Ventral hernias are a common surgical challenge, requiring effective and durable repair to prevent recurrence and ensure optimal patient outcomes. Laparoscopic Ventral Hernia Repair (LVHR) has become an extensively adopted approach, offering advantages such as reduced postoperative pain, shorter hospital stays, and quicker recovery compared to traditional open techniques. ¹ Mesh fixation is a critical step in ensuring the long-term success of LVHR, with various methods employed to secure the mesh in place. 2 The reported recurrence rate after LVHR ranges from 2 to 3%. ³ Compared to other minimally invasive procedures, LVHR causes a considerable amount of pain in the postoperative period. This self-limiting pain can last as long as 2 weeks and can also become chronic pain, which can last for more than 8 weeks. The cause of this postoperative pain has been attributed to the mesh fixation technique. ⁴

CapSure™ Permanent Fixation System device fixation (poly-ether-ether-ketone PEEK), ProTack™ Fixation Device (Titanium Helical fastener), and suturing with 2-0 polypropylene represent three widely utilized approaches, each with its own set of advantages and potential drawbacks. ^{5 T}he outcome of the surgery depends on the stability of the mesh, which will impact the recurrence rates. CapSure™ Permanent Fixation System involves the use of a specially designed tacking device to affix the mesh securely to the abdominal wall. ⁶ ProTack™ Fixation Device device fixation, on the other hand, utilizes a different type of tacking device to secure the mesh. Suturing with 2-0 polypropylene involves traditional surgical sutures to attach the mesh to the abdominal wall. While mesh fixation is crucial for preventing hernia recurrence, it is essential to consider the potential complications associated with each fixation method. Common complications may include infections, seromas, and chronic pain.7 By thoroughly assessing and comparing these complications across the different mesh fixation methods, the study aims to provide a comprehensive understanding of the overall safety profile of each technique. Beyond the technical aspects of mesh fixation, patient-reported outcomes play a crucial role in evaluating the success of hernia repair procedures. The occurrence of complications can lead on to patient dissatisfaction and can impact the overall outcome of the procedure. By incorporating patient perspectives into the evaluation, the study aims to provide a more holistic understanding of the outcomes associated with CapSure™ Permanent Fixation System, ProTack™ device fixation, and suturing with 2-0 polypropylene in laparoscopic ventral hernia repair.

An observational study was conducted at the minimal access surgery department of a tertiary care hospital between September 2023 and January 2024. The institutional ethics committee approved this study’s protocol. Patients aged above 18 years who require non-emergency ventral hernia repair were included in the study. Patients with contraindications for laparoscopic surgery, such as chronic cough, active infection, loss of abdominal domain or ascites, were excluded from the study. Informed written consent was obtained from all participants, and data confidentiality was maintained throughout the study. The type of mesh fixation technique to be used for the patient was decided by the operating surgeon. Based on the fixation technique used, patients were divided into groups. Group A are patients in whom CapSure™ Permanent Fixation System was used to fix the mesh, Group B are patients in whom ProTack™ Fixation Device was used, and group C are those in whom suturing with 2-0 polypropylene was used.

Comparing the findings of the current study with previously published articles in the field of laparoscopic ventral hernia repair (LVHR) provides valuable insights into the consistency and variability of results across different investigations ^{2, 5, 6}. Several aspects, including patient demographics, surgical characteristics, and postoperative outcomes, were explored in the context of mesh-fixation methods.

During the early postoperative (PO) period, the persistence of pain is a notable concern, leading to an increased reliance on pain medications, delayed bowel function, and prolonged hospital stays. 10, 11 Studies on laparoscopic incisional hernia repair have reported a chronic pain incidence ranging from 1% to 3%. ^{1, 2} Various investigations into PO pain after laparoscopic ventral hernia repair, including those by Leblanc and Booth in 1993, focused on the controversial topic of mesh fixation techniques. Initially LeBlanc utilized transfacial suture (TS) and titanium tack in operations. ^{12 Ho}wever, the emergence of chronic pain in patients undergoing laparoscopic ventral hernia repair prompted further exploration of fixation methods.

Numerous studies, such as those by researchers employing transfacial suture (TS) or tack fixation, found no significant difference in terms of pain and recurrence outcomes. 13, 14, 15 Over time, the search for alternative fixation methods led to the use of fibrin sealants and absorbable tacks by some investigators. 16 While absorbable fixation devices were developed to provide sufficient tensile fixation strength with acceptable PO pain compared to traditional nonabsorbable devices, the debate over the optimal mesh fixation technique in laparoscopic ventral hernia repair continues. In the current study, the suture group had significantly lower pain in postoperative week 2 compared to the other groups.

Contrary to some earlier studies that reported significant differences in mean mesh size among different fixation techniques, our study did not find such distinctions. ¹⁷ This aligns with the findings by Elsayed ME et al., who also reported no significant impact of mesh-fixation methods on mesh size in their respective investigations. ^{18 Th}e consistency in these results suggests that the choice of mesh-fixation may not be a critical determinant of mesh dimensions in LVHR, corroborating the notion that variations in surgical technique may not necessarily translate into differences in mesh-related parameters.

The significant differences in mean operating time and postoperative stay observed in our study align with the results reported by Rasul S et al., 10 These studies also found variations in surgical duration and length of hospital stay associated with different mesh-fixation methods. However, the specific factors contributing to these differences warrant further investigation, as our study did not delve into the detailed operative steps that my influence these outcomes.

The study's findings regarding postoperative pain outcomes at 2 weeks and 6 weeks align with the results reported by Shankaran R et al., who observed differences in early postoperative pain based on mesh-fixation methods. ¹⁹ However, the convergence of pain scores at the 3-month postoperative mark, as seen in our study, is consistent with the findings of Silfvenius AU et al. and suggests that the impact of fixation techniques on pain may be more pronounced in the immediate postoperative period. ²⁰

The assessment of health-related quality of life using the SF 36-item Short-Form Health Survey revealed differences in physical functioning and role limitations due to emotional problems among mesh-fixation groups, consistent with the findings of Wassenaar E et al. ²¹

Firstly, the sample size in each mesh-fixation group was relatively small, which may limit the generalizability of the findings. A larger sample size would provide more robust statistical power and allow for more reliable conclusions. Furthermore, the follow-up period was limited to 3 months postoperatively, which may not capture long-term outcomes and complications associated with mesh fixation methods. The observational nature of the study also restricted the scope of generalizability. Addressing these limitations in future randomized controlled studies would enhance the validity and applicability of the findings.

Our study investigated various aspects of laparoscopic ventral hernia repair (LVHR) with different mesh-fixation techniques. The analysis revealed no significant differences in mean mesh size or defect size among the groups, indicating that mesh-fixation methods were not influenced by these parameters. However, significant variations were observed in the mean number of tacks used per patient, operating time, and postoperative stay, suggesting an impact of mesh-fixation techniques on surgical outcomes and recovery duration. Pain scores showed early differences but converged over time, while health-related quality of life outcomes demonstrated improvements in certain domains, particularly physical functioning, and role limitations due to emotional problems, with variations across the mesh-fixation groups. Furthermore, the incidence of complications was generally low across all groups, with no significant differences detected among them. These findings underscore the importance of considering mesh-fixation methods in LVHR to optimize surgical outcomes and patient recovery. Further research with larger sample sizes and longer follow-up periods is warranted to validate these findings and inform clinical practice effectively.