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Surgical Endoscopy

, Volume 30, Issue 10, pp 4363–4371 | Cite as

When is mesh fixation in TAPP-repair of primary inguinal hernia repair necessary? The register-based analysis of 11,230 cases

  • F. Mayer
  • H. Niebuhr
  • M. Lechner
  • A. Dinnewitzer
  • G. Köhler
  • M. Hukauf
  • R. H. Fortelny
  • R. Bittner
  • F. Köckerling
Open Access
Article

Abstract

Whereas for TEP the guidelines do not recommend mesh fixation on the basis of meta-analyses regardless of the defect size, for TAPP mesh fixation can be omitted only up to a defect size of 3 cm because of the paucity of studies on this topic. Hence, this study now seeks to explore this subject on the basis of prospective data from the Herniamed Hernia Registry. In the period September 01, 2009, to January 31, 2014, 11,228 male patients were operated on with the TAPP technique for a primary unilateral inguinal hernia and were followed up for 1 year. Mesh fixation was used for 7422 (66.1 %) of these patients and no mesh fixation for 3806 patients (33.9 %). Unadjusted analysis did not find any significant difference in the recurrence rate (0.88 % with fixation vs. 1.1 % without fixation; p = 0.259). Multivariable analysis of all potential influence factors (age, ASA, BMI, risk factors, defect size, mesh fixation, localization of defect, mesh size) did not identify any factor that impacted recurrence on 1-year follow-up. Only for medial and combined defect localization versus lateral localization was a highly significant effect identified (p < 0.001). With mesh fixation and larger mesh size, it was possible to significantly reduce the recurrence rate for larger medial hernias in this series (p = 0.046). For TAPP repair of an inguinal hernia, mesh fixation is not necessary in a significant number of patients. Patients with a medial and combined hernia are at higher risk of recurrence. In the patient series analyzed, it was possible to significantly reduce the recurrence rate with mesh fixation and larger mesh size for medial defects.

Keywords

Inguinal hernia TAPP Mesh fixation Medial hernia Recurrence 

The longstanding standard practice for TAPP was to use mesh fixation with tackers to prevent recurrence [1]. But atraumatic mesh fixation fibrin sealants are being increasingly employed to prevent chronic pain in the wake of traumatic fixation methods [2]. Numerous studies have attested to the excellent results in terms of the recurrence rate achieved with fibrin sealants for atraumatic mesh fixation [3, 4, 5, 6]. Comparative studies then explored, in particular for the total extraperitoneal patchplasty (TEP), whether mesh fixation could be completely dispensed with [7, 8]. In the guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia of the International Endohernia Society (IEHS), a statement with level of evidence 1 B pointed out that fixation and non-fixation of the mesh were associated with equally low recurrence rates in both TAPP and TEP [9]. However, in most studies the hernia opening was small (<3 cm) or not measured [9]. Therefore, the guidelines recommended that when using TAPP or TEP techniques non-fixation could be considered for types L I, II, and M I, II hernias (EHS classification) [9]. For TAPP and TEP repair of big defects (L III, M III), the mesh should be fixed [9]. In an update of the Guidelines of the International Endohernia Society, ten new studies with evidence level 1 have been included. For TEP, with evidence level 1 A, these stated that fixation and non-fixation of the mesh in TEP were associated with an equal risk of recurrence [10]. For TAPP, the recommendations remained unchanged. Hence, in the case of TAPP it remained unclear whether mesh fixation was needed to prevent recurrence, at least for defect sizes >3 cm (EHS classification L III, M III). Therefore, this paper now seeks to explore this subject on the basis of prospective data of the Herniamed Hernia Registry.

