Mesh Fixation Devices and Techniques: A Review of the ...

Mesh Fixation Devices and Techniques: A Review of the ...

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This month’s featured expert

Abraham Fridman, DO, Clinical Fellow at the Bariatric Institute and Section of Minimally Invasive Surgery, Cleveland Clinic, Weston, Florida

Bariatric Times, Volume 9, Issue 6: 10-12. A Message from Column Editor Samuel Szomstein, MD, FACS

Dear Readers of Bariatric Times,
Welcome to the June issue of "The Hole in the Wall." This month's feature highlights Abraham Fridman, DO, a Clinical Fellow in Bariatric and Minimally Invasive Surgery at Cleveland Clinic Florida. This month, Dr. Fridman provides us with an excellent literature review on mesh fixation devices and techniques. Do you have any “pearls” or “tricks” that you use in your daily practice related to meshes and fixation devices? Please share them with us at [protected], and I would love to share them with our readers.

Once again, welcome to “The Hole in the Wall.” We hope you enjoy this column and look forward to your questions, comments, and participation in future issues.

Sincerely,

Samuel Szomstein, MD, FACS

No funding was provided in the preparation of this article.

Financial disclosures: Dr. Fridman reports no conflicts of interest relevant to the content of this article.

Introduction

Hernia repair has significantly evolved over the last few decades. Since the introduction of prosthetic materials (mesh) for hernia repairs, various techniques have been developed to minimize recurrence. The advent of laparoscopy for hernia repair has also led to innovative methods of mesh fixation, transitioning from simple sutures to absorbable screw-type fasteners.

Suture materials, both absorbable and non-absorbable, were used for hernia repair long before prosthetic materials. Many surgeons today continue to use sutures for both open and laparoscopic repairs. One of the earliest non-suture fixation methods was the titanium tack/staple (ProTack®, Covidien), a permanent spiral fastener that gained market leadership in the early 21st century.

Recently, the preference among surgeons has shifted towards absorbable spiral tacks, which appear to cause fewer long-term complications and reabsorb within a year (as noted by the manufacturers of AbsorbaTack). Tissue glues, commonly used in vascular and cardiothoracic procedures, are also being considered an acceptable method for mesh fixation. However, no single fixation material has been deemed the "ideal" in the literature. Below is a brief review of current mesh fixation methods and their efficacy.

Ventral/Incisional Hernia

The incidence of incisional hernia following laparotomy is reported in up to 20% of patients. Presently, incisional hernias can be repaired either laparoscopically or via an open approach, with no single method universally accepted as the best. The choice of repair technique remains dependent on the surgeon.

Laparoscopic repair offers aesthetic advantages over open surgery. However, potential challenges include selecting the right mesh size, proper mesh fixation, and using the appropriate mesh type. The primary goal in all repairs is to prevent mesh migration and minimize postoperative pain. Various techniques have been employed to fix mesh during laparoscopic repair.

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One technique involves the use of transfascial sutures, which can be absorbable or non-absorbable. These sutures have shown excellent tensile strength, minimal adhesion formation, and cost-effectiveness. A literature review by LeBlanc suggests that recurrence rates are slightly lower with sutures. A recent innovation from Israel describes a new suture passer that simplifies the procedure and reduces time. Despite these advancements, the process can be time-consuming and may contribute to chronic pain.

Titanium tacks, which gained popularity in the early 21st century, offered excellent tensile strength and easy application. However, their long-term use has been associated with bowel injury and dense adhesion formation. Nowadays, newer absorbable screw fasteners cause fewer adhesions and pain while maintaining sufficient tensile strength. A porcine model study by Byrd et al. demonstrated decreased adhesions with screw-type devices. Lyons et al. also described the use of barbed anchor sutures, which secure tissue without knot tying, although no clinical trials have been definitive.

Open repair lacks consensus on the ideal fixation method, with surgeons employing various materials and techniques. Some clinical trials suggest open repair may be preferable to laparoscopic approaches. Different fixation techniques are described in the literature, with no single method deemed superior. Grommes et al. demonstrated in a pig model that retromuscular mesh placement for hernia repair might not require fixation.

The researchers also concluded that using tissue adhesive (BioGlue® Surgical Adhesive) for mesh fixation is a viable method with fewer complications, such as pain and seroma, and equal recurrence rates.

Inguinal Hernia

Inguinal hernias, common complaints among patients, have seen reduced recurrence rates with the introduction of prosthetic materials for repair. Today, the laparoscopic approach, particularly the total extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) repairs, is widely used. The debate between laparoscopic and open repair for inguinal hernias continues.

