Effect of pseudosac suturing to Cooper’s ligament on seroma formation following laparoscopic totally extraperitoneal inguinal hernia repair
Keywords:
inguinal hernia, totally extraperitoneal (TEP) repair, pseudosac suturing, Cooper’s ligament, seroma, laparoscopic hernia surgery, randomized controlled trialAbstract
Abstract. Background: Seroma is a frequent early complication after laparoscopic inguinal hernia repair, often arising in the residual “pseudosac” created after sac reduction. Suturing this lax pseudosac to Cooper’s ligament has been proposed to reduce dead space and seroma formation, but comparative data in totally extraperitoneal (TEP) repair remain limited. Materials and Methods: This prospective single-centre randomized controlled trial was conducted over 30 months in adults undergoing laparoscopic TEP repair for symptomatic inguinal hernia. Forty patients were randomized 1:1 to TEP with pseudosac suturing to Cooper’s ligament (intervention) or standard TEP without suturing (control), all performed by a single surgeon. The primary outcome was seroma formation within 15 days. Secondary outcomes included postoperative pain on day 1 (VAS 0–10), duration of hospital stay, and wound infection at day 1 and 1 week. Results: Baseline demographic and clinical characteristics were comparable between groups. Seroma within 15 days occurred in 1/20 (5%) patients in the suturing group and 3/20 (15%) in the non-suturing group, yielding a 66.7% relative risk reduction, 10% absolute risk difference, and number needed to treat of 10; no seroma persisted beyond 15 days. Mean day-1 pain scores were low and similar (1.80 ± 1.74 vs 1.65 ± 1.73; p=0.72). Early discharge (2–3 days) was achieved in 95.0% of suturing patients versus 80.0% of controls. Two superficial surgical site infections (10%) occurred only in the non-suturing group, with no deep or organ-space infections. Conclusion: Suturing the pseudosac to Cooper’s ligament during laparoscopic TEP inguinal hernia repair confers a clinically meaningful reduction in early seroma formation, with comparable pain, low infection rates, and a trend toward earlier discharge. This simple, reproducible maneuver can be considered as an adjunct in TEP repair, particularly in patients at higher risk of seroma.
References
Katkhouda N, Mavor E, Friedlander MH, et al. Use of fibrin sealant for prosthetic mesh fixation in laparoscopic extraperitoneal inguinal hernia repair. Ann Surg. 2001 Jan;233(1):18-25. doi: 10.1097/00000658-200101000-00004.
Agca B, Iscan Y, Tasdelen I, Memisoglu K. Effect of Drains on Complications in Laparoscopic Repair of Unilateral Inguinal Hernia. JSLS. 2025 Jul-Sep;29(3):e2025.00052. doi: 10.4293/JSLS.2025.00052.
Bittner R, Schwarz J. Inguinal hernia repair: current surgical techniques. Langenbecks Arch Surg. 2012 Feb;397(2):271-82. doi: 10.1007/s00423-011-0875-7.
Bittner R, Schmedt CG, Schwarz J, et al. Laparoscopic transperitoneal procedure for routine repair of groin hernia. Br J Surg. 2002 Aug;89(8):1062-6. doi: 10.1046/j.1365-2168.2002.02178.x.
Bendavid R. New techniques in hernia repair. World J Surg. 1989 Sep-Oct;13(5):522-31. doi: 10.1007/BF01658865.
Callesen T, Bech K, Kehlet H. Prospective study of chronic pain after groin hernia repair. Br J Surg. 1999 Dec;86(12):1528-31. doi: 10.1046/j.1365-2168.1999.01320.x.
Karoń H. Historia leczenia operacyjnego przepukliny pachwinowej [History of surgical treatment of inguinal hernia]. Pol Przegl Chir. 1973 Sep;45(9):1279-87. Polish.
He C, Lu J, Ong MW, et al. Seroma prevention strategies in laparoscopic ventral hernia repair: a systematic review. Hernia. 2020 Aug;24(4):717-731. doi: 10.1007/s10029-019-02098-1.
Xie HY, Chen B, Shen J, et al. Risk factors and clinical impact of seroma formation following laparoscopic inguinal hernia repair: a retrospective study. BMC Surg. 2024 Oct 1;24(1):274. doi: 10.1186/s12893-024-02574-1.
Sains PS, Tilney HS, Purkayastha S, et al. Outcomes following laparoscopic versus open repair of incisional hernia. World J Surg. 2006 Nov;30(11):2056-64. doi: 10.1007/s00268-006-0026-4.
Toma H, Eguchi T, Toyoda S, et al. A 10-year experience of totally extraperitoneal endoscopic repair for adult inguinal hernia. Surg Today. 2015 Nov;45(11):1417-20. doi: 10.1007/s00595-014-1101-3.
Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA. 2006 Jan 18;295(3):285-92. doi: 10.1001/jama.295.3.285. Erratum in: JAMA. 2006 Jun 21;295(23):2726.
Pierides G, Scheinin T, Remes V, et al. Randomized comparison of self-fixating and sutured mesh in open inguinal hernia repair. Br J Surg. 2012 May;99(5):630-6. doi: 10.1002/bjs.8705.
Wantz GE. Complications of inguinal hernial repair. Surg Clin North Am. 1984 Apr;64(2):287-98. doi: 10.1016/s0039-6109(16)43285-8.
Klinge U, Klosterhalfen B. Modified classification of surgical meshes for hernia repair based on the analyses of 1,000 explanted meshes. Hernia. 2012 Jun;16(3):251-8. doi: 10.1007/s10029-012-0913-6.
Haladu N, Alabi A, Brazzelli M, et al. Open versus laparoscopic repair of inguinal hernia: an overview of systematic reviews of randomised controlled trials. Surg Endosc. 2022 Jul;36(7):4685-4700. doi: 10.1007/s00464-022-09161-6.
Li J, Gong W, Liu Q. Intraoperative adjunctive techniques to reduce seroma formation in laparoscopic inguinal hernioplasty: a systematic review. Hernia. 2019 Aug;23(4):723-731. doi: 10.1007/s10029-019-01903-1.
O'Reilly EA, Burke JP, O'Connell PR. A meta-analysis of surgical morbidity and recurrence after laparoscopic and open repair of primary unilateral inguinal hernia. Ann Surg. 2012 May;255(5):846-53. doi: 10.1097/SLA.0b013e31824e96cf. Erratum in: Ann Surg. 2012 Aug;256(2):393.
Liem MS, van der Graaf Y, van Steensel CJ, et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N Engl J Med. 1997 May 29;336(22):1541-7. doi: 10.1056/NEJM199705293362201.
Downloads
Published
Issue
Section
License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
You are free to share, copy and redistribute the material in any medium or format under these terms.