Patients and methods

As of March, 19, 2015, 426 participating hospitals and office-based surgeons mainly from Germany, Austria, and Switzerland had entered prospective data into the multicenter internet-based Herniamed Hernia Registry on their patients who had undergone hernia surgery [11]. This present study analyzed the prospective data collected for all male patients who had been operated on with an endoscopic TAPP technique for repair of a primary unilateral inguinal hernia in the period September 01, 2009, up to and including January 31, 2014. On 1-year follow-up, the general practitioner and patients were asked by questionnaire about any recurrences. Only those patients for whom 1-year follow-up results were available were included in the analysis. Other inclusion criteria included: age >16 years and medial/lateral/combined types of inguinal hernia based on the EHS classification [12]. In total, 11,228 patients were included in uni- and multivariate analysis for investigation of the impact of mesh fixation as well as of other potential influence factors impacting onset of a recurrence during the 1-year follow-up of TAPP operation. Details of all enrolled patients regarding the documented hernia defect size are given in Table 1 and of the fixation method in Table 2. During the observation period, 7422 patients (66.1 %) were operated on while using mesh fixation and 3806 patients (33.9 %) without mesh fixation.
Table 1

Distribution of defect size and fixation/non-fixation

 

Size of defect

Total

I (<1.5 cm)

II (1.5–3 cm)

III (>3 cm)

 

n

%

n

%

n

%

n

%

Mesh fixation

852

56.76

4652

62.91

1918

82.25

7422

66.10

No mesh fixation

649

43.24

2743

37.09

414

17.75

3806

33.90

Total

1501

100.00

7395

100.00

2332

100.00

11,228

100.00

Table 2

Distribution of defect size in the group with mesh fixation and fixation type

 

Size of defect

Total

I (<1.5 cm)

II (1.5–3 cm)

III (>3 cm)

n

%

n

%

n

%

n

%

Type of fixation

 Suture

121

14.20

760

16.34

446

23.25

1327

17.88

 Tacker

393

46.13

2219

47.70

956

49.84

3568

48.07

 Glue

331

38.85

1607

34.54

468

24.40

2406

32.42

 Combination

7

0.82

66

1.42

48

2.50

121

1.63

Total

852

100.00

4652

100.00

1918

100.00

7422

100.00

All analyses were performed with the software SAS 9.2 (SAS institute Inc., Cary, NY, USA) and intentionally calculated to a full significance level of 5 %, i.e., they were not corrected in respect of multiple tests, and each p value ≤ 0.05 represents a significant result. Unadjusted analyses were carried out to analyze how any individual influence variable affected an outcome parameter. For categorical target (outcome) variables, Fisher’s exact test was applied. For continuous target variables that followed the normal distribution, the robust t test (Satterthwaite) was used.

To eliminate the effect of any confounders arising from different characteristics related to the patient or surgical technique, the results of unadjusted analysis were verified once again in multivariable analysis. In addition to fixation (yes/no), it was also possible to simultaneously review all the other influence factors.

The binary regression model for dichotomous target variables was used to identify the influence of the various factors in multivariable analysis. Odds ratios (OR) and corresponding 95 % confidence intervals based on the Wald test are given for estimates. For influence variables with more than two categories, one of these values was used in each case as a reference category. For the continuous variable age (years), the 10-year odds ratio is given, for BMI (kg/m2) a five-point odds ratio, and for mesh size the ten-point odds ratio. The results are sorted on the basis of influence and presented in tabular form.

Results

Unadjusted results

Unadjusted analysis of the groups compared, i.e., TAPP with versus without mesh fixation, revealed, in some cases, significant differences in the patient characteristics and hernia findings (Table 3). The patients in the mesh fixation group were significantly older (57.4 years ± 14.8 vs. 54.4 years ± 15.7 [mean ± STD], p < 0.001), and larger meshes were used (151.1 cm2 ± 19.3 vs. 145.8 cm2 ± 15.6 [mean ± STD], p < 0.001). For large hernia defects (EHS III), the mesh was fixed significantly more often (82.2 % with mesh fixation vs. 17.8 % without mesh fixation) (Table 1). Likewise, for a medial hernia the implanted mesh was fixed significantly more often (30.8 % with mesh fixation vs. 24.9 % without mesh fixation; p < 0.001) (Table 3). A clear difference was identified between the two groups with regard to the presence of at least one risk factor (p = 0.011). A large proportion, at 25.8 %, of patients without mesh fixation had at least one relevant risk factor compared with those without mesh fixation, at 23.6 % (p = 0.001). That was also true for nicotine abuse (12.4 % without mesh fixation vs. 8.7 % with mesh fixation; p < 0.001).
Table 3

