Clinical Comparison of New Peritoneal Suture and Traditional Suture in Transabdominal Preperitoneal Prosthetic Operation for Inguinal Hernia

Abstract

Objectives

This study aimed to assess the efficacy of intraperitoneal suturing for peritoneal closure in preventing adhesions and improving clinical outcomes during laparoscopic transabdominal preperitoneal prosthetic (TAPP) hernia repair for inguinal hernia.

Materials and Methods

A retrospective cohort study of 126 patients undergoing TAPP herniorrhaphy between November 2021 and November 2022 compared intraperitoneal suture technique (n = 64) versus conventional suturing (n = 62) for peritoneal flap closure. Evaluated parameters included demographic characteristics (age, sex, body mass index [BMI]), operative metrics (suture count, peritoneal closure time), procedural efficacy (complete peritoneal closure rate), and postoperative outcomes encompassing Visual Analog Scale (VAS) pain scores, adhesion formation, seroma incidence, recurrence rates, and intestinal obstruction occurrence.

Results

The intraperitoneal suture group achieved significantly higher complete internal inversion success rates (57 [89.1%] vs. 5 [8.1%]; p < 0.001), lower peritoneal adhesion incidence (1 [1.6%] vs. 9 [14.5%]; p = 0.018), and shorter peritoneal suture time (481.20 ± 47.91 vs. 584.77 ± 70.77 minutes; p < 0.001) compared with the traditional suture group. No significant intergroup differences were identified in age, sex, BMI, stitch counts, VAS scores, seroma, recurrence rates, or ileus incidence.

Conclusion

The application of the intraperitoneal suture technique in TAPP to prevent peritoneal adhesion is effective, safe, and easy to learn, with good clinical effect and deserves promotion and application.

 

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Keywords

laparoscope - peritoneal suture - TAPP - peritoneal adhesion

Laparoscopic surgery has many advantages, such as minimal invasion, less formation of adhesions, and lower risk of intra-abdominal infection.[1] Many studies[2] have shown that patients undergoing laparoscopic surgery for inguinal hernia repair have fewer postoperative complications and a low recurrence rate, and they return to normal activities faster than patients undergoing open surgery. The two most commonly used methods in laparoscopic inguinal hernia repair are total extraperitoneal prosthetic (TEP) and transabdominal preperitoneal prosthetic (TAPP). Although previous studies have not reported a significant difference in the postoperative effect between the two techniques,[3] TAPP can explore the intra-abdominal situation and find occult hernia, which is convenient to use. Currently, many surgeons use TAPP to perform inguinal hernia repair.[2] After the safe placement of a mesh during TAPP, it is necessary to close the peritoneal incision to prevent adhesions. At present, there is no unified standard for the peritoneal incision suture method in TAPP. The traditional method of suturing is simple continuous suturing, which leads to the exposure of the peritoneal fat eversion in the abdominal cavity and rough peritoneal incision ([Supplementary Fig. S1], available in online version). Postoperative complications of TAPP include pain, small bowel adhesion, hematoma formation, fluid accumulation, and incision infection,[4] [5] [6] whereas emergency surgery, use of anticoagulant drugs, coagulation disorders, elevated inflammatory factors due to tissue injury, and oxidative stress are important factors contributing to these complications.[7] [8]

Compared with open surgery, laparoscopic technology can reduce the immune response. Although the incidence of intestinal adhesion is not high, it is an important complication after abdominal and pelvic surgery.[3] [9] Once it occurs, it is likely to cause a significant disease burden. Fibrous adhesions may be formed during the operation into the abdominal cavity, and the damaged peritoneum may undergo repair obstacles during the repair process, resulting in adhesions between the injured peritoneum tissues and organs in the pelvic and abdominal cavity.[10] [11] Abdominal adhesions can be found in approximately 95% of patients with abdominal operations, but most patients with abdominal adhesions have few clinical symptoms and physical problems.[12] However, some patients may experience serious postoperative complications, among which intestinal obstruction is a more serious consequence of adhesion. According to some previous studies, 30 to 41% of patients who need reoperation after abdominal surgery have intestinal adhesions. The proportion of small bowel obstruction in these patients is 65 to 75%.[12] [13] [14] Many patients need hospitalization and surgical treatment because of intestinal adhesion and intestinal obstruction, and some even die because of acute twisted intestinal obstruction.[3] [12]