Laparoscopic repair for inguinal hernias, whether TEP or TAPP, remains controversial regarding mesh fixation. Tackers are popular for their simplicity and efficacy in preventing mesh migration—a leading cause of recurrence. However, they carry a risk of causing long-term postoperative pain. Taylor et al. showed that tacking heightens postoperative pain compared to no fixation, leading to a decline in their use.

An alternative method is using tissue adhesives, producing less pain than tacks while maintaining adequate fixation strength to prevent mesh migration and recurrence. This method is applicable to both TEP and TAPP repairs. Studies suggest decreased postoperative hypoesthesia with tissue adhesives compared to staples, though the necessity of mesh fixation in inguinal hernias remains debated.

Numerous studies indicate that mesh fixation in inguinal hernias may prolong the procedure and increase pain without significantly reducing recurrence rates. Ferzli et al. published early findings showing good outcomes with no fixation during TEP repair. Recent meta-analyses support non-fixation due to lower costs, shorter operative times, and reduced hospital stays.

Open repair remains a popular method for inguinal hernias, with techniques evolving since the introduction of prosthetic materials. While many still advocate mesh fixation to the inguinal floor, newer methods like self-gripping mesh are gaining traction. Self-gripping mesh features tissue-adhering anchors, providing equivalent tensile strength to sutures and potential reductions in postoperative pain. Although tissue glue has also been proposed for fixation, conclusive evidence is lacking.

Conclusion

Hernias are among the most common conditions seen in clinical practice. The techniques and materials used in their repair have been evolving, and further clinical trials are necessary to determine the optimal repair method.

References

1. Grommes J, Binnebosel M, Klink CD, et al. Different methods of mesh fixation in open retromuscular incisional hernia repair: a comparative study in pigs. Hernia; 14(6):623-627.
2. Byrd JF, Agee N, Swan RZ, et al. Evaluation of absorbable and permanent mesh fixation devices: adhesion formation and mechanical strength. Hernia; 15(5):553-558.
3. Bansal VK, Misra MC, Kumar S, et al. A prospective randomized study comparing suture mesh fixation versus tacker mesh fixation for laparoscopic repair of incisional and ventral hernias. Surg Endosc; 25(5):.
4. LeBlanc KA. Laparoscopic incisional hernia repair: are transfascial sutures necessary? A review of the literature. Surg Endosc; 21(4):508-513.
5. Elazary R, Abu-Gazala M, Schlager A, et al. Trans-fascial laparoscopic mesh fixation: a procedural comparison using the standard suture passer versus iMESH stitcher device. Hernia; 15(3):321-324.
6. Wassenaar E, Schoenmaeckers W, Raymakers J, et al. Mesh-fixation method and pain and quality of life after laparoscopic ventral or incisional hernia repair: a randomized trial of three fixation techniques. Surg Endosc; 24(6):.
7. Lyons C, Joseph R, Salas N, et al. Mesh fixation with a barbed anchor suture results in significantly less strangulation of the abdominal wall. Surg Endosc; 26(5):.
8. Itani KMF, Hur K, Kim LT, et al. Comparison of laparoscopic and open repair with mesh for the treatment of ventral incisional hernia. Arch Surg; 145(4): 322-328
9. Teng YJ, Pan SM, Liu YL, et al. A meta-analysis of randomized controlled trials of fixation versus nonfixation of mesh in laparoscopic total extraperitoneal inguinal hernia repair; 25(9):.
10. Brugger L, Bloesch M, Ipaktchi R, et al. Objective hypoesthesia and pain after transabdominal preperitoneal hernioplasty: a prospective, randomized study comparing tissue adhesive versus spiral tacks. Surg Endosc; 26(4):.
11. Taylor C, Layani L, Liew V, et al. Laparoscopic inguinal hernia repair without mesh fixation, early results of a large randomized clinical trial. Surg Endosc; 22(3):757-762.
12. Ferzli GS, Frezza EE, Pecoraro AM Jr, Ahern KD. Prospective randomized study of stapled versus unstapled mesh in a laparoscopic preperitoneal inguinal hernia repair. J Am Coll Surg; 188:461-465.
13. Kapischke M, Schulze H, Caliebe A. Self-fixating mesh for the Lichtenstein procedure-a prestudy. Langenbecks Arch Surg; 395(4):317-322.

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