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International Surgery Journal | March 2018 | Vol 5 | Issue 3 Page 1016
International Surgery Journal
Mir IS et al. Int Surg J. 2018 Mar;5(3):1016-1020
http://www.ijsurgery.com
pISSN 2349-3305 | eISSN 2349-2902
Original Research Article
Laparoscopic totally extraperitoneal repair of inguinal hernia using
three-dimensional mesh: a 5 years experience at a tertiary care hospital
in Kashmir, India
Iqbal Saleem Mir1, Tajamul Rashid2, Irfan Nazir Mir1*, Suhail Nazir1, Imtiyaz Ali1,
Mansoor Ul Haq1
INTRODUCTION
Repair of inguinal hernia is performed in all general
surgery departments. Approximately 20 million repairs
are performed annually worldwide and hence is the most
common elective surgical procedure performed.1 Marlex
mesh for repairing tissue defects in incisional and
inguinal hernias was first introduced by Usher in 1958.2
This is a landmark in the history of hernia surgery. Since
then, the use of mesh has become essential in the repair
of all hernias. Arnaud, defined the necessary qualities of
ABSTRACT
Background: Inguinal hernia repair by laparoscopy is gaining acceptance worldwide. A flat mesh used in
laparoscopic inguinal hernia repair is associated with more complications especially early and late postoperative pain
owing to the need of mechanical fixation of this mesh. A three-dimensional mesh in this context is an emerging
alternative which needs no or minimal fixation.
Methods: A retrospective study of 123 patients was carried out from July 2012 to August 2017. All patients who
underwent TEP by a single surgical team using three-dimensional mesh were included in the study. Data collected
was analysed retrospectively.
Results: Out of a total of 123 patients, 114 patients had unilateral hernia and 9 had bilateral hernia. A total of 132
laparoscopic hernia repairs were done using three-dimensional mesh. All the patients were male aged 29 to 75 years
with a mean age of 51.5 years. Indirect hernias were more common comprising of 87.7%. The mean operative time
was 46.9 minutes. The average mesh fixation time was 12.6 minutes. No major intraoperative complications were
noted in any of the patients. Three patients (2.45%) experienced severe postoperative pain. Most of the patients 117
(95.12%) were discharged within 24 hours of surgery. Mean hospital stay in our study was 1 day. The mean length of
follow-up was 12 months. Mild persistent groin pain was found in four patients (3.25%). Seroma was noted in five
patients (4.06%). Hematoma and wound infection was noted in none. One patient (0.81%) had recurrence after
completion of follow up. We found use of 3D mesh costly.
Conclusions: Laparoscopic inguinal mesh hernioplasty using 3D mesh is a viable alternative of hernioplasty with
minimal post-operative pain and recurrence and using 3D mesh has a technical advantage of easy insertion in an
anatomically correct position with minimal fixation.
Keywords: Hernia, Mesh fixation, TEP
1Department of Surgery, Government Medical College, Srinagar, Jammu and Kashmir, India
2Department of Surgery, Hamdard Institute of Medical Sciences and Research, New Delhi, India
Received: 01 January 2018
Revised: 12 January 2018
Accepted: 30 January 2018
*Correspondence:
Dr. Irfan Nazir Mir,
E-mail: irfanazir@gmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: http://dx.doi.org/10.18203/2349-2902.isj20180822
Mir IS et al. Int Surg J. 2018 Mar;5(3):1016-1020
International Surgery Journal | March 2018 | Vol 5 | Issue 3 Page 1017
prostheses, which were established by Cumber Land and
Scales. These are:
• It should be strong, pliable and easy to handle
• It should be inert, non-allergic, non-biodegradable
and non-carcinogenic
• It should have optimum thickness
• It should stimulate adequate fibroblastic activity and
get rapidly incorporated in the tissues
• It should be biocompatible
• It should achieve early, rapid and optimum ingrowth
of fibrocollagenous tissue to prevent dislocation or
migration
• It should preferably be macroporous, monofilament,
transparent and should resist infection.
• It should provide a barrier to adhesions in the intra-
abdominal placement
So far, no single mesh fulfils all the criteria and the
search for an ideal mesh still continues.
