Skip to main content
Top

23-10-2024 | Review Article

Navigating hernia sac management in minimally invasive inguinal hernia repair: to abandon or to reduce? An updated systematic review and meta-analysis

Authors: Ana Caroline Dias Rasador, Carlos Balthazar da Silveira, João Pedro Kasakewitch, Gabriele Lech, Diego Laurentino Lima, Prashanth Sreeramoju, Flavio Malcher

Published in: Surgical Endoscopy

Login to get access

Abstract

Aim

Minimally invasive inguinal hernia repair has become increasingly accepted, demonstrating superior outcomes over open procedures in postoperative complications. However, certain postoperative complications, such as seroma, remain a dilemma, with many attributing it to the management of the hernia sac. We aimed to perform a systematic review and meta-analysis comparing the reduction versus abandonment of the hernia sac during laparoscopic inguinal hernia repair.

Material and methods

Cochrane, Scopus, SciELO, and PubMed were searched for studies comparing reduction and abandonment of the hernia sac. Our primary outcome was seroma. Secondary outcomes were overall complications, postoperative pain, surgical site infection, recurrence, hospital length of stay (LOS), and operative time. We performed a subgroup analysis of transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) techniques. Statistical analysis was performed with R Studio.

Results

2388 studies were screened, and seven studies were included, comprising 3153 patients, of which 916 (29%) were in the abandonment group. We found higher seroma rates for the abandonment group (RR 1.52; 95% CI 1.22 to 1.89; P < 0.001). No differences were found in overall complications (RR 0.88; 95% CI 0.55 to 1.42; P = 0.61), postoperative pain (RR 1.15; 95% CI 0.46 to 2.87; P = 0.76), recurrence (RR 2.67; 95% CI 0.51 to 14.05; P = 0.25), operative time (MD − 4.45 min; 95% CI − 12.77 to 3.86; P = 0.29), and LOS (MD -0.06 days; 95% CI − 0.14 to 0.02; P = 0.14) between both groups. Subgroup analysis of seroma showed no differences between the groups when analyzing TAPP (19.3% vs. 13%; RR 1.65; 95% CI 0.91 to 2.99; P = 0.1) and TEP (9% vs. 4.3%; RR 1.69; 95% CI 0.62 to 4.6; P = 0.3) procedures.