Demographic and surgery-related data

 

Mesh fixation

No mesh fixation

p

Age (years)

Mean ± STD

57.4 ± 14.8

54.4 ± 15.7

<0.001

BMI (kg/m²)

Mean ± STD

25.9 ± 3.4

25.9 ± 3.3

0.573

Mesh size (cm²)

Mean ± STD

151.1 ± 19.3

145.8 ± 15.6

<0.001

 

n (7422)

%

n (3806)

%

p

ASA

 I

2601

35.04

1282

33.68

0.027

 II

3994

53.81

2037

53.52

 III/IV

827

11.14

487

12.80

Defect size (EHS)

 I (<1.5 cm)

852

11.48

649

17.05

<0.001

 II (1.5–3 cm)

4652

62.68

2743

72.07

 III (>3 cm)

1918

25.84

414

10.88

Localization of defect (EHS)

 Medial (M)

2285

30.79

948

24.91

<0.001

 Lateral (L)

4477

60.32

2298

60.38

 Combined (C)

660

8.89

560

14.71

Risk factors

Overall

 Yes

1749

23.57

980

25.75

0.011

 No

5673

76.43

2826

74.25

COPD

 Yes

321

4.32

196

5.15

0.051

 No

7101

95.68

3610

94.85

Diabetes

 Yes

318

4.28

164

4.31

0.961

 No

7104

95.72

3642

95.69

Aortic aneurysm

 Yes

22

0.30

9

0.24

0.705

 No

7400

99.70

3797

99.76

Immunosuppression

 Yes

34

0.46

14

0.37

0.544

 No

7388

99.54

3792

99.63

Corticoids

 Yes

50

0.67

23

0.60

0.711

 No

7372

99.33

3783

99.40

Smoking

 Yes

643

8.66

470

12.35

<.001

 No

6779

91.34

3336

87.65

Coagulopathy

 Yes

74

1.00

37

0.97

1.000

 No

7348

99.00

3769

99.03

Antiplatelet medication

 Yes

525

7.07

206

5.41

<0.001

 No

6897

92.93

3600

94.59

Cumarin medication

 Yes

133

1.79

52

1.37

0.100

 No

7289

98.21

3754

98.63

Demographic parameters (Table 3) are demonstrated in relation to fixation/non-fixation and include the age of the patients (years), BMI (kg/m2), size of the mesh implant (cm2), ASA score (I–IV), size of the hernia defect (EHS I–III), localization of the hernia defect (medial-M/lateral-L/combined-C; EHS classification), and hernia-specific risk factors

Unadjusted analysis of the relationship between mesh fixation and non-fixation for TAPP did not reveal any significant difference in the recurrence rate on 1-year follow-up (Table 4). The recurrence rate was 0.9 % in the mesh fixation group and 1.1 % in the non-fixation group (p = 0.259).
Table 4

Unadjusted analysis of the recurrence rates on 1-year follow-up

 

Mesh fixation

No mesh fixation

p

 

n

%

n

%

Recurrent hernia (1-year follow-up: 100 %)

 Yes

65

0.88

42

1.10

0.259

 No

7357

99.12

3764

98.90

 

Multivariable analysis

In this multivariable analysis (Table 5), all potential influence factors were reviewed with regard to onset of a recurrence. No relevant influence was identified for mesh fixation compared with non-fixation (p = 0.399). That was also true for the defect size (p = 0.383), with no significant difference observed on comparing defect sizes >3 cm (EHS classification III) with sizes <1.5 cm (EHS classification I) and 1.5–3 cm (EHS classification II). Nor did the mesh size have any significant impact on onset of recurrence. For the patient-related influence factors such as age, ASA score, BMI value, the risk factors COPD, and smoking as well as the other risk factors, multivariable analysis did not identify any effect on onset of recurrence. The only factor that had a highly significant impact on recurrence was hernia localization (p < 0.001). Whereas a lateral hernia was associated with a lower probability of onset of recurrence, a medial inguinal hernia and a combined hernia with a medial portion presented a highly significantly higher risk for onset of recurrence (p < 0.001). With a prevalence of 0.9 % for the entire patient collective, this would correspond to five recurrences for every 1000 operations of hernias with lateral EHS localization compared with 11 recurrences for patients with medial EHS localization. Hence, medial and combined hernias constitute a highly significant risk factor for onset of recurrence following TAPP, but that was not true for patient-related factors, hernia size, and mesh non-fixation.
Table 5

