Mesh fixation versus non-fixation in laparoscopic inguinal hernia repair: absolute burden and clinical relevance of chronic pain - a systematic review and meta-analysis of randomized controlled trials.

Authors

Gustavo Magalhães Albuquerque, Victoria Frasson, Lorraine Michelle da Silva de Almeida, Leticia Hanna Moura Silva Gattas Graciolli, Raquel Nogueira, Flavio Malcher, Leandro Totti Cavazzola, Diego Laurentino Lima

Published in

Hernia : the journal of hernias and abdominal wall surgery. Volume 31. Issue 1. Nov 12, 2026. Epub Nov 12, 2026.

Abstract

Mesh fixation has long been standard practice in laparoscopic inguinal hernia repair (L-IHR), but its necessity remains debated, as fixation devices may contribute to chronic groin pain and increased costs without a clear benefit in mesh stability. While non-fixation is now widely regarded as a safe default, the absolute magnitude and clinical relevance of the pain attributable to fixation remain poorly quantified. This systematic review and meta-analysis aimed to compare mesh fixation versus non-fixation in adults undergoing L-IHR and to quantify the absolute burden of chronic pain associated with fixation.
A comprehensive online search was conducted across databases (PubMed/MEDLINE, EMBASE, and Cochrane Library) from inception to March 31, 2026. Additionally, a citation reference search was performed to identify further relevant studies. Randomized controlled trials (RCTs) exclusively comparing mesh fixation versus non-fixation in adults undergoing L-IHR were included, with no language restrictions. The primary outcomes were chronic pain, postoperative pain, surgical site infection (SSI), seroma formation, and hernia recurrence. Secondary outcomes included time to resume normal activities, length of stay (LOS), operative time (OT), and procedural cost. Meta-analysis was performed using Review Manager (RevMan) version 5.4, and heterogeneity was assessed using I² statistics. Certainty of evidence was assessed with the GRADE approach.
A total of 4,826 records were identified, and 28 RCTs comprising 3,702 patients were included, 16 evaluating the totally extraperitoneal (TEP) and 12 the transabdominal preperitoneal (TAPP) technique. Postoperative pain consistently favored non-fixation at all timepoints in both techniques (TEP: SMD, 0.3 to 0.8; TAPP: SMD, 0.8 to 2.3; all P ≤ 0.04). Chronic pain differed by technique: fixation showed no significant excess in TEP (RR, 1.3; 95% CI, 0.9 to 1.9) but a higher incidence in TAPP (RR, 5.9; 95% CI, 1.6 to 21.7; NNTH, 9); this TAPP estimate was not robust to the exclusion of one or two trials, and no significant excess was observed in trials that assessed chronic pain at six months or later (TEP: RR, 1.4; 95% CI, 0.7 to 2.9; TAPP: RR, 2.0; 95% CI, 0.4 to 9.8). When six-month pain scores were re-expressed on a 0-10 scale, the pooled difference was approximately 0.6 points (95% CI, 0.4 to 0.8), below thresholds of clinical importance proposed for acute and chronic pain, although no threshold has been validated for chronic post-herniorrhaphy pain. No difference was observed in surgical site infection (SSI), seroma formation, or hernia recurrence (all P > 0.05). Return to normal activities favored non-fixation in TAPP (MD, 2.2 days; P < 0.00001), with a borderline effect in TEP that did not reach significance (MD, 0.8 days; P = 0.05). Operative time (OT) was longer with fixation by approximately 4.3 min, with no difference between techniques (MD, 4.3 min; P < 0.0001). Length of stay (LOS) favored non-fixation in TAPP (MD, 0.6 days; P < 0.00001) but not in TEP. Total procedural costs were higher with fixation in all six trials reporting them, with unweighted mean differences of US$542 (range, 303 to 852) in TEP and US$591 (range, 503 to 704) in TAPP, derived from heterogeneous health-care settings. Certainty of evidence ranged from very low to moderate.
In L-IHR, mechanical fixation was associated with greater postoperative pain than non-fixation, with a small pooled difference at six months, while SSI, seroma, and hernia recurrence showed no evidence of a difference between groups, although the estimates for SSI and recurrence were imprecise. An excess of chronic pain with fixation was observed in TAPP but not in TEP; this signal was not robust in sensitivity analyses, and no significant excess was observed in trials that assessed chronic pain at six months or later. Fixation also prolonged OT by a few minutes and added procedural cost, while non-fixation conferred faster recovery and shorter stay in TAPP. Non-fixation remains the approach recommended by current guidelines for most hernia types, with fixation reserved for large medial defects; these data quantify, rather than justify, the pain, time, and cost associated with departing from that default. The certainty of the evidence ranged from very low to moderate.
PROSPERO CRD420261419247.

PMID:
43018797
Bibliographic data and abstract were imported from PubMed on 13 Nov 2026.

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