Conclusion

Our systematic review and meta-analysis support that hernia sac abandonment may be associated with increased early seroma rates following laparoscopic inguinal hernia repair, but limited data are available for technique-specific analyses.
Literature
1.
go back to reference Rankin A, Kostusiak M, Sokker A (2019) Spigelian hernia: case series and review of the literature. Visc Med 35(2):133–136CrossRefPubMed Rankin A, Kostusiak M, Sokker A (2019) Spigelian hernia: case series and review of the literature. Visc Med 35(2):133–136CrossRefPubMed
2.
go back to reference Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J et al (2009) European hernia society guidelines on the treatment of inguinal hernia in adult patients. Hernia J Hernias Abdom Wall Surg 13(4):343–403CrossRef Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J et al (2009) European hernia society guidelines on the treatment of inguinal hernia in adult patients. Hernia J Hernias Abdom Wall Surg 13(4):343–403CrossRef
3.
go back to reference Tran HM, MacQueen I, Chen D, Simons M (2023) Systematic review and guidelines for management of scrotal inguinal hernias. J Abdom Wall Surg 27(2):11195CrossRef Tran HM, MacQueen I, Chen D, Simons M (2023) Systematic review and guidelines for management of scrotal inguinal hernias. J Abdom Wall Surg 27(2):11195CrossRef
4.
go back to reference Ruze R, Yan Z, Wu Q, Zhan H, Zhang G (2019) Correlation between laparoscopic transection of an indirect inguinal hernial sac and postoperative seroma formation: a prospective randomized controlled study. Surg Endosc 33(4):1147–1154CrossRefPubMed Ruze R, Yan Z, Wu Q, Zhan H, Zhang G (2019) Correlation between laparoscopic transection of an indirect inguinal hernial sac and postoperative seroma formation: a prospective randomized controlled study. Surg Endosc 33(4):1147–1154CrossRefPubMed
5.
go back to reference Li W, Li Y, Ding L, Xu Q, Chen X, Li S et al (2020) A randomized study on laparoscopic total extraperitoneal inguinal hernia repair with hernia sac transection vs complete sac reduction. Surg Endosc 34(4):1882–1886CrossRefPubMed Li W, Li Y, Ding L, Xu Q, Chen X, Li S et al (2020) A randomized study on laparoscopic total extraperitoneal inguinal hernia repair with hernia sac transection vs complete sac reduction. Surg Endosc 34(4):1882–1886CrossRefPubMed
6.
go back to reference Lau H, Lee F (2002) Lessons learned from ligation of indirect hernia sac: an alternative to reduction during endoscopic extraperitoneal inguinal hernioplasty. J Laparoendosc Adv Surg Tech 12(6):419–423CrossRef Lau H, Lee F (2002) Lessons learned from ligation of indirect hernia sac: an alternative to reduction during endoscopic extraperitoneal inguinal hernioplasty. J Laparoendosc Adv Surg Tech 12(6):419–423CrossRef
7.
go back to reference Claus C, Malcher F, Trauczynski P, Morrell AC, Morrell ALG, Furtado M et al (2023) Primary abandon of hernia sac for inguinoscrotal hernias: a safe way to cut corners. Surg Endosc 37(11):8421–8428CrossRefPubMed Claus C, Malcher F, Trauczynski P, Morrell AC, Morrell ALG, Furtado M et al (2023) Primary abandon of hernia sac for inguinoscrotal hernias: a safe way to cut corners. Surg Endosc 37(11):8421–8428CrossRefPubMed
8.
go back to reference Powell BS, Lytle N, Stoikes N, Webb D, Voeller G (2015) Primary prevascular and retropsoas hernias: incidence of rare abdominal wall hernias. Hernia 19(3):513–516CrossRefPubMed Powell BS, Lytle N, Stoikes N, Webb D, Voeller G (2015) Primary prevascular and retropsoas hernias: incidence of rare abdominal wall hernias. Hernia 19(3):513–516CrossRefPubMed
9.
go back to reference Haitian Z, Jian L, Qinghua L, Naichang X, Xiaolong G, Jiehua L et al (2009) Totally extraperitoneal laparoscopic hernioplasty: the optimal surgical approach. Surg Laparosc Endosc Percutan Tech 19(6):501–505CrossRef Haitian Z, Jian L, Qinghua L, Naichang X, Xiaolong G, Jiehua L et al (2009) Totally extraperitoneal laparoscopic hernioplasty: the optimal surgical approach. Surg Laparosc Endosc Percutan Tech 19(6):501–505CrossRef
