الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Inguinal hernia repair is one of the most prevalent operations for the most variable pathology of the region of the most complex and variable tridimensional anatomy. Hence, despite of whose huge number of highly significant and provisional studies , a mature universal guidelines informative just by EBHC about the best procedure for each case individually according to his type of hernia and his own local and systemic parameters isn’t reached yet.
Indeed , guidelines and information delivered from these trials are important parts of the tools of the surgeon to choose the best procedure for the most fitting target case but the tools include in most the clinical sence , the skills , The own concept and sometimes the more trained upon procedure.
This effort in studying feasibility and outcome of modification of fixation of the mesh in the most recent and successful laparoscopic henioplasty ,TAPP, by external fixation of the mesh rather than stappling to reduce neurological and vascular complications, whatever small observational case series thesis in a relatively small scale ,20 cases , but not neglecting taking some large meta-analysis and large reference case series and RCTs of the traditional TAPP with other procedures as a slandered comparative base stressing in every part of the review , practice and analysis of data upon the points making such procedure more or less convenient as a part of large overview of the operation of choice for each case individually.
According to such view and after this case series it is highly recommended to suggest to Bani Suif faculty of medicine to offer its own ischeme for classification of inguinal hernia and operation of choice which tell now is completely depending on surgeon ’s knowledge , experience and clinical sence and not EBHC.
The need to avoid different complications, such as neuralgia or meralgia paresthetica by nerve entrapment or osteitis is the mother of the invent of replacing fixation with stapling by external fixation of the mesh.
This is a prospective study on 20 patients who were been admitted from outpatient clinics of Bani suief University Hospital and Insurance Hospital of Bani Suief and diagnosed provisionally as patients with inguinal hernia.
Five operations were done in Bani suief University Hospital and Fifteen were done in Insurance Hospital of Bani Suief.
The 20 operations of TAPP with external fixation were done during the period from 2/3/2011 till 12/6/2012. They were followed up postoperatively for seven to eighteen (7– 22) months with mean of about 9.7 months.
Indeed, this small scale study isn’t enough to categorize TAPP with external fixation as a day care surgeryand is insufficient to allow conclusions to drow external fixation in TAPP as a more save, less expensive and effective alternative to stapling but highly recommend to direct efforts to start and complete adequately powered RCTs. comparing both types of fixation.
Conclusion
TAPP with external fixation is feasible in treatment of inguinal hernias of any type direct or indirect , primary or recurrent , unilateral or bilateral except for Type 3B according to Nyhus classification while the defect was larger than 3 Cm according to the EHS classification (i. e. M3 or L3 types). In such type failure of the technique had been confirmed .
TAPP with external fixation has benefits as compared with data from large meta-analysis of traditional TAPP with stapling including being of lower costs , lower incidence of postoperative neuralgia and had confirmed the same advantages of reduced hospital stay , early resumption of physical and social activities . while the complication rate was comparable with large meta-analysis and showed significant improvement of the coincidental part of learning curve of the traditional TAPP and with 3 of the small number case series. The study’s operative time was comparable with the total mean of more than 1600 cases of TAPP in (McCormack, et al. 2005)a large meta-analysis while it had showed a significant shorter time compared with 14 studies of that review coincidental in learning curve.
Also , there is no deaths, no major complications, no visceral injury, no vascular injury, no Mesh or deep infection , and no Port-site hernia and no recurrence within 6 monthes.
As regard to comparison between different designs of external fixation the port closure device’s design was the more easy with the least operative time and least complications while these results were comparable with the Straight needle slings’ design but the through canula design was significantly the worse one.
Even with these promising conclusions, yet, this comparison has a bias; being a small scale observational analytic study, so is insufficient to allow conclusions to draw external fixation in TAPP as an effective alternative to stapling , less expensive, more save and a day care surgery yet at least it is highly recommended to direct efforts to start and complete adequately powered RCTs. comparing both types of fixation.
Even if not statistically accepted, but the obvious comparable outcome compared with fibrin glue fixation despite of the significant cost benefit and short operatve time must be respected as a preliminary step for future RCTs research.