Laparoscopic hernia repair was first reported by Ralph
Ger and colleagues in 1982. Since then laparoscopic
hernia repair has undergone revolutionary advances in
technique of repair, types of meshes used and various
methods of fixation of mesh.3 Among endoscopic
hernioplasty, totally extraperitoneal (TEP) and
transabdominal preperitoneal (TAPP) approach are
widely accepted alternatives to open surgery, both
providing less postoperative pain, hospital length of stay
and early return to work.4,5
The measures of success for any type of hernia repair is
based on its outcome. When the results of open mesh
repair and laparoscopic inguinal hernia repair are
compared, the incidence of complications decreased in
laparoscopic inguinal repair.6 The choice of the type of
the mesh in hernia surgery is often left to the surgeon’s
preference and cost factor.7 In international studies, it has
been mentioned that choice of the prosthesis in hernia
repair is far more important than technique as a
determinant of outcome.8
PPM has been widely used for last 50 years. It is
described that polypropylene meshes, as a hydrophobic
material, cause some degree of contraction and scar
formation in the long-term follow-up. The authors
conclude that polypropylene meshes give risk of
recurrence, owing to overall decrease in the size of mesh,
as well as an increased subjective foreign body feeling
from contracture and scarring.9
After years research, Dr. Pajotin in 1998, came to the
realization that a flat sheet of mesh may not be the ideal
configuration for a laparoscopic repair. The inguinal
anatomy was viewed only as two dimensional image on
the monitor. So, after careful cadaver research, Dr.
Pajotin developed what he believed to be the ideal
prosthetic. He developed the three dimensional mesh
which conformed better to the inguinal anatomy.3
Key benefits
• Anatomically Designed
• Easy Positioning
• Fixation-Free Repair
• Reduced Patient Pain
• Compatible with Various Laparoscopic Approaches
• TAPP
• TEP
• Robotic TAPP
Warnings
• The use of any permanent mesh or patch in a
contaminated or infected wound lead to fistula
formation and/or extrusion of the prosthesis.
• If an infection develops, treat the infection
aggressively. Consideration should be given
regarding the need to remove the mesh.
Precautions
• Do not cut or reshape the 3D mesh as this may
affect its effectiveness.
• If fixation is used, care should be taken to ensure
that the mesh is adequately fixed to the abdominal
wall. If necessary, additional tacks or sutures should
be used.
• If sutures are used, non-absorbable monofilament
sutures should be used.
METHODS
Authors present their experience of a 5 year retrospective
study of totally extraperitoneal repair (TEP) of inguinal
hernia repair using three dimensional mesh at
Government Medical College, Srinagar. This study was
conducted during July 2012 and August 2017.The study
enrolled a total of 123 patients who underwent TEP using
three dimensional mesh (BARD 3D Max LIGHT Mesh).
113 patients had unilateral inguinal hernia and 9 patients
had bilateral inguinal hernia. Incidentally all patients in
the study were male and majority of patients belonged to
the age group of 29-75 years. All patients had clinically
diagnosed inguinal hernia and were admitted from the
outpatient department one day before surgery. After
anaesthetic clearance, patients were operated by standard
technique of totally extraperitoneal repair using three
dimensional mesh in accordance with recommended
guidelines. A total of 132 TEP repairs were performed by
a single surgical team. Operative time was recorded from
the time of skin incision to closure of ports at the end of
the procedure. Mesh fixation time was recorded from the
time of insertion of mesh to placement and fixation of
mesh. Any intraoperative complications were noted.
Postoperatively patients were monitored in the general
ward. For postoperative pain parenteral analgesics were
given. Early ambulation was encouraged and oral diet
was started 06 hours after surgery in all patients. Patients
Mir IS et al. Int Surg J. 2018 Mar;5(3):1016-1020
International Surgery Journal | March 2018 | Vol 5 | Issue 3 Page 1018
were discharged from the hospital as soon as possible
depending upon the ambulation and diet. Patients were
followed-up in outpatient department at 1week, 2 weeks,
4 weeks, 3months, 6months and then yearly. Parameters
which were recorded on each follow up visit were;
postoperative pain as assessed by VAS scale,
postoperative complications, seroma, hematoma or
wound infection, duration of hospitalization, recurrence
and cost.Data analysed was expressed as average,
percentage and mean ± SD, median (range) as
appropriate.