10.
go back to reference Tai HC, Lin CD, Chung SD, Chueh SCJ, Tsai YC, Yang SSD (2011) A comparative study of standard versus laparoendoscopic single-site surgery (LESS) totally extraperitoneal (TEP) inguinal hernia repair. Surg Endosc 25(9):2879–2883CrossRefPubMed Tai HC, Lin CD, Chung SD, Chueh SCJ, Tsai YC, Yang SSD (2011) A comparative study of standard versus laparoendoscopic single-site surgery (LESS) totally extraperitoneal (TEP) inguinal hernia repair. Surg Endosc 25(9):2879–2883CrossRefPubMed
11.
go back to reference Misra MC, Bhowate PD, Bansal VK, Kumar S (2009) Massive scrotal hernias: problems and solutions. J Laparoendosc Adv Surg Tech 19(1):19–22CrossRef Misra MC, Bhowate PD, Bansal VK, Kumar S (2009) Massive scrotal hernias: problems and solutions. J Laparoendosc Adv Surg Tech 19(1):19–22CrossRef
12.
go back to reference Abbas AE, Abd Ellatif ME, Noaman N, Negm A, El-Morsy G, Amin M et al (2012) Patient-perspective quality of life after laparoscopic and open hernia repair: a controlled randomized trial. Surg Endosc 26(9):2465–2470CrossRefPubMed Abbas AE, Abd Ellatif ME, Noaman N, Negm A, El-Morsy G, Amin M et al (2012) Patient-perspective quality of life after laparoscopic and open hernia repair: a controlled randomized trial. Surg Endosc 26(9):2465–2470CrossRefPubMed
13.
go back to reference Bittner R, Montgomery MA, Arregui E, Bansal V, Bingener J, Bisgaard T et al (2015) Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society). Surg Endosc 29(2):289–321CrossRefPubMed Bittner R, Montgomery MA, Arregui E, Bansal V, Bingener J, Bisgaard T et al (2015) Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society). Surg Endosc 29(2):289–321CrossRefPubMed
14.
go back to reference Cihan A, Ozdemir H, Uçan BH, Acun Z, Comert M, Tascilar O et al (2006) Fade or fate: seroma in laparoscopic inguinal hernia repair. Surg Endosc 20(2):325–328CrossRefPubMed Cihan A, Ozdemir H, Uçan BH, Acun Z, Comert M, Tascilar O et al (2006) Fade or fate: seroma in laparoscopic inguinal hernia repair. Surg Endosc 20(2):325–328CrossRefPubMed
15.
go back to reference Lau H, Lee F (2003) Seroma following endoscopic extraperitoneal inguinal hernioplasty. Surg Endosc 17(11):1773–1777CrossRefPubMed Lau H, Lee F (2003) Seroma following endoscopic extraperitoneal inguinal hernioplasty. Surg Endosc 17(11):1773–1777CrossRefPubMed
16.
go back to reference Schmidt L, Andresen K, Öberg S, Rosenberg J (2019) Surgical techniques and convalescence recommendations vary greatly in laparoscopic groin hernia repair: a nationwide survey among experienced hernia surgeons. Surg Endosc 33(7):2235–2241CrossRefPubMed Schmidt L, Andresen K, Öberg S, Rosenberg J (2019) Surgical techniques and convalescence recommendations vary greatly in laparoscopic groin hernia repair: a nationwide survey among experienced hernia surgeons. Surg Endosc 33(7):2235–2241CrossRefPubMed
17.
go back to reference Choi YY, Kim Z, Hur KY (2011) Transection of the hernia sac during laparoscopic totally extraperitoneal inguinal hernioplasty: is it safe and feasible? J Laparoendosc Adv Surg Tech 21(2):149–152CrossRef Choi YY, Kim Z, Hur KY (2011) Transection of the hernia sac during laparoscopic totally extraperitoneal inguinal hernioplasty: is it safe and feasible? J Laparoendosc Adv Surg Tech 21(2):149–152CrossRef
18.
go back to reference Liu L, Hu J, Zhang T, Zhang C, Wang S (2023) Influence of the hernia sac treatment method on the occurrence of seroma after laparoscopic transabdominal preperitoneal hernia repair. Asian J Surg 46(2):718–722CrossRefPubMed Liu L, Hu J, Zhang T, Zhang C, Wang S (2023) Influence of the hernia sac treatment method on the occurrence of seroma after laparoscopic transabdominal preperitoneal hernia repair. Asian J Surg 46(2):718–722CrossRefPubMed
19.
go back to reference Moher D, Liberati A, Tetzlaff J, Altman DG, For the PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535–b2535CrossRefPubMedCentralPubMed Moher D, Liberati A, Tetzlaff J, Altman DG, For the PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535–b2535CrossRefPubMedCentralPubMed
