World Journal of Laparoscopic Surgery
Volume 16 | Issue 3 | Year 2023

Primary Closure of Direct Inguinal Hernia Defect in Laparoscopic Repair by Pre-tied Suture Loop Technique for Prevention of Seroma: A Prospective Cohort Study

Singh Sachin S1, Rajyaguru Ajay M2https://orcid.org/0000-0001-9509-5396

1,2Department of General Surgery, Pandit Deendayal Upadhyay Medical College, Rajkot, Gujarat, India

Corresponding Author: Sachin S Singh, Department of General Surgery, Pandit Deendayal Upadhyay Medical College, Rajkot, Gujarat, India, Phone: +91 7990858247, e-mail: drsachinsingh2930@gmail.com

How to cite this article: Singh SS, Rajyaguru AM. Primary Closure of Direct Inguinal Hernia Defect in Laparoscopic Repair by Pre-tied Suture Loop Technique for Prevention of Seroma: A Prospective Cohort Study. World J Lap Surg 2023;16(3):166–168.

Source of support: Nil

Conflict of interest: None

Received on: 30 September 2023; Accepted on: 28 October 2023; Published on: 11 January 2024


Aims and background: Postoperative seroma is a common complication of laparoscopic mesh repair of direct inguinal hernia. Several kinds of attempts have been made to reduce its incidence though they are not without problems. The aim of this study was to evaluate the efficiency of a new alternate technique that must be safe and with fewer complications, using a widely available and inexpensive pre-tied suture loop (endoloop) for plication of the weakened transversalis fascia (TF)/pseudosac.

Materials and methods: A prospective cohort study of 47 patients diagnosed with a total of 63 direct inguinal hernias during a 57-month period fit for laparoscopic tranabdominal preperitoneal (TAPP) meshplasty. Each of the M2 or M3 direct defects, according to the European Hernia Society (EHS), was systematically repaired by TAPP using pre-tied suture loop application at the base of TF. Patients were reviewed during follow-up at 2, 6 weeks, and 1 year after the operation to look for primary postoperative outcome parameters, i.e., seroma formation; secondary outcome parameters, i.e., groin pain, wound infection, and recurrence.

Results: During the follow-up period, no patient presented with seroma formation and wound infection. Only two patients had complaints of groin pain at 2-week follow which was resolved by analgesics and there was no hernia recurrence after a follow-up of 1 year.

Conclusion: Application of a pretied suture loop at the base of TF during laparoscopic repair of direct inguinal hernia is cost effective, safe method and does not increase the risk of seroma formation and recurrence.

Clinical significance: Seroma formation is a major concern for surgeons as well as patients during postoperative period following laparoscopic inguinal hernia repair. The development of a cost-effective, reliable technique with the least or no seroma formation and recurrence prevention is needed at this time.

Keywords: Laproscopy, Pseudosac, Pretied suture loop (endoloop), Seroma, Transabdominal preperitoneal meshplasty, Transversalis fascia.


Seroma is a common complication in postoperative period after performing procedures in which tissue dead spaces have been created. Seromas occur after surgery due to the presence of mesh in pre-peritoneal space and mechanical injury causing local inflammatory response.1 Mostly seromas are typically self-resolving, but in some cases, if unresolved, they require aspiration under strict aseptic precaution. The formation of seroma causes anxiety and discomfort to the patients. The rate of seroma formation after total extraperitoneal (TEP) repair is between 0.5 and 12.2% and for tranabdominal preperitoneal (TAPP) meshplasty between 3.0 and 8.0% as per the report.2,3 If measures are not taken for the prevention of seroma, then its incidence is 4–5%.4 Seroma formation and hernia recurrence may be difficult to distinguish. Seromas carry the risk of becoming infected and resulting in an abscess. Preoperatively, the patient should be explained about the possibility of seroma formation.5 The clinical factors significantly associated with seroma formation are a large hernia defect, old age, hernia sac extending into the scrotum, and presence of a residual sac of indirect hernia.1 Seroma formation is a common complication of laparoscopic mesh repair of moderate to large-size direct inguinal hernia.6 Methods to reduce the incidence include-closed suction drainage of the preperitoneal space or tacking the transversalis fascia (TF) to the pubic ramus.3,7 But these techniques have their own complications like iatrogenic injuries and postoperative pain. Less number of studies have been conducted on the application of pre-tied suture loop on direct hernial defect at the base of pseudo sac, and studies showed that endoloop application on base of pseudo sac reduces the risk of seroma formation, recurrence, iatrogenic injury, and chronic postoperative pain that occur in tacking.8 Hence we have conducted a study for seroma prevention by application of endoloop at the base of pseudosac in laparoscopic direct hernia repair to establish its efficacy in our setup.


Between August 2017 and May 2022, all patients above 18 years of age with direct inguinal hernia having defect size M2 and M3 according to EHS classification, fit for laparoscopic mesh repair were included. All were operated on by laparoscopic TAPP. Peritoneal flap was created (Fig. 1), meticulous dissection was performed in the space of Retzius and the space of Bogros. Intraoperatively the hernia was reduced, base of pseudosac was ligated with a pretied suture loop made by polydioxanone (PDS) 2–0 (Fig. 2). A polypropylene Mesh of size 15 × 13 cm size was placed in preperitoneal space (Fig. 3) and fixed medially at cooper’s ligament and rectus using a tacker followed by a closer of the peritoneum.

