A hernia of the inguinal canal is the result of the contents of the abdominal cavity being forced out through the inguinal canal. There are 75% of all abdominal wall hernias that are inguinal hernias, and the lifetime chance of developing an inguinal hernia is 27% for males and 3% for women. Symptoms are present in about 66% of affected individuals.  The etiology of inguinal hernia formation is a combination of genetic, environmental, and metabolic factors, along with individual patient factors such as activity level, immune status, infection, medication, personal habits, and changes in body mass index.  

Repair of inguinal hernias is one of the most commonly performed surgical procedures globally. Laparoscopic inguinal hernia repair began in the early 1990s as laparoscopy became more prevalent in general surgery.  Recurrence has historically been a significant issue following inguinal hernia repairs. However, the routine use of prosthetic mesh in these procedures has substantially reduced recurrence rates, bringing them down to 1-2%..  The transabdominal pre-peritoneal (TAPP) repair is an acceptable and safe method for repairing inguinal hernias, providing an alternative to open mesh repair. It offers several advantages, including less trauma, fewer early complications, and quicker postoperative recovery. Other benefits include reduced postoperative pain, diminished need for narcotics, and earlier return to work.

 An inguinal hernia can be repaired with TAPP by employing spiral tacks to secure the mesh to the abdominal wall. This is the traditional method of performing the procedure. On the other hand, mesh fixation might not be required because there is not much room for the mesh to move around, and tack fixation can put patients at risk for experiencing postoperative pain.

The results of a randomized control trial, which included seventy men who underwent inguinal or femoral hernia repair, revealed that the mean postoperative pain score at days 1, 2, 3, 4, 5, 6, and 7 was 5.54 ± 1.68, 4.74 ± 1.77, 3.29 ± 1.60, 2.37 ± 1.71, 1.97 ± 2.25, 1.49 ± 1.65, and 0.80 ± 1.05, respectively, in the tacker group. In contrast, the scores for the vicryl group were 4.63 ± 1.59, 3.34 ± 1.90, 2.69 ± 1.65, 1.86 ± 1.66, 1.46 ± 2.00, 0.89 ± 1.43, and 0.49 ± 0.91, respectively, in the vicryl group (p<0.05), indicating that the vicryl group experienced less pain than the tacker group.

Although both vicryl and tacker are used in TAPP repair to anchor the mesh, literature on their use in terms of postoperative pain score is scarce both internationally and locally. Therefore, I aim to conduct this study to determine the advantages of vicryl over tacker in terms of pain. If the study shows better results with vicryl, this technique will be recommended for future use to improve patient outcomes.

The primary aim of this study was to compare post-operative pain levels between the use of tacker and vicryl for mesh fixation in transabdominal pre-peritoneal (TAPP) laparoscopic inguinal hernia repair. Pain was assessed using the Visual Analogue Scale (VAS), a commonly used pain measurement tool. This study seeks to determine which method of mesh fixation results in less post-operative pain for patients undergoing TAPP laparoscopic inguinal hernia repair. Post-operative pain was assessed at 8 hours, on day 1, and on day 2 post-operatively. Standard TAPP repair was performed for inguinal hernia repair. The diagnosis was established through a comprehensive history and clinical examination, which included a crucial assessment of the inguinal swelling in both standing and lying positions.A cough test, where patients were asked to cough and any resultant bulge in the inguinal region was noted, was used to confirm the presence of an inguinal hernia. It was hypothesized that pain would be less in the vicryl 2/0 group compared to the tacker Xn TAPP laparoscopic inguinal hernia repair. This study was a randomized controlled trial conducted in the Department of General Surgery at Jinnah Postgraduate Medical Centre (JPMC), Karachi, over six months from April 11, 2019, to October 11, 2019. For a confidence interval of 95% and a power test of 90%, each group needs at least 37 patients, totaling 74 patients for the study. This ensures a robust comparison of mean pain severity at day 2, with the study group averaging 4.74 ± 1.77 and the control group 3.34 ± 1.90. Male patients aged 20-60 years diagnosed with inguinal hernia for more than one month were enrolled. Patients with complications of inguinal hernia (irreducible, obstructed, and strangulated) or a past history of pelvic surgery were excluded. Patients meeting the inclusion criteria were enrolled through the Surgery Department OPD at JPMC, Karachi. They were admitted and operated upon after obtaining anesthesia fitness, ethical approval, and informed written consent. The study included patients undergoing inguinal hernia repair, divided into two groups. Group 1 (study group) had mesh fixation with tacker, while Group 2 (control group) had mesh fixation with vicryl 2/0. All patients received standard TAPP laparoscopic inguinal hernia repair, performed by a surgical team led by a consultant with at least five years of post-fellowship experience. Post-operative pain was assessed using the VAS at 8 hours after surgery, and on days 1 and 2, with the final outcome assessed on day 2. A database was developed using SPSS software. Quantitative Analysis was done for age, height, weight, BMI, duration of inguinal hernia, and post-operative pain scores at 8 hours, day 1, and day 2. Qualitative analysis was done for gender. The two groups were compared for mean post-operative pain using the student t-test. Effect modifiers were controlled through stratification to assess their effect on the outcome variable.