20.
go back to reference Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M et al (2016) ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 12:i4919CrossRef Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M et al (2016) ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 12:i4919CrossRef
21.
go back to reference Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I et al (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 28:l4898CrossRef Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I et al (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 28:l4898CrossRef
22.
go back to reference Sodergren MH, Swift I (2010) Seroma formation and method of mesh fixation in laparoscopic ventral hernia repair — highlights of a case SERIES. Scand J Surg 99(1):24–27CrossRefPubMed Sodergren MH, Swift I (2010) Seroma formation and method of mesh fixation in laparoscopic ventral hernia repair — highlights of a case SERIES. Scand J Surg 99(1):24–27CrossRefPubMed
23.
go back to reference Tamme C, Garde N, Klingler A, Hampe C, Wunder R, Köckerling F (2005) Totally extraperitoneal inguinal hernioplasty with titanium-coated lightweight polypropylene mesh: early results. Surg Endosc 19(8):1125–1129CrossRefPubMed Tamme C, Garde N, Klingler A, Hampe C, Wunder R, Köckerling F (2005) Totally extraperitoneal inguinal hernioplasty with titanium-coated lightweight polypropylene mesh: early results. Surg Endosc 19(8):1125–1129CrossRefPubMed
24.
go back to reference Varnell B, Bachman S, Quick J, Vitamvas M, Ramshaw B, Oleynikov D (2008) Morbidity associated with laparoscopic repair of suprapubic hernias. Am J Surg 196(6):983–988CrossRefPubMed Varnell B, Bachman S, Quick J, Vitamvas M, Ramshaw B, Oleynikov D (2008) Morbidity associated with laparoscopic repair of suprapubic hernias. Am J Surg 196(6):983–988CrossRefPubMed
25.
go back to reference Pan C, Xu X, Si X, Yu J (2022) Effect of complete reduction of hernia sac and transection of hernia sac during laparoscopic indirect inguinal hernia repair on seroma. BMC Surg 22(1):149CrossRefPubMedCentralPubMed Pan C, Xu X, Si X, Yu J (2022) Effect of complete reduction of hernia sac and transection of hernia sac during laparoscopic indirect inguinal hernia repair on seroma. BMC Surg 22(1):149CrossRefPubMedCentralPubMed
26.
go back to reference Zhu X, Cao H, Ma Y, Yuan A, Wu X, Miao Y et al (2014) Totally extraperitoneal laparoscopic hernioplasty versus open extraperitoneal approach for inguinal hernia repair: a meta-analysis of outcomes of our current knowledge. The Surgeon 12(2):94–105CrossRefPubMed Zhu X, Cao H, Ma Y, Yuan A, Wu X, Miao Y et al (2014) Totally extraperitoneal laparoscopic hernioplasty versus open extraperitoneal approach for inguinal hernia repair: a meta-analysis of outcomes of our current knowledge. The Surgeon 12(2):94–105CrossRefPubMed
27.
go back to reference Shah NS, Fullwood C, Siriwardena AK, Sheen AJ (2014) Mesh fixation at laparoscopic inguinal hernia repair: a meta-analysis comparing tissue glue and tack fixation. World J Surg 38(10):2558–2570CrossRefPubMed Shah NS, Fullwood C, Siriwardena AK, Sheen AJ (2014) Mesh fixation at laparoscopic inguinal hernia repair: a meta-analysis comparing tissue glue and tack fixation. World J Surg 38(10):2558–2570CrossRefPubMed
28.
go back to reference Leibl BJ, Schmedt CG, Kraft K, Ulrich M, Bittner R (2000) Scrotal hernias: a contraindication for an endoscopic procedure?: results of a single-institution experience in transabdominal preperitoneal repair. Surg Endosc 14(3):289–292CrossRefPubMed Leibl BJ, Schmedt CG, Kraft K, Ulrich M, Bittner R (2000) Scrotal hernias: a contraindication for an endoscopic procedure?: results of a single-institution experience in transabdominal preperitoneal repair. Surg Endosc 14(3):289–292CrossRefPubMed
29.
go back to reference Poli M, de Figueiredo S, Belyansky I, Lu R (2023) Pitfalls and complications of enhanced-view totally extraperitoneal approach to abdominal wall reconstruction. Surg Endosc 37(5):3354–3363CrossRef Poli M, de Figueiredo S, Belyansky I, Lu R (2023) Pitfalls and complications of enhanced-view totally extraperitoneal approach to abdominal wall reconstruction. Surg Endosc 37(5):3354–3363CrossRef
