To close or not to close the deep inguinal ring in laparoscopic hernia repair. A comparative study

Closing the deep inguinal ring (DIR) in laparoscopic inguinal hernia repair (LIHR) is a potential alternative to improve surgical outcomes, however, its implementation remains controversial. We aimed to compare postoperative results after DIR closure in laparoscopic TAPP repair for large indirect inguinal hernias.

A retrospective analysis was conducted in patients who underwent LIHR with indirect defects ≥ 3 cm (L3 according to the European Hernia Society classification) between January 2022 and December 2024. Patients were divided into two groups: closed ring repair (CRR) and standard repair (SR) group. Demographic, intraoperative, and postoperative variables were analyzed.

A total of 177 laparoscopic TAPP repairs with L3 defects were included for analysis. Seventy-two repairs were in the CRR group and 105 in the SR group. Defect area was significantly larger in CRR group (CRR: 15.7 cm² vs. SR: 13.9 cm²; p = 0.02). Mesh fixation was less frequently required in CRR group (CRR: 56% vs. SR: 90.5%; p < 0.0001), and when fixation was used, fewer tackers were applied (CRR: 3.2 vs. SR: 4.7; p < 0.0001). Postoperative pain was significantly lower in CRR group at 1 week (VAS CR: 0.71 vs. SR: 1.63; p = 0.01) and at 1 month (VAS CRR: 0.19 vs. SR: 0.58; p = 0.04). After a mean follow-up of 15 (9-25) months, only one recurrence was observed in the SR group.

Closing the deep inguinal ring in laparoscopic inguinal TAPP repair for L3 defects is safe. It was associated with a significant reduction of acute postoperative pain scores and mesh fixation requirements.