Divided into two groups, the study comprised 74 patients having transabdominal preperitoneal (TAPP) laparoscopic hernia repairs: X, where mesh fixation was done with a tacker, and Y, where fixation was done with vicryl 2/O. X comprised 37 subjects, with a nearly equal distribution of males (25.7%) and females (24.3%), and a mean age of 40.918 years. Y also had 37 patients, with slightly more males (27%) than females (23%), and a slightly lower mean age of 35.567 years. The overall mean age across both groups was 40.243 years.

In terms of physical characteristics, Y had a slightly higher mean height (160.243 cm) and mean weight (69.135 kg) compared to X (154.810 cm and 67.891 kg, respectively). However, the mean BMI was slightly higher in X (27.897 kg/m²) compared to Y (26.596 kg/m²). Y also had a longer mean duration of inguinal hernia (5.945 months) compared to X (4.270 months), resulting in an overall mean duration of hernia of 5.108 months.

Post-operative pain scores were assessed at 8 hours, 1 day, and 2 days after the procedure. Group Y consistently exhibited lower mean pain scores at all time points compared to Group X, with statistically significant differences observed at 8 hours and 1 day.

Table-1 Age and gender Distribution with respect to groups

Table-2 Weight, height and BMI with respect to groups

Table-3 Comparison of mean pain score at 8 hours 8 hours, 1 day and 2 days between two groups:(n=74)

The stratification of mean pain scores at 8 hours, 1 day, and 2 days between the two groups with respect to different variables provides valuable insights into the outcomes of the study.

Age: No significant difference in pain scores was observed between age brackets (20-40 years and 41-60 years), suggesting age does not affect postoperative pain outcomes.

Gender: While there was no significant difference in pain scores at 8 hours post-surgery between males and females, at 2 days, males experienced slightly higher pain scores. This suggests a minor gender influence on later-stage recovery pain outcomes.

BMI: Pain scores did not significantly differ between BMI categories (17-30 kg/m2 and 30.01-40 kg/m2), indicating BMI does not impact postoperative pain outcomes.

Duration of Inguinal Hernia: Pain scores showed no significant difference based on the duration of inguinal hernia (1-7 months and 8-14 months), indicating no significant impact on postoperative pain outcomes. Overall, while there are some minor variations in postoperative pain scores based on gender, the age, BMI, and duration of inguinal hernia do not appear to significantly influence postoperative pain outcomes following TAPP laparoscopic inguinal hernia repair. This suggests that factors other than these variables may play a more substantial role in determining postoperative pain levels in this patient population.