To prevent possible peritoneal adhesions after TAPP, we applied the intraperitoneal suture method to close the peritoneal incision, and the peritoneal incision was smooth after closure ([Supplementary Fig. S2], available in online version). The clinical comparison between the intraperitoneal suture method and conventional suture was made.

Materials and Methods

Patient Information

The hospitalized patients were collected from November 2021 to November 2022. The inclusion criteria were as follows: adult and preoperative patients with unilateral inguinal hernia. The exclusion criteria were as follows: (1) recurrent hernia or bilateral hernia; (2) incarceration or twisted hernia; (3) the presence of ascites, connective tissue disease, heart/kidney/liver failure, or hypoproteinemia; (4) use of aspirin, clopidogrel, or other drugs affecting coagulation function; (5) abdominal trauma, surgical history, and pelvic inflammation; (6) presence of constipation, dysuria, and chronic cough; (7) scar constitution; (8) intraoperative abdominal adhesion; (9) the patient has contraindications for general anesthesia. This study was approved by the Ethics Committee and conforms to the Declaration of Helsinki.

 

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Surgical Procedure

All operations are performed by a senior surgeon under general anesthetic. At the time of surgery, each patient was placed in a supine position on a bed slightly tilted to the healthy side for 15 to 30 degrees, with low head and foot height of 15 to 30 degrees. The operator was located on the healthy side, and the assistant was located at the head. The operator used a 10-mm trocar to make observation holes at the lower umbilical margin, and a 5-mm trocar was placed at the lateral margin of the rectus abdominis muscle on the left and right sides of the flat umbilical cord to make operation holes. The length of the peritoneal incision in the inguinal region was measured and marked with a measuring scale before the incision, so that the incision of the peritoneal flap in each case was 7 cm. The Bogros space and the Retzius space were separated one by one, and the smaller hernia sac was removed and reduced as completely as possible. As for the larger hernia sac (the hernia sac entering the scrotum), the neck of the hernia sac was transected, and the proximal end was sealed with 3–0 absorbable wire before transecting, whereas the distal hernia sac was removed and parietalisation of spermatic cord was performed. After placing an approximately 10 × 15-cm polypropylene 3D mesh in the preperitoneal space, the varus suturing group received 11 to 14 varus stitches to the peritoneal flap using a sledge needle ([Figs. 1], [2]) (prebent with 3–0 Polysorb ½ round needle produced by COVIDIEN). In the traditional suture group, the 3–0 Polysorb ½ round needle produced by COVIDIEN was used for continuous 11 to 14 stitches suturing from the lower peritoneal fold to the upper peritoneal fold ([Fig. 3]).

Fig. 1 3–0 Polysorb ½ circle needle is prebent to make a sledge needle.

Fig. 2 The peritoneal flap was sutured with a sledge needle in the varus suture group.

Fig. 3 The peritoneal flap was sutured with a circular needle in the traditional suture group.

In both groups, the first needle was stitched from the peritoneal valve on the right side of the lead surgeon, and the end of the thread was tied. Before the last suture was tied, the suture tightness was measured and adjusted to ensure that the peritoneal valve incision after each closure was approximately 7 cm, and then the suture was fixed by tying. The number of stitches, peritoneal suture time, and complete peritoneal inversion cases were recorded. Visual analogue score (VAS) was determined on the first postoperative day, and the postoperative follow-up was completed through outpatient treatment. Follow-up ultrasound was performed at 1 week, 1 month, 3 months, and half a year after operation to record the occurrence of peritoneal adhesions, seroma, recurrence, and intestinal obstruction.

