Mesh Fixation Strategy and Recovery Trajectories after Unilateral Totally Extraperitoneal Inguinal Hernia Repair: A Defect-Size–Stratified Analysis

Background: Mesh fixation strategy is a modifiable intraoperative factor that may influence postoperative recovery following totally extraperitoneal (TEP) inguinal hernia repair. Although self-fixating meshes were developed to avoid penetrating fixation and potentially reduce pain, their effect on multidimensional recovery trajectories remains unclear. Methods: This retrospective cohort study included consecutive adults undergoing elective unilateral TEP repair at a tertiary referral center. Patients were grouped according to fixation strategy: self-fixating mesh or polypropylene mesh secured with absorbable tacks. The primary outcome was early quality of recovery measured using the Quality of Recovery-15 (QoR-15) questionnaire at postoperative week 1. Secondary outcomes included longitudinal QoR-15 and visual analog scale (VAS) pain scores at postoperative months 1 and 3, analgesic consumption, and time to functional recovery. Recovery trajectories were analyzed using linear mixed-effects models, with additional stratification by defect size (<20 mm versus ≥20 mm). Results: A total of 134 patients were included (56 tack fixation, 78 self-fixating mesh). Early recovery at week 1 was comparable between groups. Mixed-effects modeling demonstrated significant improvement over time in both groups, without an independent association between fixation strategy and overall QoR-15 trajectory. However, in defects ≥20 mm, self-fixating mesh was associated with higher QoR-15 scores. Pain scores improved over time in both groups, with small but statistically significant differences favoring self-fixating mesh. Conclusions: In unilateral TEP repair, fixation strategy does not substantially influence overall early and short-term recovery. However, in larger defects (≥20 mm), self-fixating mesh may provide modest recovery advantages, suggesting a context-dependent rather than uniform effect.