Invest Clin 64(4): 495 - 504, 2023 https://doi.org/10.54817/IC.v64n4a6

Corresponding author: Bixiang Zheng: Department of General Surgery, Santai People’s Hospital, Mianyang, Si-

chuan Province, China. E-mail: yanhuizhong20@163.com

Influence of different peritoneal incision

closure methods on the operative outcomes

and prognosis of patients undergoing

laparoscopic inguinal hernia repair.

Bixiang Zheng, Xiaobin Luo, Changdong Wang, Rendong Zheng and Xiaofeng Yang

Department of General Surgery, Santai People’s Hospital, Mianyang, Sichuan Province,

China.

Keywords: Laparoscopic inguinal hernia repair; peritoneal rupture; bipolar coagulation.

Abstract. The aim was to investigate the effect of different peritoneal tear

closure methods on the operative outcomes and prognosis of patients undergo-

ing laparoscopic inguinal hernia repair (LIHR). Ninety patients who underwent

LIHR in our hospital from August 2019 to December 2020 and had peritoneal

tears during the operation were selected, and the patients were divided into

a control group (CG) and the observation group (OG) according to different

treatment plans, with 45 cases in each group. Patients in the CG were treated

with absorbable sutures to repair the peritoneal tears, while patients in the OG

were treated with bipolar coagulation to close and repair the peritoneal tears.

The surgical conditions, postoperative pain scores, quality of life scores, com-

plications, and recurrence were compared between the CG and OG groups. The

operation time and hospital stay in the OG were shorter than those in the OG

(p<0.05). The pain scores in the OG at 24 hours after operation were lower

than those in the CG (p<0.05), and the pain scores of the two groups were

not significantly different at two hours and 12 hours (p>0.05). Postoperative

complications were not significantly different between the groups (p>0.05).

The scores of material life, physical, social, and psychological function in the

OG were higher than in the CG (p<0.05). There were no recurrences in the two

groups during the 1-year follow-up. Closing repair of peritoneal rupture with

bipolar coagulation reduces the operation time of patients with peritoneal rup-

ture during TEP (total extraperitoneal hernioplasty) operations, reduces pain,

and improves their quality of life. The treatment outcome is safe, effective, and

has an excellent clinical application effect.

496 Zheng et al.

Investigación Clínica 64(4): 2023

Influencia de diversos métodos de cierre de la incisión

peritoneal en los resultados quirúrgicos y el pronóstico en

pacientes sometidos a reparación laparoscópica de hernia inguinal.

Invest Clin 2023; 64 (4): 495 – 504

Palabras clave: reparación laparoscópica de la hernia inguinal; ruptura peritoneal;

coagulación bipolar.

Resumen. El propósito de este trabajo fue investigar el efecto de distintos

métodos de cierre de desgarros peritoneales sobre el resultado quirúrgico y

el pronóstico en pacientes sometidos a la reparación laparoscópica de hernia

inguinal (LIHR). Fueron elegidos un total de 90 pacientes sometidos a LIHR

en nuestro hospital desde agosto de 2019 a diciembre de 2020 y que tuvieron

desgarros peritoneales durante la operación; los pacientes fueron divididos en

un grupo control (GC) y un grupo de observación (OG) según distintos planes

de tratamiento, con 45 casos en cada grupo. Los pacientes del GC fueron tra-

tados con suturas absorbibles para reparar los desgarros peritoneales, mientras

que los pacientes del OG fueron tratados con coagulación bipolar para cerrar y

reparar los desgarros peritoneales. Se realizó una comparación de ambas con-

diciones quirúrgicas, que incluyeron las puntuaciones de dolor posoperatorio y

calidad de vida, las complicaciones y la recurrencia entre los grupos GC y OG.

El tiempo de operación e ingreso en el hospital en el OG fueron más cortos que

en el OG (p<0,05). Las puntuaciones de dolor en el OG a las 24 horas después

de la operación fueron menores que las del GC (p<0,05) y las puntuaciones de

dolor de ambos grupos no fueron diferentes de modo significativo a las 2 horas

y 12 horas (p>0,05). Las complicaciones postoperatorias no fueron significati-

vamente diferentes entre OG (p>0,05). Los puntajes de vida material, función

física, función social y función psicológica en el OG fueron más elevados que

los del GC (p<0,05). No hubo recurrencias en ninguno de los grupos durante el

seguimiento de 1 año. En conclusión, la reparación de cierre de la ruptura peri-

toneal con coagulación bipolar redujo el tiempo de operación de los pacientes,

redujo su dolor y mejoró su calidad de vida. El efecto del tratamiento es seguro,

efectivo y tiene un excelente resultado en su aplicación clínica.