Multivariable analysis of recurrence (model fit: p = 0.004)

Parameter

p value

Variables

OR

95 %-CI

Localization of defect (EHS)

<0.001

Combined versus medial

1.137

0.656

1.970

Lateral versus medial

0.463

0.303

0.707

Risk factors: COPD/smoking

0.097

Yes versus no

0.556

0.278

1.111

BMI (five-point OR)

0.109

 

1.240

0.953

1.613

Size of mesh (ten-point OR)

0.192

 

0.929

0.832

1.038

Size of defect (EHS)

0.383

I (<1.5 cm) versus III (>3 cm)

1.330

0.694

2.546

  

II (1.5–3 cm) versus III (>3 cm)

0.914

0.558

1.499

Fixation of mesh

0.399

No fixation versus fixation

1.194

0.791

1.800

Risk factors (others)a

0.408

Yes versus no

1.269

0.721

2.234

ASA

0.720

II versus I

1.106

0.683

1.791

III/IV versus I

1.352

0.650

2.812

Age [10-year OR]

0.869

 

1.013

0.868

1.183

aRisk factors (others): immunosuppression, antiplatelet medication, coagulopathy, diabetes, corticoids, anticoagulation, aortic aneurysm

Subgroup analysis

If, in view of the results of multivariable analysis, one compares the recurrence rates in unadjusted analysis in relation to the EHS localization, highly significant differences unfavorable to medial and combined hernias are seen (Table 6). If one then checks the role of fixation in the medial inguinal hernia group, which is at higher risk of recurrence, one notes that it was possible to significantly reduce the recurrence rate with mesh fixation (Table 7). No significant difference was found in the recurrence rate between the various fixation techniques (tacker, glue, suture, combination) (Table 8). In addition, where mesh fixation was used to repair medial inguinal hernias, a significantly larger mesh size was used (Table 9). Besides, analysis of the meshes used for at least 5 % of medial inguinal hernias demonstrated significant differences (Table 10). For example, one notable finding was that in the group with no mesh fixation a greater number of self-adhesive, titanized, and 3D standard meshes were used (Table 10). Since the medial sac reduction is not documented in the Herniamed Registry, no conclusions on its implications can be drawn from the data presented here.
Table 6

Comparision of recurrence rates depending on EHS localization

 

Medial

Lateral

Combined

p

 

n

%

n

%

n

%

 

Recurrence

 Yes

44

1.36

44

0.65

19

1.56

<0.001

 No

3190

98.64

6732

99.35

1201

1.56

 
Table 7

Comparision of recurrence rates in TAPP with and without mesh fixation in medial inguinal hernias

 

Mesh fixation

No mesh fixation

p

 

n

%

n

%

 

Recurrence

 Yes

25

1.09

19

2.00

0.046

 No

2260

98.91

929

98.00

Table 8

Comparision of recurrence rates in TAPP with mesh fixation depending on type of fixation in medial inguinal hernias

 

Suture

Tacker

Glue

Combined

p

n

%

n

%

n

%

n

%

 

Recurrence

 Yes

4

0.97

16

1.34

5

0.79

0

0

0.746

 No

407

99.03

1182

98.66

627

99.21

44

100.00

 
Table 9

Comparision of mesh sizes in TAPP with and without mesh fixation in medial inguinal hernias

  

Fixation

p

Mesh fixation (n = 2285)

No Mesh fixation (n = 948)

Mesh size (cm2)

Mean ± STD

151.0 ± 21.1

145.2 ± 19.0

<0.001

Table 10

Comparision of meshes used in TAPP with and without mesh fixation in medial inguinal hernias

 