30.
go back to reference Nikolian VC, Pereira X, Arias-Espinosa L, Bazarian AN, Porter CG, Henning JR, et al (2024) Primary abandonment of the sac in the management of scrotal hernias: a dual-institution experience of short-term outcomes. Hernia. 2024 Mar 19 [cited 2024 Jun 14]; https://link.springer.com/https://doi.org/10.1007/s10029-024-03009-9 Nikolian VC, Pereira X, Arias-Espinosa L, Bazarian AN, Porter CG, Henning JR, et al (2024) Primary abandonment of the sac in the management of scrotal hernias: a dual-institution experience of short-term outcomes. Hernia. 2024 Mar 19 [cited 2024 Jun 14]; https://​link.​springer.​com/​https://​doi.​org/​10.​1007/​s10029-024-03009-9
31.
go back to reference Petro CC, Montelione KC, Zolin SJ, Renton DB, Yunis JP, Meara MP et al (2023) Robotic eTEP versus IPOM evaluation: the REVEAL multicenter randomized clinical trial. Surg Endosc 37(3):2143–2153CrossRefPubMed Petro CC, Montelione KC, Zolin SJ, Renton DB, Yunis JP, Meara MP et al (2023) Robotic eTEP versus IPOM evaluation: the REVEAL multicenter randomized clinical trial. Surg Endosc 37(3):2143–2153CrossRefPubMed
32.
go back to reference Choudhary A, Ali S, Siddiqui A, Rattu P, Pusuluri R (2023) A randomised control trial study of early post-operative pain and intraoperative surgeon workload following laparoscopic mesh repair of midline ventral hernia by enhanced-view totally extraperitoneal and intraperitoneal onlay mesh plus approach. J Minimal Access Surg 19(3):427–432CrossRef Choudhary A, Ali S, Siddiqui A, Rattu P, Pusuluri R (2023) A randomised control trial study of early post-operative pain and intraoperative surgeon workload following laparoscopic mesh repair of midline ventral hernia by enhanced-view totally extraperitoneal and intraperitoneal onlay mesh plus approach. J Minimal Access Surg 19(3):427–432CrossRef
33.
go back to reference Xu H, Huang W, Guo Y, Li M, Peng G, Wu T (2023) Efficacy of extended view totally extra peritoneal approach versus laparoscopic intraperitoneal on lay mesh plus for abdominal wall hernias: a single center preliminary retrospective study. BMC Surg 23(1):200CrossRefPubMedCentralPubMed Xu H, Huang W, Guo Y, Li M, Peng G, Wu T (2023) Efficacy of extended view totally extra peritoneal approach versus laparoscopic intraperitoneal on lay mesh plus for abdominal wall hernias: a single center preliminary retrospective study. BMC Surg 23(1):200CrossRefPubMedCentralPubMed
34.
go back to reference Chen L, Hu M, Huang S (2023) Analysis of influencing factors of complications after laparoscopic inguinal hernia repair: an observational study. Medicine (Baltimore) 102(49):e36516CrossRefPubMed Chen L, Hu M, Huang S (2023) Analysis of influencing factors of complications after laparoscopic inguinal hernia repair: an observational study. Medicine (Baltimore) 102(49):e36516CrossRefPubMed
Metadata
Title
Navigating hernia sac management in minimally invasive inguinal hernia repair: to abandon or to reduce? An updated systematic review and meta-analysis
Authors
Ana Caroline Dias Rasador
Carlos Balthazar da Silveira
João Pedro Kasakewitch
Gabriele Lech
Diego Laurentino Lima
Prashanth Sreeramoju
Flavio Malcher
Publication date
23-10-2024
Publisher
Springer US
Published in
Surgical Endoscopy
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI
https://doi.org/10.1007/s00464-024-11323-7
SPONSORED

Mastering chronic pancreatitis pain: A multidisciplinary approach and practical solutions

  • Webinar | 06-02-2024 | 20:00 (CET)

Severe pain is the most common symptom of chronic pancreatitis. In this webinar, experts share the latest insights in pain management for chronic pancreatitis patients. Experts from a range of disciplines discuss pertinent cases and provide practical suggestions for use within clinical practice.

Sponsored by:
  • Viatris
Developed by: Springer Healthcare
Watch now