Received: 19-03-2023 Accepted: 21-05-2023

INTRODUCTION

An inguinal hernia is a common medi-

cal problem that develops when tissue, such

as a portion of the intestine or abdominal

fat, pushes through a weak area or hole in

the abdominal wall 1. This type of hernia is

most common in men, but women can also

develop them 2. The lifetime risk of develop-

ing an inguinal hernia is 27-43% for men and

3-6% for women 3.

Inguinal hernias can be brought on by

many things, such as heredity, age, persis-

tent coughing, obesity, and physical stress4,5.

Inguinal hernias often generate a visible

bulge or swelling in the groin area, which

Peritoneal incision closure methods and inguinal hernia repair 497

Vol. 64(4): 495 - 504, 2023

might become more noticeable while cough-

ing or moving heavy things. The hernia may

be painful or uncomfortable in certain cir-

cumstances, especially while standing or

walking for extended periods 6,7.

Inguinal hernias can develop problems

like incarceration or strangulation, in which

the projecting tissue becomes trapped and

loses blood flow, potentially resulting in tis-

sue damage or even death. So, early diagnosis

and treatment are essential in managing the

condition and preventing complications 8.

Inguinal hernias are commonly treat-

ed with surgical repair, which may be done

using laparoscopic or open methods. Dur-

ing surgery, the projecting tissue is pulled

back into position, and the weak muscle wall

is strengthened with sutures or synthetic

mesh. Inguinal hernia surgery is frequently

very successful and can offer long-lasting

symptom alleviation 9,10.

However, during abdominal operations,

peritoneal rips are a typical occurrence. Ab-

sorbable sutures and bipolar coagulation are

two methods available to heal peritoneal in-

juries 11. After a laparotomy or laparoscopy,

the surgeon may close the peritoneum based

solely on personal preference 12. In order

to minimize abdominal wall weakening and

to prevent incisional hernias, it has been

claimed by surgeons and in the standard sur-

gical texts that the peritoneum should be

sutured 13. Nevertheless, clinical and experi-

mental studies have shown that the raw peri-

toneal defect heals spontaneously, quickly,

smoothly, and without apparent catastrophe

because the peritoneum has no discernible

impact on the healing process or the tensile

strength of the laparotomy wound. So, after

the laparoscopic hernia repair, the peritone-

um should be left to heal spontaneously 14-16.

Since limited studies have compared

these two techniques, and due to the exis-

tence of disagreements regarding the need

to perform therapeutic measures and the

need not to take action to repair the peri-

toneal rupture, this study was indicated to

be conducted to compare the efficiency and

safety of these two techniques and investi-

gate the necessity or not of intervention in

the repairment of peritoneal rupture during

laparoscopic inguinal hernia surgery.

MATERIALS AND METHODS

General data

Ninety patients who underwent LIHR

in our hospital from August 2019 to Decem-

ber 2020 and had peritoneal tears during

the operation were selected and divided into

the control group (CG) and the observation

group (OG), with 45 cases in each group.

The general data between the two groups

was not significantly different (p>0.05)

(Table 1). The ethics committee in the hos-

pital approved this study, and all patients

signed an informed consent form. Inclusion

criteria: ①The age range considered for

Table 1

General data.

Groups Cases Sex Age

(years)

Disease course

(months)

BMI

(kg/m2)

Type (cases)

Male Female III III IV

Observation

group

45 40

(88.8%)**

(11.12%)

63.56±7.76* 50.52±10.25 24.75±2.47 7

(15.5%)**

(31.1%)

(28.8%)

(24.6%)

Control

group

45 38

(84.4%)

(15.6%)

62.23±7.85* 52.56±9.58 24.95±2.82 9

(20%)

(26.7%)

(33.3%)

(20%)

χ2/t/Z 0.385 0.808 -0.975 -0.358 -0.377

p&0.535 0.421 0.332 0.721 0.706

*Quantitative variables expressed by mean ± standard deviation. ** Qualitative variables expressed by frequency

(percent). &P-value based on t-test / chi-square χ2. Significance level ≤ 0.05.