Fig. 1: Peritoneal flap creation

Fig. 2: Endoloop placement at pseudosac

Fig. 3: Mesh placement


About 45 patients with only direct inguinal hernia were studied, with 27 unilateral inguinal hernia and 18 bilateral inguinal hernia (Table 1). All patients were male. Around 36 patients have defect size M2 (<3 cm), 27 patients have defect size M3 (>3 cm) (Table 2). All were managed by laparoscopic TAPP with a pre-tied suture loop applied at pseudosac base. Groin pain was developed in two patients during the postoperative period at 2-week follow-up, which was resolved at 6-week follow-up. No patient developed seroma, wound infection and early recurrence.

Table 1: Total number of cases

  Unilateral Bilateral Total no. of cases
Number of cases 27 18 45
Table 2: Repartition of 63 direct (medial) hernias according to the size of defect as per European Hernia Society (EHS) classification
Size of defect Medium (M2) Large (M3) Total no. of cases
No. of cases 36 27 63


This study reviewed 45 patients who underwent Laparoscopic repair of moderate and large-size direct inguinal hernial defect closure by endoloop technique. This study has evaluated the outcome of each case and also helped us to identify the safety and effectiveness of the application of a pretied suture loop at the base of TF during laparoscopic repair of direct inguinal hernia. Here we discuss the primary outcome of the study in terms of seroma, and the secondary outcome in terms of groin pain, recurrence, and wound infection, this technique. All patients were male with a median age of 56.5 years. A total 63 direct inguinal hernia repairs are done using a pretied suture loop in laparoscopic technique in 45 patients, with 27 unilateral and 18 bilateral cases. Defect size according to EHS classification was 27 M3 and 36 M2. Only 2 (4.44%) patients, one in case of unilateral and another bilateral inguinal hernia, developed groin pain at 2 weeks follow-up, which was managed with oral analgesics and was resolved at 6 weeks. Further follow-up was done at 1 year when no patient presented with recurrence. Seroma formation can be influenced by several factors, i.e., direct vs indirect or dual hernias, larger defects, inguinoscrotal extension of sac, old age, and presence of a residual sac of indirect hernia. Smaller hernial defects also present with a comparatively lower risk of seroma formation, as do indirect. An analysis showed that glue compared to tacking and non-fixation, led to a higher rate of seroma formation.6 There is a curtain-like closure after indirect hernial sac excision as these defects are in line with the anatomy of the groin whereas a direct hernia defect persists as TF evagination after repair.6 To minimize the postoperative seroma formation, after TEP/TAPP repair of large direct inguinal hernia which can cause discomfort and stress for the patient, there are many intra-operative techniques for prevention of seroma formation i.e. tacking of pseudo sac with pubic bone using tacker, closed suction drainage of the preperitoneal space, fibrin sealant application in preperitoneal dead space as well as postoperative technique such as external compression over inguinal region.3,7,9 If one pretied suture loop is unable to completely obliterate pseudo sac, then another pretied suture loop can be applied.8 In the present study we have investigated the feasibility, reliability, and safety of pretied suture loop technique application for the management of direct inguinal hernia defect in laparoscopic repair. No patient developed seroma at 2 weeks and even 6 weeks follow-up. Thus, our study satisfies the primary outcome measure in the sense that the application of a pretied suture loop at the base of TF during Laparoscopic management of direct inguinal hernia is beneficial in the prevention of seroma. Investigating the secondary outcome of the present study, only 4.44% of patients developed groin pain on 2 weeks follow-up which sub-sided at 6 weeks follow-up after giving analgesics. The symptom of groin pain at 2nd week of follow-up is not related to the pretied suture loop but possibly due to exposed cord structures prior to mesh placement and stretching of the genital branch of the genitofemoral nerve while mobilization of the peritoneal sac. Our study has now confirmed that even after long-term follow-up, pre-tied suture loop application does not cause any additional symptoms for the patient and has the advantage of low cost, as there was no requirement of tackers, glue, drain and external compression; thus validates its unrestricted usage for any size of direct hernia defects. This technique of pre-tied suture loop application has been adopted by the International Endo hernia Society’s updated guidelines as an alternative to the fixation of transversalis fascia to Copper’s ligament, while dealing with large direct defects.


The seroma formation is comparatively more common in direct inguinal hernia and cannot be prevented by laparoscopic inguinal hernia repair. Application of pre-tied suture loop over the base of TF during laparoscopic management of direct inguinal hernia defect is a reliable and safe method for prevention of seroma. This method is cost-effective and does not increase the recurrence risk. This method should be preferred over the tacking of TF or closed suction drainage during repair of direct inguinal hernia defect by laparoscopy.

Clinical Significance

Pretied suture loop application at the base of pseudosac effectively prevents seroma formation and recurrence. This technique is cost-effective, and reliable. Formation of seroma mimics recurrence which creates anxiety and discomfort to the patient, hence development of a cost-effective and reliable technique for seroma prevention by use of a pre-tied suture loop is important.


Ajay M Rajyaguru https://orcid.org/0000-0001-9509-5396


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