Mesh fixation

No mesh fixation

p

 

n

%

n

%

Type of meshes

 Other <5 %

1079

47.22

416

43.88

<0.001

 Ultrapro

604

26.43

80

8.44

 Parietene ProGrip

6

0.26

186

19.62

 TiMesh light

184

8.05

107

11.29

 3DMax Light Mesh

61

2.67

135

14.24

 Optilene Mesh LP

351

15.36

24

2.53

Discussion

This present analysis of data from the Herniamed Hernia Registry compared the recurrence rates on 1-year follow-up in respect of mesh fixation versus non-fixation in TAPP. Univariable analysis did not find any significant difference between these two parameters. However, since there were significant differences between the two groups in terms of their demographic and surgery-related data, multivariable analysis was performed to identify the influence factors that significantly impacted the recurrence rate on 1-year follow-up. The latter revealed that for TAPP, too, mesh fixation did not have any relevant impact on the recurrence rate regardless of the defect size. A similar conclusion was reported by a prospective randomized trial that compared 273 TAPP operations with mesh fixation versus 263 without mesh fixation [13].

Nor did multivariable analysis find any evidence that age, ASA score, BMI value, or patient-related risk factors exerted any influence on onset of recurrence. Here it must be pointed out that unlike one systematic review [14], no effect on recurrence rate was identified for patients with either COPD or nicotine abuse.

The only highly significant factor impacting onset of recurrence following TAPP for primary unilateral inguinal hernia repair in men was a medial or combined hernia based on the EHS classification. That finding was also confirmed in the systematic review by Burcharth et al. [14] which found that a direct inguinal hernia was found to be a risk factor for recurrence with a pooled RR of 1.91 (95 % CI 1.62–2.36; p < 0.001).

Unlike a lateral inguinal hernia, where the peritoneal hernia sac is removed from the inguinal canal and the inguinal canal closes curtain-like, additional surgical measures are necessary taken to repair the hernia defect for the medial inguinal hernia [9, 15, 16, 17, 18, 19]. The content of the direct hernia cavity, generally composed of preperitoneal fat, is dissected out, leaving the hernia cavity as a rigid outpouching of the transversalis fascia. Consequently, there is a higher risk of seroma for medial inguinal hernias following endoscopic repair [9, 15, 16, 17, 18, 19]. This medial hernia cavity is at also greater risk of recurrence since it represents more a bridging situation compared with the lateral inguinal hernia. Therefore, the requirements for adequate overlap are more stringent.

It is crucial when using an endoscopic technique (TEP, TAPP) to repair medial inguinal hernia that “complete medial sac reduction” be performed to avoid onset of seroma or recurrence. Since the lining of the medial hernia cavity is formed by the transversalis fascia outpouching, the latter is clasped and pulled inwards until the space is completely reduced (“complete medial sac reduction”) [9, 15, 16, 17, 18, 19]. Next, the transversalis fascia that has been pulled inwards is now either fixed with a suture to Cooper’s ligament or blocked off with a Roeder loop [18, 19]. The utmost attention should be paid to this technical step of “complete medial sac reduction” in both TAPP and TEP since it serves to prevent seromas as well as recurrence.

Moreover, in this situation it may be necessary to use a mesh size of 17 × 12 cm instead of the standard size of 15 × 10 cm. For example, analysis of the subgroup of medial inguinal hernias in the Herniamed Registry did indeed reveal that in the mesh fixation group significantly larger size meshes were used. By contrast, in the group with no mesh fixation a greater number of self-adhesive, titanized and 3D standard meshes were also used. The data presented here also demonstrate that for larger medial and combined hernias additional fixation of the mesh is needed using either properly placed absorbable tackers, sutures, or atraumatic fibrin sealants. The data also show that the type of fixation did not impact the recurrence rate.

In summary, it can be stated that for TAPP repair of an inguinal hernia fixation of the mesh is not needed in a significant number of patients. Patients with a medial and combined hernia are at a higher risk of recurrence. The choice of a greater mesh and “complete medial sac reduction” must be carefully made to obtain a plane inguinal region surface for mesh placement and greater mesh overlap. This helps to reduce both the recurrence and the seroma rates. The present study has demonstrated that on using mesh fixation for TAPP, regardless of whether with tacker, suture, glue, or combined, the recurrence rates for larger medial hernias were significantly lower.