498 Zheng et al.

Investigación Clínica 64(4): 2023

this study was between 30 and 80 years old;

②Patients who were diagnosed with a direct

inguinal hernia by clinical symptoms, signs,

B-ultrasound, and other examinations17, and

who underwent TEP surgery and had perito-

neal rupture during the operation; ③They

fell within the American Society of Anesthe-

siologists grade I-II score; ④Patients with

complete clinical medical records. Exclusion

criteria: ①Patients with a history of mid-low-

er abdominal surgery; ②those with indirect

inguinal hernia, incarcerated or strangulat-

ed hernia, or recurrent hernia; ③those with

contraindications to general anesthesia;

④those with severe cardiac, hepatic, and re-

nal dysfunction.

Operation methods

All patients received general anesthesia

after entering the operating room. Surgeons

performed all operations in the same group,

and the specific operation steps strictly fol-

lowed the “Guidelines for Standardized Op-

eration of Laparoscopic Surgery for Inguinal

Hernia”. All patients were treated with TEP.

In the observation group, a small incision of

about 1.5 cm in length was made at 1 cm

below the umbilicus to the line alba, fol-

lowed by an incision of the skin, subcutane-

ous tissue, and anterior sheath of the rectus

abdominis. The skin retractor was used to

pull the rectus abdominis fiber to both sides

until the posterior sheath was exposed, a one

cm cannula was inserted, and the pneumo-

peritoneum was created. The other two five-

mm cannulas were located five cm and ten

cm below the median line umbilicus, respec-

tively. The endoscope push method enlarged

the preperitoneal space, and the pubic sym-

physis and the pubic ligament were exposed,

turning laterally to isolate the Bogros space

in the groin area.

After the direct hernia sac was freed and

restored under direct vision, it was ligated at

its base, and the distal end of the ligation line

was cut off. The spermatic cord components

were then abdominally walled, the iliac ves-

sels were exposed, and the Bogros space in

the groin area was fully exposed. The edge of

the peritoneum cephalad was freed as much

as possible to make room for patch place-

ment. A 10 cm×15 cm polypropylene mesh

was used as the repair material, and the mesh

was rolled into a “cigarette” shape with the

long axis as the edge and was placed in the

casing. After entirely unfolding, the mesh was

centered on the myopubic foramen to cover

the inguinal foramen. The spermatic vessels

and the Vas deferens were freed by 6 to 8 cm

to expose the spermatic cord fully. The ab-

dominal wall suture straight needle was used

with No. 7 silk thread to enter the preperito-

neal space twice; at the hernia ring, a needle

thread and a needle and hook thread were

successively passed on the patch, and the

patch was subcutaneously fixed.

Peritoneal rupture closure methods

After the peritoneal rupture occurred

during the operation, the peritoneum was

closed by the corresponding methods: CG

patients were treated with absorbable suture

to repair the peritoneal tears, after entering

the abdominal cavity, continuous suture with

micro-wire or continuous suture was used

with absorbable line, and then closed; while

the patients in the OG were treated with

bipolar coagulation to close and repair the

peritoneal tears: the peritoneal rupture was

repaired by bipolar electrocoagulation and

hemostasis, and then the mesh was placed

extraperitoneally.

Observation indicators

Operation situation

We observed and recorded both groups’

operation time, intraoperative blood loss,

and hospital stay.

Postoperative pain

At 2 h, 12 h, and 24 h after surgery, pa-

tients were evaluated using the visual analog

scale (VAS) 18. A 10 cm long straight line

was used to show the degree of pain, and the

scores ranged from 0 to 10 points, with 0 rep-

resenting no pain and 10 as the most painful.

Peritoneal incision closure methods and inguinal hernia repair 499

Vol. 64(4): 495 - 504, 2023

Complications

Patients’ complications (including

postoperative puncture hernia, intestinal

fistula, intestinal obstruction, and chronic

pain) were recorded.

Quality of life

The Comprehensive Assessment Ques-

tionnaire for Quality of Life (GQOL-74) 19

evaluated the patient’s quality. Material life,

physical function, social function, and psy-

chological function were rated on a scale of

0 - 100 points, with higher scores being a

better patient quality of life.

Recurrence conditions

The recurrence of hernia sac in the two

groups after one year of treatment was re-

corded.

Statistical methods

SPSS 20.0 was used for statistical analy-

sis, enumeration data were compared by X2

test, rank data were compared by rank sum

test, measurement data were expressed by

mean±standard deviation (

sx ±

), and a t-

test was used for comparison. The statistical

result was regarded as statistically signifi-

cant when p<0.05.

RESULTS

Comparison of operation conditions

The operation time and hospital stay in

the OG were reduced compared to the CG

(p<0.05), and in both groups, the intraop-

erative blood loss was not significantly differ-

ent (p>0.05), as seen in Table 2.