RESULTS
A total of 123 patients included in the study were
reviewed retrospectively from July 2012 to August 2017,
out of which 114 patients had unilateral hernia and 9 had
bilateral hernia. A total of 132 TEP repairs were done
using three dimensional mesh. All the patients were male
aged 29 to 75 years with a mean age of 51.5 years.
Indirect hernias were more common comprising of
87.7%. The mean operative time was 46.9 minutes
ranging from 31 to 76 minutes.
Table 1: Intraoperative and postoperative
complications.
Complications observed
Percentage
Intra-operative complications
0.00
Severe postoperative pain
1.62
Seroma
4.06
Hematoma
0.00
Wound infection
0.00
Recurrence
0.81
Table 2: Intraoperative and postoperative
parameters observed.
Parameters
Duration
Mean operative time (in minutes)
46.9 minutes
Average mesh fixation time (in
minutes)
12.6 minutes
Mean hospital stay (in days)
1.00 day
Mean length of follow up (in months)
12.00 months
The average mesh fixation time was 12.6minutes. No
major intraoperative complications were noted in any of
the patients. Two patients (1.62%) experienced severe
postoperative pain which was managed by parenteral
analgesics. Most of the patients 117 (95.12%) were
discharged within 24 hours of surgery. Mean hospital
stay in this study was 1 day. The mean length of follow-
up was 12 months. Mild persistent groin pain was found
in four patients (3.25%) after 3 months of follow up
which resolved overtime. Seroma was noted in five
patients (4.06%) which resolved with assurance and
conservative management. Hematoma and wound
infection was noted in none of these patients. 01 patients
(0.81%) had recurrence after completion of follow up. In
this study authors found three dimensional mesh to be
slightly costly. Most of this patient returned to normal
activities within one month (Table 1 and Table 2).
DISCUSSION
The repair of an inguinal hernia has been an area of
controversy in general surgical practice ever since it was
conceived.10 The fact that countless procedures are in use
reflects the complexity of inguinal hernia repair. The goal
of a hernia repair is to strengthen the weak abdominal
wall. In the laparoscopic procedure, the repair is
accomplished by placement of a prosthetic mesh to cover
the entire groin area, including the sites of direct, indirect,
femoral and obturator hernias. The totally extraperitoneal
procedure (TEP) combines the advantages of tension-free
mesh reinforcement of the groin with those of
laparoscopic surgery.5 The establishment of this
technique by Dulucq in Europe may be considered a
logical further development of transabdominal
preperitoneal hernia repair (TAPP).11,12 The surgeon can
use the endoscopic inguinal hernia technique for the
repair of a primary hernia, providing the surgeon is
sufficiently experienced in the specific procedure.12
Laparoscopic hernia repair has many advantages over
open methods as shown by prospective randomized trials
comparing laparoscopic to tension-free open
herniorrhaphy.13 The major advantages include less
postoperative pain, earlier return to normal activities and
work, better cosmetic results and cost effectiveness.14,15
Laparoscopic inguinal hernia repair is a technically
demanding procedure. A learning curve of at least 40
cases is necessary to reduce the rate of complications and
recurrences.16 It is currently thought that all recurrences
appear within the first 2 years of follow-up. One of the
ways to shorten the learning curve and minimize the
recurrence rate is to refine the techniques in a major
centre. Historically, cost analysis favoured open hernia
repair over laparoscopy. However, with more than a
decade of experience in laparoscopic hernia repairand the
dissemination of knowledge to all centres, costs have
fallen and are now comparable to open repair.17,18
Intraoperative major complications are rarely seen in
hernia surgery unless the surgeon is not well oriented to
inguinal anatomy. A more common intraoperative
complication encountered with TEP/TAPP is injury to the
bladder (0%-0, 2%), mainly in patients with previous
suprapubic surgery. Studies on TEP/TAPP report
intraoperative bowel injury in 0% to 0,3% of cases, with
rates of 0% to 0,06% in large investigations involving
considerably more than 1000 patients, and damage to
major vessels at rates of 0% to 0,11%.19 In this study
authors did not encounter any major intraoperative
complications.