 

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Diagnostic Criteria for Postoperative Adhesion

A high-frequency linear array probe (4–15 MHz) was used by the same experienced ultrasound physician. The patients who returned 1 month after surgery were placed in a supine position, and the primary peritoneal incision and suture area at the upper margin of the internal ring opening were examined by ultrasound. If the longitudinal and transverse “visceral slip” distance was greater than 1 cm, we judged that there was no peritoneal adhesion in this area. If the longitudinal and horizontal “visceral slide” distance was less than 1 cm, we then asked the patient to lie on the healthy side at 90 degrees for dynamic comparative observation. If the “visceral slide” distance was still less than 1 cm, it was judged that there was peritoneal and visceral adhesion in this area. [Fig. 4] left shows the appearance of adhesion in the inguinal area of the surgical side under ultrasound, whereas [Fig. 4] right shows the absence of adhesion in the surgical side (in the two sonograms, A represents the abdominal wall, B represents the peritoneal line, C represents the abdominal viscera, and the white arrow indicates the peritoneal adhesion).

Fig. 4 Ultrasound imaging features of adhesion or without adhesion (white arrow) were observed in the inguinal area on the surgical side. A represents the abdominal wall, B represents the peritoneal line, C represents the abdominal viscera, and the white arrow indicates the peritoneal adhesion.

 

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Statistical Analysis

All statistical analyses were performed using SPSS 26.0 (IBM, Chicago, Illinois, United States). Continuous variables were presented as mean ± standard deviation and analyzed by Student's t test or Mann–Whitney U test. Categorical variables were described by percentages and analyzed by the chi-square test. For all analyses, p-values lower than 0.05 were considered statistically significant.

 

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Results

All of the 126 surgical patients were admitted with recurring unilateral mass in the inguinal region. Preoperative investigation and abdominal B-scan ultrasound examination clarified the diagnosis of inguinal hernia. A total of 64 patients were included in the intraperitoneal suture group, whereas 62 patients were included in the traditional suture group. As shown in [Table 1], the male-to-female ratio in the peritoneal varus suture group was not different from that in the traditional suture group (63/1 vs. 60/2, p = 0.978), and the mean age was 60.55 ± 15.60 and 60.21 ± 15.87, respectively (p = 0.904). Body mass index (BMI) was 23.01 ± 2.44 and 22.33 ± 2.25, respectively (p = 0.106). There were no significant differences in sex, age, and BMI between the two groups.

Table 1 General characteristics of the 126 patients divided into two groups

Variables	Intraperitoneal suture (n = 64)	Traditional suture (n = 62)	p-Value
Sex
Male	63 (98.4%)	60 (96.8%)	0.978
Female	1 (1.6%)	2 (3.2%)
Age	60.55 ± 15.60	s	0.904
BMI	23.01 ± 2.44	22.33 ± 2.25	0.106

Abbreviation: BMI, body mass index.

As shown in [Table 2], the success rate of complete peritoneal varus was significantly higher in the intraperitoneal suturing group than in the traditional suturing group (57 [89.1%] vs. 5 [8.1%], p < 0.001). The peritoneal adhesion rate was lower in the intraperitoneal suturing group than in the traditional suture group (1 [1.6%] vs. 9 [14.5%], p = 0.018). The peritoneal suture time in the intraperitoneal suturing group was shorter than that in the traditional suturing group (481.20 ± 47.91 vs. 584.77 ± 70.77, p = 0.000), and there was a significant difference between the two groups. There were no significant differences in the number of stitches, VAS, and occurrence of seroma between the two groups.

Table 2 Comparison of postoperative data between the two groups

Variables	Intraperitoneal suture (n = 64)	Traditional suture (n = 62)	p-Value
Suture time (s)	481.20 ± 47.91	584.77 ± 70.77	<0.001
Number of stitches	12.34 ± 0.88	12.56 ± 1.03	0.198
VAS	2.05 ± 0.52	2.11 ± 0.58	0.499
Complete peritoneal varus	57 (89.1%)	5 (8.1%)	<0.001
Peritoneal adhesions	1 (1.6%)	9 (14.5%)	0.018
Seroma	3 (4.7%)	4 (6.5%)	0.966

Abbreviation: VAS, Visual Analog Scale.