Comparison of postoperative pain scores

The pain scores in the OG at 24 hours

after the operation were reduced than those

in the CG (p<0.05), and the pain scores at

two hours and 12 hours in both groups were

not significantly different (p>0.05), seen in

Table 2.

Incidence of complications

The incidence of postoperative compli-

cations between the OG was not significant-

ly different (p>0.05), as shown in Table 3.

Postoperative quality of life between the

two groups

The scores of material life, physical

function, social function, and psychological

function in the OG were higher than those

in the CG (p<0.05), as seen in Table 4.

Table 2

Operation conditions and postoperative pain scores in two groups.

Groups Cases Operation conditions Postoperative pain scores

Operation

time (min)

Intraoperative

blood loss

(mL)

Hospital

stay (d)

Postoperative

2 h

Postoperative

12 h

Postoperative

24 h

Observation

group

40.56±6.52*

24.45±4.74

3.54±1.22

3.58±1.34

2.27±0.75

1.20±0.28

Control

group

60.35±10.74*

25.12±4.23

4.22±1.54

3.83±1.55

2.43±0.68

1.43±0.30

t-10.566 -0.708 -2.322 -0.819 -1.060 -3.760

p&0.001 0.471 0.023 0.415 0.292 0.001

*Quantitative variables expressed by mean ± standard deviation.

&P-value based on t-test. Significance level ≤ 0.05.

500 Zheng et al.

Investigación Clínica 64(4): 2023

Comparison of postoperative quality

of life between the two groups

There were no recurrences in the two

groups during a one-year follow-up.

DISCUSSION

Laparoscopic inguinal hernia repair has

become increasingly popular due to its mini-

mally invasive nature, faster recovery times,

and lower postoperative complications than

open surgical methods. The peritoneal inci-

sion’s closure, which might affect the pa-

tient’s recovery and general prognosis, is a

crucial component of this treatment. The

two main methods for closing the peritoneal

incision are bipolar coagulation and absorb-

able sutures 11,20. This study compared the

operative outcomes and prognosis of pa-

tients undergoing laparoscopic inguinal her-

nia repair with these two different peritoneal

incision closure methods.

This bipolar coagulation during TEP

operation (OG) offers several advantages

compared to the absorbable suture method

(CG). The results showed a significantly

shorter operation time and hospital stay,

reduced pain scores at 24 hours’ post-oper-

ation, and improved quality of life in various

aspects for patients in the OG. Importantly,

no significant difference was observed in

the incidence of postoperative complica-

tions between the groups, indicating that

the bipolar coagulation method is safe and

effective.

The findings of this study are consistent

with previous research, which has reported

various benefits of using bipolar coagula-

tion for the repair of peritoneal rupture. The

study’s results by Meyer et al. 21, showed that

the rate of complications in the TEP method

is low, and this laparoscopic hernia repair

technique is repeatable and reliable.

Table 3

Incidence of complications between the two groups.

Groups Cases Postoperative

Puncture hernia

Intestinal

fistula

Intestinal

obstruction

Chronic

pain Total

Observation group 45 0 (0.00) * 0 (0.00) 1 (2.22) 1 (2.22) 2 (4.44)

Control group 45 1 (2.22) * 2 (4.44) 0 (0.00) 2 (4.44) 5 (11.11)

χ20.620

p&0.431

* Qualitative variables expressed by frequency (percent). &P-value based chi-square χ2. Significance level ≤ 0.05.

Table 4

Postoperative quality of life between the two groups.

Groups Cases Psychological function Social function Physical function Material life

Observation

group 45 72.40±6.45* 75.62±5.46 77.46±6.72 73.46±6.85

Control

group 45 67.58±7.52* 70.32±7.14 73.34±5.76 68.63±7.03

t3.264 3.956 3.123 3.301

p&0.002 0.000 0.002 0.001

*Quantitative variables expressed by mean ± standard deviation. &P-value based on t-test. Significance level ≤ 0.05.

