Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia

Abstract

We thank Christophe Berney for his interesting and very important Letter to the Editor, in which he addresses a number of aspects of the evidence-based technique of total extraperitoneal patchplasty (TEP) discussed in the ‘‘Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia’’ [1]. The technique must once again be clarified in more precise terms. At issue is the role of fibrin sealant for mesh fixation in TEP and the implications of the role of fibrin sealant in seroma formation. Christophe Berney reports on his own experiences with fibrin sealant for mesh fixation in 650 TEP operations with low complication and recurrence rates [2]. In the subsection entitled ‘‘Should a drain be used after a TEP repair? Should seromas be aspirated?’’ [1, p. 2794], the study by Lau [3] is cited as a level 1B statement. In that prospective randomized comparative study of bilateral inguinal hernias, it was noted that the use of fibrin sealant compared to staples for mesh fixation in TEP led to a significant reduction in the need for analgesics, but it also led to a significant rise in the rate of postoperative seromas. Here it is important to focus on the definition used by Lau [3] for a postoperative seroma: ‘‘A seroma was defined as the clinical presence of a palpable fluid collection over the groin in the absence of bruising during follow-up.’’ Also noteworthy in the Lau study [3] is that the proportion of direct hernias was very high, amounting to 56.5% in the fibrin sealant group and 58.5% in the staple group. In the Lau study [3] a clinically palpable seroma with protrusion of the skin was noted in only 5.3% of cases in which staples were used and in 17.4% (p = 0.009) of cases in which fibrin sealant was used for mesh fixation. Therefore, by virtue of the Lau study [3], it must be borne in mind that mesh fixation to Cooper’s ligament with staples tends to be more suitable for prevention of a clinically palpable seroma with protrusion of the skin in the groin after a TEP operation for direct hernias. The classification system used in the Guidelines means that queries relating to both TEP and TAPP are dealt with in separate sections. Therefore, further statements and commentaries on the issues raised by Christophe Berney can be checked in Chapter 9, ‘‘Mesh fixation modalities: is there an association with acute or chronic pain?’’ and Chapter 10, ‘‘Risk factors and prevention of acute and chronic pain.’’ On p. 2822 there is a clear statement on the scientific level 1B whereby the risk of acute and chronic pain after staple mesh fixation is higher compared with fibrin fixation or nonfixation. On p. 2817 nonfixation of mesh in TEP is then elaborated on in greater detail: ‘‘In total, seven studies have compared fixation versus nonfixation in TEP, of which only two have 1 B evidence level. They did not discover any difference in the incidence of recurrence between fixated versus nonfixated mesh. In total, 12,114 hernia repairs F. Kockerling D. A. Jacob (&) Department of Surgery and Center for Minimally Invasive Surgery, Vivantes Hospital, Neue Bergstr. 6, 13585 Berlin, Germany e-mail: dietmar.jacob@vivantes.de