Notes

Acknowledgments

Open access funding provided by Paracelsus Medical University. Ferdinand Köckerling—Grants to fund the Herniamed Registry from Johnson & Johnson, Norderstedt, Karl Storz, Tuttlingen, pfm medical, Cologne, Dahlhausen, Cologne, B Braun, Tuttlingen, MenkeMed, Munich and Bard, Karlsruhe.

Disclosures

F. Mayer, H. Niebuhr, M. Lechner, A. Dinnewitzer, G. Köhler, M. Hukauf, R. H. Fortelny, R. Bittner have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Bittner R, Leibl BJ, Jöger C, Kraft B, Ulrich M, Schwarz J (2006) TAPP-Stuttgart technique and result of a large single center series. J Minim Access Surg 2(3):155–159CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Bittner R, Gmähle E, Gmühle B, Schwarz J, Aasvang E, Kehlet H (2010) Lightweight mesh and noninvasive fixation: an effective concept for prevention of chronic pain with laparoscopic hernia repair (TAPP). Surg Endosc 24(12):2958–2964. doi: 10.1007/s00464-010-1140.9 CrossRefPubMedGoogle Scholar
  3. 3.
    Fortelny RH, Petter-Puchner AH, May C, Jaksch W, Benesch T, Khakpour Z, Redl H, Glaser KS (2012) The impact of atraumatic fibrin sealant vs. staple mesh fixation in TAPP hernia repair on chronic pain and quality of life: results of a randomized controlled study. Surg Endosc 26(1):249–254. doi: 10.1007/s00464-011-1862-3 CrossRefPubMedGoogle Scholar
  4. 4.
    Lau H (2005) Fibrin sealant versus mechanical stapling for mesh fixation during endoscopic extraperitoneal inguinal hernioplasty: a randomized prospective trial. Ann Surg 242:670–675CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Olmi S, Scaini A, Erba L, Guaglio M, Groce E (2007) Quantification of pain in laparoscopic transabdominal preperitoneal (TAPP) inguinal hernioplasty identifies marked differences between prothesis fixation systems. Surgery 142:40–46CrossRefPubMedGoogle Scholar
  6. 6.
    Lovisetto F, Zonta S, Rota E, Mazzilli M, Bardone M, Bottero L, Faillace G, Longoni M (2007) Use of human fibrin glue (Tissucol) versus staples for mesh fixation in laparoscopic transabdominal preperitoneal hernioplasty: a prospective, randomized study. Ann Surg 245:222–231CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Tam KW, Liang Hung-Hua, Chai Chiah-Yang (2010) Outcomes of staple fixation of mesh versus nonfixation in laparoscopic total extraperitoneal inguinal repair: a meta-analysis of randomized controlled trials. World J Surg 34(12):3065–3074. doi: 10.1007/s00268-010-0760-5 CrossRefPubMedGoogle Scholar
  8. 8.
    Koch CA, Greenlee SM, Larson DR, Harrington JR, Farley DR (2006) Randomized prospective study of totally extraperitoneal inguinal hernia repair: fixation versus no fixation of mesh. JSLS 10:457–460PubMedPubMedCentralGoogle Scholar
  9. 9.
    Bittner R, Arregui ME, Bisgaard T, Dudai M, Ferzli GS, Fitzgibbons RJ, Fortelny RH, Klinge U, Kockerling F, Kuhry E, Kukleta J, Lomanto D, Misra MC, Montgomery A, Morales-Conde S, Reinpold W, Rosenberg J, Sauerland S, Schug-Paß C, Singh K, Timoney M, Weyhe D, Chowbey P (2011) Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]. Surg Endosc 25:2773–2843. doi: 10.1007/s00464-011-1799-6 CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Bittner R, Montgomery MA, Arregui E, Bansal V, Bingener J, Bisgaard T, Buhck H, Dudai M, Ferzli GS, Fitzgibbons RJ, Fortelny RH, Grimes KL, Klinge U, Koeckerling F, Kumar S, Kukleta J, Lomanto D, Misra MC, Morales-Conde S, Reinpold W, Rosenberg J, Singh K, Timoney M, Weyhe D, Chowbey P (2015) Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society). Surg Endosc 29:289–321. doi: 10.1007/s00464-014-3917-8 CrossRefPubMedGoogle Scholar