Peritoneal incision closure methods and inguinal hernia repair 501

Vol. 64(4): 495 - 504, 2023

The bipolar coagulation sealing tech-

nology converts electrical energy into heat

energy to dissolve and denature tissue pro-

teins, resulting in a permanent lumen or rup-

tured tissue coagulation and closure effect

22,23. This technology can safely close tissue

bundles, ligaments, and blood vessels with a

<0.7 cm 24 diameter. The peritoneal injury

stimulates the release of cytokines, acti-

vates the coagulation cascade, and deposits

fibrin as a temporary matrix 25. When bipo-

lar electrocoagulation sealing technology is

used to repair peritoneal ruptures, it rapidly

dissolves and denatures fibrin and collagen

to form new peritoneal tissue, resulting in

a better sealing effect. Precautions should

be taken during the operation to ensure the

entire edge of the breach is closed, and the

size of the bipolar energy and use time are

critical to the closure effect 26. The results

of the study by Liang et al. 27, showed that

compared with ultrasonic and bipolar elec-

trocoagulation techniques, advanced bipolar

use was more reliable for mesenteric vessels

in laparoscopic surgery; however, bipolar

electrocoagulation with optimal power can

be used for its simplicity of operation and

low cost. Various new electrosurgical devices

will cause less damage as laparoscopic tech-

nology progresses, making surgery more ac-

curate and less damaging. Although bipolar

electrocoagulation has a broad thermal dam-

age breadth, it is nevertheless relatively safe.

Oguz et al. 28, conducted a study to

compare peritoneal closure techniques in

laparoscopic transabdominal inguinal hernia

repair. This study analyzed tucker and suture

techniques to close the peritoneum based on

the patient results. The results showed that

tucker and suture have comparable safety

for peritoneal closure in laparoscopic TAPP

inguinal hernia surgery. However, what can

be seen is that no study has simultaneously

examined the variables of operation time and

hospitalization, pain level, physical function,

social function, and psychological function.

The results of our study showed that

the use of bipolar coagulation reduces the

operation time and hospitalization and also

leads to a reduction in the pain score 24

hours after the operation. In addition, this

study showed that patients who underwent

closing repair with bipolar coagulation im-

proved their scores in material life, physical

functioning, social functioning, and psycho-

logical functioning, indicating an improve-

ment in their overall quality of life.

The reduced operation time in the OG

group can lead to increased patient satisfac-

tion, decreased anesthesia-related complica-

tions, and reduced healthcare costs. Addi-

tionally, the shorter hospital stay observed in

the OG group may further reduce healthcare

costs and improve patient satisfaction.

The lower pain scores observed in the

OG group may be attributed to the reduced

tissue trauma and inflammation associated

with bipolar coagulation compared to su-

tures 29. This reduction in pain may contrib-

ute to a faster return to normal activities

and improved postoperative quality of life.

The lack of significant differences in the

incidence of postoperative complications

between the two groups indicates that both

methods are safe and effective in repairing

peritoneal rupture. However, the improved

quality of life scores in the OG group further

emphasizes the potential benefits of the bi-

polar coagulation method.

Several factors can explain the prefer-

ence for bipolar coagulation over spontane-

ous release of the peritoneum. Bipolar coag-

ulation allows for better control of bleeding

during the process, which can assist in short-

ening the operation time and lower the risk

of complications 30. Reduced operation time

and bleeding can also contribute to a short-

er hospital stay and lower pain scores, as ob-

served in the study results.

Bipolar coagulation can accomplish he-

mostasis by denaturing proteins in the tis-

sues, resulting in coagulation and closure of

tiny blood vessels. This shortens the dura-

tion of the procedure by minimizing blood

loss and lowering bleeding from the location

of the peritoneal rupture. In contrast, spon-

502 Zheng et al.

Investigación Clínica 64(4): 2023

taneous release of the peritoneum may re-

sult in ongoing bleeding from the rupture,

lengthening the time needed for surgery 31.

Bipolar coagulation is a quick and sim-

ple technique that does not require sutur-

ing. It reduces operation complexity with-

out compromising efficacy. In conclusion,

bipolar coagulation is a simple and effective

method for managing peritoneal rupture

during TEP inguinal hernia repair with sig-

nificant benefits over the spontaneous re-

lease of the peritoneum 32; so, it should be

considered as the first-line treatment option

for this intraoperative complication.

Funding

None

Conflict of interests

The authors declared that they have no

competing interests.

Authors’ ORCID

• Bixiang Zheng (BZ):

0000-0002-8546-7472

• Xiaobin Luo (XL):

0000-0002-1986-5819

• Changdong Wang (CW):

0000-0001-8944-1280

• Rendong Zheng (RZ):

0000-0003-4912-6758

• Xiaofeng Yang (XY):

0000-0002-4334-2356

Contribution of authors

BZ played a crucial role in study design

and conducted expertise in laparoscopic sur-

gery. XL provided the statistical analysis and

critical insights. CW contributed to the lit-

erature review and information synthesis. RZ

conducted data collection and data analysis.

XY contributed to the manuscript.

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