Tack Number as an Independent Predictor of Recurrence after TEP Repair: A Multicenter Retrospective ROC-Based Study

Background: Mesh fixation during totally extraperitoneal (TEP) inguinal hernia repair remains controversial, and the optimal number of fixation tacks required to balance recurrence risk and postoperative recovery has not been clearly defined. This study aimed to assess the influence of tack quantity on recurrence, chronic pain, and return to daily activities after TEP repair. Methods: This multicenter retrospective study included 412 patients who underwent laparoscopic TEP repair between January 2023 and March 2025. Recurrence, chronic pain, and time to return to daily activities were evaluated. Receiver operating characteristic (ROC) analysis was performed to explore a potential threshold for recurrence risk. To avoid bias related to data-derived dichotomization, the number of tacks was included as a continuous variable in multivariable logistic regression analysis adjusting for hernia diameter, hernia type, and laterality. Results: Recurrence occurred in 30 patients (7.3%). ROC analysis suggested four tacks as a potential threshold for recurrence risk (AUC = 0.68). Patients receiving fewer than four tacks had higher recurrence rates than those receiving four or more tacks (11.6% versus 3.6%, P = .002). In multivariable analysis, hernia diameter (odds ratio [OR]: 1.08, 95% confidence interval [CI]: 1.02–1.15; P = .012), direct hernia type (OR 3.79, 95% CI: 1.55–9.26; P = .004), and bilateral repair (OR: 7.92, 95% CI: 2.85–22.02; P < .001) were independent predictors of recurrence. Higher tack number was independently associated with lower recurrence odds (OR: 0.79, 95% CI: 0.64–0.97; P = .023). Chronic pain scores did not differ significantly between groups, whereas return to daily activities was slightly earlier in patients receiving fewer tacks. Conclusion: A higher number of fixation tacks was independently associated with lower recurrence risk after TEP repair. These findings suggest that fixation strategy should be individualized, with stronger fixation considered particularly in large direct or bilateral hernias.