Laparoscopic repair, nylon darn, Shouldice multilayer, and Lichtenstein mesh are some of the surgical procedures that are considered to be the most effective treatment options.1, The inguinal hernia repair procedure that is performed using the laparoscopic approach has gained significant recognition among both surgeons and the patients they treat as a result of substantial advancements in laparoscopic surgery. This minimally invasive technique is associated with a number of advantages, including a lower level of postoperative pain and discomfort, which can significantly enhance patient recovery. Additionally, the laparoscopic approach allows for smaller incisions, leading to less scarring and a lower risk of wound infections compared to the traditional open repair method. One of the most notable benefits is the faster recovery time, which enables patients to return to their normal activities and work earlier. This early return to daily routines and employment can have positive economic implications for patients and reduce the overall burden on healthcare systems. Consequently, the laparoscopic method has become a preferred choice for many healthcare professionals and patients seeking effective and efficient treatment for inguinal hernias. The specific laparoscopic surgery employed in this investigation was TAPP, an acronym for transabdominal preperitoneal hernia repair. This technique involves the fixation of a synthetic mesh to the front part of the abdominal wall. This is accomplished by positioning the mesh behind a peritoneal flap, which effectively hinders the mesh from sticking to the internal organs. The prevailing technique for securing the mesh in this treatment involves using titanium tackers on the surface between the suprainguinal abdominal wall layers. Mesh fixation is an essential element of the operation, as it guarantees the stability and efficacy of the hernia repair. Nevertheless, it is crucial to acknowledge that this action has the potential to result in substantial issues. Improper fixation might result in harm to the vascular system or the neurological system, highlighting the significance of accuracy and proficiency in executing this method. Neuralgia is found in 0.5–14% of hernia surgeries that use titanium tackers, as indicated by the majority of prior studies. The wide range of occurrence of neuralgia suggests that it is crucial to use precise methods and carefully evaluate potential problems when employing titanium tackers to secure mesh during hernia surgeries. , In our study, the mean postoperative pain score 8 hours after surgery was 5.27 ± 1.15 in X (mesh fixation with tacker), while in Y (mesh fixation with Vicryl), it was 4.65 ± 0.68. The overall mean postoperative pain score after 8 hours was 4.96 ± 0.99. After 1 day, the mean postoperative pain score in X was 5.86 ± 0.92, whereas in Y, it was significantly lower at 2.32 ± 0.63. The overall mean postoperative pain score after 1 day was 2.59 ± 0.83. After 2 days, the mean postoperative pain score was 1.27 ± 0.45 in X and 1.19 ± 0.40 in Y, with an overall mean score of 1.23 ± 0.42. These findings are compared to a study by Kleidari et al., which included 70 men undergoing inguinal or femoral hernia repair. In their study, the mean postoperative pain scores in the tacker (study) group were as follows: day 1 (5.54 ± 1.68), day 2 (4.74 ± 1.77), day 3 (3.29 ± 1.60), day 4 (2.37 ± 1.71), day 5 (1.97 ± 2.25), day 6 (1.49 ± 1.65), and day 7 (0.80 ± 1.05). In contrast, the Vicryl (control) group had lower pain scores: day 1 (4.63 ± 1.59), day 2 (3.34 ± 1.90), day 3 (2.69 ± 1.65), day 4 (1.86 ± 1.66), day 5 (1.46 ± 2.00), day 6 (0.89 ± 1.43), and day 7 (0.49 ± 0.91). The p-value was less than 0.05, indicating a statistically significant decrease in pain in the Vicryl group. Overall, these results suggest that using Vicryl for mesh fixation is associated with lower postoperative pain compared to using tackers. In the study conducted by Oguz et al., patients who received peritoneal closure with sutures had a substantially lower Visual Analog Scale (VAS) score at 1 day after the operation (VAS 1) compared to those who had peritoneal closure with tackers. In addition, the Visual Analog Scale (VAS) ratings at 7 days (VAS 7) and 30 days (VAS 30) were lower when peritoneal closure was done with sutures compared to tackers. Based on these findings, it may be inferred that neuralgia is a substantial burden after TAPP hernia repair. Various techniques are being employed to reduce neurological difficulties caused by attackers. These measures involve positioning the stapling instrument in a vertical orientation while inserting the tacks and minimizing the quantity of tacks utilized. These measures are designed to reduce the likelihood of nerve injury and consequent pain, hence improving patient outcomes following the treatment.16 Smith et al. and Ferzli et al . have shown that securing the mesh to the abdominal wall is not required for successful hernia repair. Nevertheless, research has shown that hernia recurrence is thought to be associated with inadequate mesh fixation. As a result of this worry, certain writers have employed other materials like Tissucol and fibrin sealant instead of titanium staple tacks for securing the mesh. These more recent techniques are linked to decreased expenses, a lower occurrence of neuralgia, and a reduced number of seroma instances. In this investigation, we employed a solitary absorbable Vicryl suture to secure the mesh. This method offers multiple advantages: it is economically efficient, as a single suture costs around 1 USD, whereas tacks cost approximately 100 USD; it leads to lower VAS scores after surgery; and it decreases the requirement for painkiller usage. The benefits of utilizing absorbable sutures for mesh fixation indicate that it could be a more effective and patient-centric substitute for conventional techniques involving titanium tacks. LIMITATIONS The study demonstrates that using a single absorbable Vicryl suture for mesh fixation in TAPP laparoscopic inguinal hernia repair results in less post-operative pain compared to titanium tackers. However, limitations include a small sample size and short follow-up duration of seven days. Despite these constraints, the findings suggest a potential improvement in patient outcomes. Surgeons may consider adopting this technique, and policymakers could use the evidence to inform guidelines. Further research is needed to explore long-term efficacy and cost-effectiveness. Overall, the study highlights the promise of Vicryl sutures in enhancing surgical practices and patient care.

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