Simpler mesh fixation with tacks in open preperitoneal mesh repair of recurrent inguinal hernia

Abstract

Dear Editor, I read with interest the recent article of Katri [1] which referred to the open preperitoneal mesh repair of recurrent inguinal hernia. I wish to describe my experience of a simple method for mesh Wxation during the open preperitoneal mesh repair of inguinal hernia. The author used “several interrupted 2–0 polypropylene sutures to the pubic tubercle, the Cooper’s ligament, the iliopubic tract medial to the iliac vessels, and then one more stitch to the iliopubic tract lateral to the iliac vessels and cord to Wxing mesh” [1]. Suturing in a deep wound, when the peritoneal sac is pushed into a previously small space, makes it more uncomfortable for the surgeon to work, is not as simple and is time-consuming. Although Ramadan et al. [2] had a ten times higher recurrence rate among those with non-Wxated mesh, the new data could not support the importance of mesh Wxation. Mesh Wxation does not add anything more in cost and, probably, post-operative pain compared to laparoscopic totally extraperitoneal (TEP) hernia repair [3]. The mesh was Wxed using a sandwich eVect between the intact peritoneal layer (as in the open preperitoneal mesh repair of inguinal hernia) and the abdominal wall, giving a Wxed position to the mesh by the even application of abdominal pressure. ‘‘Indeed some pioneers in the development of preperitoneal hernia repair including Stoppa and Ferzli advocate that Wxation of preperitoneal mesh may be unnecessary” [3]. With the advent of laparoscopic hernia surgery, we now have a new option for mesh Wxation. Tacks have been used for years in laparoscopic hernia surgery. A decade ago, Ramadan et al. [2] used metal clips for mesh Wxation during the open preperitoneal mesh repair of inguinal hernia. We have currently used tacks for this purpose for several years. One or two tacks simply and quickly Wxes an adequately large mesh to the pubic tubercle, medial to the iliac vessels. After that, it is the responsibility of abdominal pressure to maintain the mesh position. During last 4 years, we have not had any problems with this simple and fast technique.