Tissue repair: suture closure of the internal inguinal ring in rTAPP

Recurrence rates and chronic postoperative inguinal pain after groin hernia repair have remained largely unchanged over the past three decades, irrespective of surgical approach. While hernia defect closure is incorporated in some open repair techniques, closure of the internal inguinal ring during endoscopic repair has not been adopted, primarily due to concerns regarding nerve entrapment. New robotic platforms provide enhanced visualization and instrument articulation, potentially enabling safe internal ring suture closure.

This prospective observational study included 43 patients with large groin hernias who underwent robotic transabdominal preperitoneal (rTAPP) inguinal hernia repair with partial suture closure of the internal inguinal ring as an adjunct to mesh implantation. Patient demographics, operative details, perioperative complications, postoperative pain, and incidence of neuropathic pain were analyzed. Quality of life was assessed using the EuraHS Quality of Life (QoL) score.

A total of 56 hernia sites were repaired (26 unilateral, 30 bilateral). 66% were EHS L3 hernias, 25% were inguinoscrotal, and 7.7% were recurrent. Postoperative pain decreased significantly from postoperative day 1 to day 2 (VAS score of 1.04 vs. 2.07, p = 0.0002). No patient developed neuropathic pain. The most common complication was seroma (12%). Persistent nociceptive pain beyond 30 days occurred in one patient (1.8%). All domains of the EuraHS QoL score demonstrated significant postoperative improvement.

Partial suture closure of the internal inguinal ring during rTAPP appears feasible and safe as an adjunct to mesh implantation in selected patients. Detailed anatomical knowledge and meticulous surgical technique are essential to prevent nerve injury. Randomized controlled studies are warranted to define appropriate patient selection criteria.