 

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Discussion

Laparoscopic inguinal hernia repair includes intra-abdominal peritoneal onlay mesh repair (IPOM), TAPP, and TEP. Since IPOM technology requires the use of expensive composite patches with antiadhesion coating,[15] and the patches are placed in the peritoneal cavity and directly in contact with the internal organs, where there are still risks of intestinal adhesion, intestinal obstruction, abdominal organ erosion, and other serious complications,[16] [17] this operation is rarely performed clinically. The mesh is placed in front of the peritoneum, which is the ideal prime position for abdominal hernia repair.[18] At present, the surgical methods widely used by surgeons include TAPP and TEP, both of which can place the mesh in front of the peritoneum. Many scholars have found that the two methods show no significant differences in postoperative complications and therapeutic effects and are both safe and effective.[19] Because TAPP can see the anatomical signs of the inguinal region and has a wide field of vision, there is no need to worry about the swing of the peritoneal flap after peritoneal perforation, resulting in a smaller operating field and a short learning curve. TAPP can also probe the intraperitoneal situation and find occult hernia, which is convenient to use. Many operators are inclined to carry out this operation, especially young surgeons. Compared with TEP, the main disadvantage of TAPP is intraperitoneal surgery, which may disturb the internal organs of the abdomen and damage them. Besides, it is necessary to cut the peritoneum approximately 7 cm long in the inguinal region and close the peritoneal incision after placing the mesh in the preperitoneal space. At present, there are many reports on the closing methods of peritoneal incision in TAPP. The closing methods include sutures, absorbable nails, clips, and fibrin glue,[19] [20] but there is no uniform international standard. However, except suture fixation, other methods seem to substantially increase consumables costs, so the current mainstream is to use sutures to close the peritoneal incision. Regardless of the method used to close the peritoneal incision, peritoneal adhesion, and intestinal obstruction may occur during the peritoneal healing process. It has been reported that in 1.4 to 17.5% of cases, peritoneum and internal organs are adherent after TAPP.[21] Another article reported that the incidence of small bowel obstruction after TAPP surgery was 0.2 to 0.5%.[22] If the peritoneal suture closure is not accurate, the intestinal tube may contact the patch, and in severe cases, postoperative intestinal tube perforation may occur.[23]

How to optimize the peritoneal suture method, making the peritoneal incision smooth, reduce the postoperative abdominal adhesion, and improve the short-term and long-term quality of life of patients, has been a difficult problem in the field of general surgery. Another problem in clinical work is how to evaluate whether peritoneum adhesion has occurred after surgery. In 1991, Sigel et al[24] reported that ultrasound showed the dynamic characteristics of abdominal visceral movement with respiration, i.e., “visceral slide.” The adhesion between the anterior abdominal wall and the viscera was judged by ultrasound examination. Comparing the results observed by ultrasound in the absence of intraoperative adhesion, the results showed that ultrasound-detected “visceral slide” could reliably judge the adhesion between the viscera and the anterior abdominal wall and successfully solve the peritoneal adhesion diagnosed by ultrasound noninvasive examination. According to another study,[25] which used magnetic resonance imaging (MRI) to detect abdominal organ sliding, abdominal adhesion can be found. The sensitivity and specificity are the same as with ultrasound diagnosis, but the test is expensive, so it is difficult to popularize MRI widely, and the use of ultrasound is preferred. “Visceral slide” refers to the normal phenomenon of pelvic and abdominal organs moving back and forth behind the wall peritoneum during breathing movement. It can be produced by normal breathing, deep breathing, Valsalva movements, or hand pressing on the abdomen. The sliding amplitude is limited when there is an adhesion of the intra-abdominal viscera to the anterior ventral wall. Several scholars[26] [27] [28] used “visceral slide” when studying peritoneal adhesion and used the intestinal movement of less than 1 cm along the long axis to diagnose peritoneal adhesion, indicating that this diagnostic standard is widely recognized. Therefore, in this study, we used a relatively economical, convenient ultrasound examination approved by most scholars to judge peritoneal adhesion and used 1 cm as the diagnostic criterion.

