Mesh fixation versus non-fixation in totally extraperitoneal inguinal hernia repair: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND

The need for mesh fixation during totally extraperitoneal (TEP) inguinal hernia repair remains controversial. Although fixation has traditionally been used to prevent mesh displacement and recurrence, it may increase postoperative morbidity, particularly chronic postoperative inguinal pain (CPIP). This systematic review and meta-analysis aimed to compare mesh fixation versus non-fixation in adult patients undergoing laparoscopic TEP inguinal hernia repair.

METHODS

A systematic literature search was conducted up to February 2026. Randomized controlled trials comparing mesh fixation with non-fixation during TEP inguinal hernia repair were included. The primary outcomes were CPIP and hernia recurrence. Secondary outcomes included operative time, early postoperative pain, seroma, urinary retention, length of hospital stay, and costs. Risk of bias was assessed.

RESULTS

Sixteen randomized controlled trials including 1,608 patients were included. Mesh fixation was associated with a significantly higher risk of CPIP compared with non-fixation (RR 1.68; 95% CI 1.29 to 2.19; p = 0.0001). No statistically significant difference in hernia recurrence was detected between fixation and non-fixation groups (RR 0.53; 95% CI 0.22 to 1.23; p = 0.14); however, recurrence events were rare, and this analysis may be underpowered to exclude small but clinically relevant differences. Fixation was associated with a longer operative time (MD 3.16 min; 95% CI 1.04 to 5.27; p = 0.003), slightly higher 24-hour postoperative pain (MD 0.21; 95% CI 0.03 to 0.38; p = 0.02), increased urinary retention (RR 3.61; 95% CI 1.88 to 6.93; p = 0.0001), and a marginally longer hospital stay (MD 0.10 days; 95% CI 0.02 to 0.18; p = 0.01). Seroma formation did not differ significantly between groups (RR 1.05; 95% CI 0.70 to 1.58; p = 0.81). Costs were generally higher in the fixation group, mainly because of fixation devices. Publication bias assessment for outcomes with at least 10 studies did not suggest major small-study effects. The certainty of evidence was high for CPIP, moderate for recurrence and most secondary outcomes, and low for urinary retention.

CONCLUSIONS

Mesh fixation was associated with a higher risk of CPIP without a statistically significant reduction in hernia recurrence. However, recurrence events were uncommon, and the available evidence does not establish equivalence or non-inferiority between the two strategies, particularly for patients with large medial or direct defects. Fixation was also associated with modest increases in operative time, early postoperative pain, urinary retention, hospital stay, and costs. Overall, non-fixation appears to be a reasonable strategy in appropriately selected patients, while selective fixation may remain relevant for large direct defects or other high-risk situations.