Outcomes of laparoscopic herniorrhaphy without fixation of mesh to the abdominal wall

Background: Recently there has been interest in performing laparoscopic hem iorrhaphies without the use of staples or tacks to fix the mesh. Although m esh fixation has been linked to an increased incidence of nerve injury and involves increased operative costs, many surgeons feel that fixation is nec essary to reduce the risk of hernia recurrence. This study evaluates the ou tcomes of laparoscopic herniorrhapies performed with and without mesh fixat ion at our institution. Methods: We retrospectively evaluated our last 172 laparoscopic herniorrhap hies, which span a period of conversion from staple fixation to nonfixation of total extraperitoneal herniorrhaphies using systematic chart review and followup self-administered questionnaires. The outcomes assessed were the incidences of postoperative neuralgia and hernia recurrence. Adjustment for important prognostic factors was achieved using Cox regression for estimat ing the risk of recurrence, and multiple logistic regression for estimating the risk of neuropathic complications. Results: Of 172 laparoscopic hemiorrhaphies performed in 129 patients since July 1993, 105 were accomplished without mesh fixation, and 67 were perfor med with fixation of mesh to the abdominal wall. There were no significant differences in demographics between the two groups. A trend toward a higher incidence of neuropathic complications was observed in the mesh-fixation g roup (risk ratio [RR], 2.2; 95% CI, 0.5-10). A nonsignificant increased ris k of hernia recurrence with fixation of mesh was observed (4.2 vs 1.6 per 1 00 hernia-years at risk; RR, 2.3; 95% CI, 0.4-13.10), but this finding may be associated with a selection bias with regard to giant hernia defects. Conclusions: Our data suggest that mesh fixation to the abdominal wall may be avoided in total extraperitoneal repairs without increasing the risk of hernia recurrence and neuropathic complications. The increased risk of recu rrence observed with mesh fixation possibly results from selection bias. La rge randomized controlled studies are needed to determine whether mesh fixa tion is truly related to neuropathic complications and the incidence of rec urrence.