In this study, the rate of peritoneal adhesion diagnosed by ultrasound in the intraperitoneal suturing group was significantly lower than that in the traditional suturing group. One case of peritoneal adhesion in the varus suturing group belonged to incomplete peritoneal varus, indicating that a complete peritoneal varus could well prevent postoperative peritoneal and visceral adhesion. We made measurements before the peritoneal incision and after the peritoneal suture, ensuring that the incision of the peritoneal flap in each case was approximately 7 cm, the suture needle distance was 0.5 to 0.8 cm, and the suture edge distance was 0.5 to 0.8 cm. Such an arrangement made the number of stitches closed by the two suture methods almost the same, and the tension of peritoneal closure was comparable between the two groups. As a result, the time of peritoneal suture was more comparable between the two groups. In the intraperitoneal suturing group, complete varus was achieved in most of the peritoneum. In seven cases, the main reason for incomplete varus was that the suture needle distance was too wide and the suture edge distance was too narrow. If the suture needle distance and suture edge distance were appropriate, the operation could be successful.

The peritoneum is composed of a single layer of mesothelial cells. Surgery is the most important cause of mesothelial injury in promoting peritoneal adhesion.[29] Inflammation of the peritoneum is associated with fibrin exudates. In the inflammatory state, mesothelial cells change from fibrinolysis to antifibrinolysis, resulting in the deposition of fibrin exudate; in addition, vascular damage and leakage of blood and gastrointestinal fluid further enhance the deposition of fibrin.[30] Ito et al[31] constructed a mouse parietal peritoneal ischemia model and found that the occurrence of adhesions and connective tissue formation was observed on the first day after surgery. In this study, the peritoneum was closely matched by the varus suture technique. Sarate et al[32] found that anatomical structural integrity can effectively reduce the mechanical stress between cells, increase cell adhesion, and facilitate the repair of damage; in addition, the tight incision can accelerate the incision neoangiogenesis, promote healing, and reduce the fluid leakage caused by mucosal eversion to promote adhesion. In this study, there were no significant differences in demographic characteristics, postoperative VAS, and seroma between the two groups. Consistent with the findings of previous studies, the adverse factors for developing seroma after laparoscopic inguinal hernia include: high body mass index and low preoperative albumin level, and so on; seroma can cause increased pain.[33] [34] The peritoneal suturing time in the intraperitoneal suturing group was slightly shorter than that in the traditional suturing group, indicating that the intraperitoneal suturing method would not increase the operation time compared with the traditional suturing method, and neither the physician nor the patient would have an additional burden.

At present, there are very few reports on the use of the intraperitoneal suture technique in TAPP surgery of inguinal hernia. The number of cases included in our study was also small, and there have been no large-scale studies. In the later stage, multicenter, large-sample, and long-term follow-up clinical studies should be performed to obtain more research conclusions.

 

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Conclusion

In conclusion, the application of the intraperitoneal suture technique in TAPP surgery to prevent peritoneal adhesion is effective, safe, simple, and easy to learn, with good clinical effect, and deserves promotion and application.

 

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Conflict of Interest

None declared.

Acknowledgments

We thank the patients enrolled in this study and the People's Hospital of Laibin.

Data Availability Statement

The datasets used or analyzed during the current study are available from the corresponding author on reasonable request.

Ethical Approval

This retrospective study was performed by the Declaration of Helsinki of the World Medical Association. It was waived by the Ethics Committee of Laibin People's Hospital, and the informed consent of patients was waived because of its retrospective study.

^* These authors contributed equally to this work. The co-first authors.

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Publication History

Received: 20 June 2025

Accepted: 06 August 2025

Article published online:
25 August 2025