The mean operative time in this study was 46.9 minutes
ranging from 31 to 76 minutes. Initially in the first 40
cases, the operative time was slightly longer. With
Mir IS et al. Int Surg J. 2018 Mar;5(3):1016-1020
International Surgery Journal | March 2018 | Vol 5 | Issue 3 Page 1019
increasing experience, the mean operative time was
reduced. Authors attribute the reduction in the mean
operative time to increasing surgeon experience and easy
handling of the 3D mesh. The mean duration of surgery
was 55 minutes for bilateral hernia repair, and 38 minutes
for unilateral hernia repair.20
Average mesh fixation time in this study was 12.6
minutes. Lacking a standard definition, authors defined
mesh fixation time in this study as the time from insertion
to the placement of mesh over the defect. The 3D mesh
because of its configuration was found to be easier to
handle thereby reducing intraoperative time, after all a
flat sheet of mesh is not an ideal configuration for
laparoscopic repair as the inguinal anatomy is anything
but the two-dimensional image as seen on the monitor
thus the 3D configuration of the mesh which is
anatomically formed and shaped to the inguinal anatomy
is ideal thus making us recommend the 3D mesh to be
used by surgeons especially beginners to minimize the
stress.21 Also a major advantage of laparoscopic hernia
repair is in cases of bilateral inguinal hernias, where
laparoscopy allows for both hernias to be repaired in a
single operation without need for additional ports or
incisions.22
Severe postoperative pain was noted in 1.62% of patients
in this study as assessed by VAS scale The lower
incidence of severe post-operative pain in this study can
be attributed to the fact that pain is a subjective feeling,
as the pain thresholds varies among various subjects, so
what can be a painful stimulus for one individual may not
be perceived as painful by the other.23 A3D mesh
eliminates the need to fix the mesh either with sutures or
tacks in TEP as is needed with a flat mesh thereby
avoiding nerve entrapment.24 The reduced post-operative
pain noted in this study has been verified by studies.25,26
Mean hospital stay in this study was 1 day. The shorter
hospital stay in this study was found to be because of less
postoperative pain and early ambulation. Almost all the
patients in this study were discharged from the hospital
on 1st postoperative day that is comparable to the study
found 88.67% patients were discharged with in 24 hour
of surgery.27
Seroma developed in 4.06% patients in this study. In the
study, it was using 3D mesh in laparoscopic hernia repair
found seroma of 3.77% of patients.27 Results of this study
were comparable with this study. All patients who
developed seroma postoperatively in this study were
managed successfully with conservative management.
Authors did not encounter any wound infection or
hematoma formation in this study. There was no
mortality in this study after 12 months of mean follow up.
The best outcome factor for any hernia repair is the
recurrence. In this study authors found recurrence in 01
(0.81%) patient after 12 months of mean follow up. Mir
IS et al. in their study found a recurrence rate of 0% after
3 months of follow up.27 Bell et al. in their study found a
recurrence rate of 0.42% after 23 months of follow up.28
The results of this study are not truly comparable to
previous studies as recurrence is a late phenomenon
which can be best determined by further long term
follow-up studies.27,28
Lastly, 3D mesh was found to be slightly costly in this
study as is evident by the fact that 3D mesh costs twice as
that of the flat mesh. However, elimination of tacks for
fixation and shorter hospital stay may compensate for the
increased cost of the 3D mesh.
CONCLUSION
Laparoscopic inguinal mesh hernioplasty using 3D mesh
is a viable alternative of hernioplasty with minimal post-
operative pain and recurrence and using 3D mesh has a
technical advantage of easy insertion in an anatomically
correct position with minimal fixation. However due to
lack of long term data, further studies are needed to
recommend 3D mesh as a potential ideal mesh for
laparoscopic inguinal hernia repairs. Further, the cost of
hernia repair using 3D mesh could be brought down by
the elimination of fixation devices.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee
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Cite this article as: Mir IS, Rashid T, Mir IN, Nazir
S, Ali I, Haq MU. Laparoscopic totally
extraperitoneal repair of inguinal hernia using three-
dimensional mesh: a 5 years experience at a tertiary
care hospital in Kashmir, India. Int Surg J
2018;5:1016-20.
