardization of hernia type, operative technique, and surgeon experience are necessary.