  11. 11.
    Stechemesser B, Jacob DA, Schug-Paß C, Köckerling F (2012) Herniamed: an internet-based registry for outcome research in hernia surgery. Hernia 16(3):269–276. doi: 10.1007/s10029-012-0908.3 CrossRefPubMedGoogle Scholar
  12. 12.
    Miserez M, Alexandre JH, Campanelli G, Corcione F, Cuccurullo D, Pascual MH, Hoeferlin A, Kongsnorth AN, Mandala V, Palot JP, Schumpelick V, Simmermacher RK, Stoppa R, Flament JB (2007) The European hernia society groin hernia classification: simple and easy to remember. Hernia 11(2):113–116CrossRefPubMedGoogle Scholar
  13. 13.
    Smith AI, Royston CM, Sedman PC (1999) Stapled and nonstapled laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair: a prospective randomized trial. Surg Endosc 13:804–806CrossRefPubMedGoogle Scholar
  14. 14.
    Burcharth J, Pommergaard HC, Bisgaard T, Rosenberg J (2015) Patient-related risk factors for recurrence after inguinal hernia repair: a systematic review and meta-analysis of observational studies. Surg Innov 22(3):303–317. doi: 10.1177/1553350614552731 CrossRefPubMedGoogle Scholar
  15. 15.
    Lau H, Lee F (2003) Seroma following endoscopic extraperitoneal inguinal hernioplasty. Surg Endosc 17:1773–1777. doi: 10.1007/s00464-002-8771-4 CrossRefPubMedGoogle Scholar
  16. 16.
    Reddy VM, Sutton CD, Bloxham L, Garcea G, Ubhi SS, Robertson GS (2007) Laparoscopic repair of direct inguinal hernia: a new technique that reduces the development of postoperative seroma. Hernia 11:393–396. doi: 10.1007/s10029-007-0233-4 CrossRefPubMedGoogle Scholar
  17. 17.
    Choi YY, Kim Z, Hur KY (2011) Sewlling after laparoscopic total extraperitoneal repair of inguinal hernias: review of one surgeon’s experience in 1,065 cases. World J Surg 35:43–46. doi: 10.1007/s00268-010-0843-3 CrossRefPubMedGoogle Scholar
  18. 18.
    Berney CR (2012) The Endoloop technique for the primary closure of direct inguinal hernia defect during the endoscopic totally extraperitoneal approach. Hernia 16:301–305. doi: 10.1007/s10029-011-0892-z CrossRefPubMedGoogle Scholar
  19. 19.
    Köckerling F, Jacob DA, Lomanto D, Chowbey P (2012) C. R. Berny: “The Endoloop technique for the primary closure of direct inguinal hernia defect during the endoscopic totally extraperitoneal approach”. Hernia 16:493–494. doi: 10.1007/s10029-012-0920-7 CrossRefPubMedGoogle Scholar

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© The Author(s) 2016

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  • F. Mayer
    • 1
  • H. Niebuhr
    • 2
  • M. Lechner
    • 1
  • A. Dinnewitzer
    • 1
  • G. Köhler
    • 3
  • M. Hukauf
    • 4
  • R. H. Fortelny
    • 5
  • R. Bittner
    • 6
  • F. Köckerling
    • 7
  1. 1.Department of SurgeryParacelsus Medical UniversitySalzburgAustria
  2. 2.Hanse Hernia CenterHamburgGermany
  3. 3.Department of General and Visceral SurgerySisters of Charity HospitalLinzAustria
  4. 4.StatConsult GmbHMagdeburgGermany
  5. 5.Department of General, Visceral and Oncological SurgeryWilhelminenspitalViennaAustria
  6. 6.Hernia CenterWinghofer MedicumRottenburg am NeckarGermany
  7. 7.Department of Surgery and Center of Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical SchoolVivantes Hospital SpandauBerlinGermany

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