What is the recommended technique for intra‑abdominal closure of the deep (internal) inguinal ring?

Intra-abdominal Closure of the Internal Inguinal Ring

For laparoscopic repair of indirect inguinal hernias, closure of the internal inguinal ring defect before mesh placement is recommended, particularly for large indirect or scrotal hernias, as it significantly reduces seroma formation without increasing complications.

Recommended Technique

Standard Laparoscopic Approach

The preferred technique involves intracorporeal suturing to close the internal ring defect during transabdominal preperitoneal (TAPP) repair, followed by mesh deployment. 1

• Defect closure should be performed using non-absorbable suture material before mesh placement 2
• The closure is accomplished through laparoscopic intraperitoneal intracorporeal suturing of the internal ring 2
• Mean closure time is approximately 6.7 minutes (range 4-10 minutes), making this a time-efficient addition to the procedure 1

Clinical Context and Indications

This closure technique is particularly indicated for:

• Large indirect hernias (European Hernia Society classification L3) 1
• Scrotal hernias where the defect size averages 3.7 cm (range 2.5-5.0 cm) 1
• Indirect hernias in general, where simple ring closure without mesh has shown 2% recurrence rates at 32-month follow-up 2

Technical Considerations

The approach varies based on patient anatomy:

• For average-sized internal rings in thin patients: Single-port technique (SEAL - subcutaneous endoscopically assisted ligation) may be sufficient, offering superior cosmetic results with one 5-mm scar versus three 3
• For wide rings (>10 mm) or thick abdominal walls: Three-port technique (TPT) with working ports is necessary for successful intracorporeal suturing and knotting 3
• In pediatric populations: Transumbilical single-site laparoscopic intraperitoneal closure (TUSLIC) demonstrates lower recurrence rates compared to multiple-site extraperitoneal closure 4

Clinical Outcomes

Benefits of Internal Ring Closure

Defect closure provides significant advantages:

• Seroma formation reduced to 6.7% in large indirect hernias, with all cases mild and self-resolving within 3 months 1
• No hernia recurrence during mean 9.4-month follow-up when combined with mesh 1
• Minimal postoperative pain (VAS score 2.2 on postoperative day 1) 1
• Short hospital stay averaging 18 hours 1

Emergency Setting Considerations

When performing laparoscopic repair in emergency situations:

• Laparoscopic approach is feasible for incarcerated hernias without strangulation or suspected need for bowel resection 5
• Open preperitoneal approach is preferable when strangulation is present or bowel resection is anticipated 5
• Laparoscopic repair shows significantly lower wound infection rates (P < 0.018) compared to open repair in emergency strangulated groin hernias, without higher recurrence 5

Common Pitfalls and Caveats

Key technical limitations to recognize:

• Wide internal rings (>10 mm) may require working ports rather than single-port techniques for adequate closure 3
• Thick abdominal walls present technical challenges for single-port approaches 3
• Intracorporeal suturing and knotting represent the rate-limiting steps requiring adequate laparoscopic skill 3
• Avoid this approach when bowel viability is questionable or resection is anticipated, as open access provides better assessment 5

The evidence strongly supports internal ring closure as a safe, feasible technique that meaningfully reduces complications, particularly seroma formation, while maintaining low recurrence rates. 1, 2 This approach represents best practice for laparoscopic indirect inguinal hernia repair when anatomically and clinically appropriate.