Inguinal hernia repair is one of the most commonly performed elective surgical procedures worldwide [1]. Although advances in surgical techniques have improved patient outcomes, the optimal method of wound closure remains a subject of debate [2-3]. Traditionally, the subcutaneous tissue is sutured to eliminate dead space, reduce the risk of seroma and hematoma, decrease skin tension, and promote better wound healing. However, some surgeons argue that suturing the poorly vascularized subcutaneous fat may increase tissue ischemia, prolong operative time, and introduce foreign material that could increase the risk of infection [4–7].

Several studies have evaluated subcutaneous tissue closure in abdominal, gynecological, and obstetric surgeries, but the results remain inconsistent. While some studies have reported no significant difference in wound complications between sutured and non-sutured wounds, others have demonstrated lower rates of seroma, hematoma, and surgical site infection with subcutaneous closure, particularly in obese patients or those with thicker subcutaneous tissue [8–12]. A Cochrane systematic review also concluded that the available evidence is insufficient to recommend either routine closure or non-closure of the subcutaneous layer in non-caesarean surgeries [11].

Elective inguinal hernia repair is considered a clean surgical procedure with a relatively low risk of wound infection. Nevertheless, postoperative complications such as seroma, hematoma, wound dehiscence, and postoperative pain can delay recovery, prolong hospital stay, and affect patient satisfaction [13–14]. Despite the large number of inguinal hernia repairs performed worldwide, evidence regarding the role of subcutaneous tissue closure in these procedures remains limited [15-16].

Therefore, the present study was undertaken to compare postoperative wound outcomes in patients undergoing elective inguinal hernia repair with and without subcutaneous tissue closure. The study aimed to evaluate wound healing, postoperative complications, pain, duration of hospital stay, and patient satisfaction, thereby providing evidence on whether routine subcutaneous tissue closure offers additional clinical benefit in elective inguinal hernia surgery.

AIM AND OBJECTIVES

Aim

To compare postoperative wound outcomes in patients undergoing elective inguinal hernia repair with and without subcutaneous tissue closure.

Objectives

• To compare wound healing following elective inguinal hernia repair in patients with and without subcutaneous tissue closure.
• To compare the incidence of postoperative wound complications, including seroma, hematoma, surgical site infection, and wound dehiscence, between the two groups.
• To compare postoperative pain, duration of hospital stay, and patient satisfaction between patients with and without subcutaneous tissue closure.

MATERIALS AND METHODS

Study Design

This study was designed as a hospital-based interventional study.

Study Setting

The research was conducted at the Department of General Surgery, Muzaffarnagar Medical College and Hospital, Muzaffarnagar, Uttar Pradesh.

Study Duration

The total duration of the study was 18 months, which included 12 months for data collection and 6 months for data compilation and analysis.

Study Population

All patients undergoing elective inguinal hernia surgery at the institute during the study period were considered for inclusion.

Sample Size

A total of 60 patients were enrolled for the study. The sample size was determined based on the average number of elective inguinal hernia surgeries performed at the hospital over a three-year period.

Sampling Technique and Grouping

Patients were randomly allocated into two groups:

Group A: Patients who underwent mesh repair in elective inguinal hernia surgery, in whom the subcutaneous tissue was sutured using 2-0 Vicryl.

Group B: Patients who underwent mesh repair in elective inguinal hernia surgery, in whom the subcutaneous tissue was not sutured.

Inclusion Criteria

• Patients undergoing elective inguinal hernia surgery.
• Patients aged more than 10 years and less than 60 years.
• Patients who provided informed written consent for participation.

Exclusion Criteria

• Patients in whom mesh repair was not performed.
• Obese patients.
• Patients with hematological disorders, long-term anticoagulation therapy, coagulation disorders, malignancy, diabetes mellitus, or septicemia.
• Patients with impaired renal, hepatic, or cardiac function.
• Patients are younger than 10 years or older than 60 years.
• Patients on chemotherapy or radiotherapy.

Data Collection and Statistical Analysis

Data were compiled and analyzed using SPSS version 26. Categorical variables were presented as frequency and percentages and analysed using Chi square test. Continuous variables were presented as Mean and SD and analysed using independent t test. A p-value of less than 0.05 was considered statistically significant.

RESULTS

Comparison of Age Distribution Between the Sutured and Non-Sutured Groups

Table 1: Comparison of Age Distribution Between the Sutured and Non-Sutured Groups

The age distribution was comparable between the two groups, with no statistically significant difference (p = 0.9657). The mean age was 41.67 ± 9.54 years in the sutured group and 39.93 ± 7.67 years in the non-sutured group, indicating that both groups were well matched with respect to age (table 1).

Comparison of Gender Distribution Between the Sutured and Non-Sutured Groups

Table 2: Comparison of Gender Distribution Between the Sutured and Non-Sutured Groups

The majority of patients in both groups were male. Gender distribution was comparable between the sutured and non-sutured groups, with no statistically significant difference (p = 0.5536), indicating that the two groups were well matched at baseline (table 2).

Body Mass Index (BMI) Distribution of the Study Participants

Table 3: Body Mass Index (BMI) Distribution of the Study Participants

The baseline BMI was similar in both groups, with no statistically significant difference (p = 0.2278). The mean BMI was 22.82 ± 2.64 kg/m² in the sutured group and 21.90 ± 3.07 kg/m² in the non-sutured group (table 3).

Side of Inguinal Hernia Among the Study Participants

Table 4: Side of Inguinal Hernia Among the Study Participants

Right-sided inguinal hernia was the most common presentation in both groups. Although the proportions of right-, left-, and bilateral hernias varied slightly between the groups, the difference was not statistically significant (p = 0.1898), indicating a comparable distribution of hernia laterality (table 4).

Comparison of Direct and Indirect Inguinal Hernias Between the Two Groups

Table 5: Comparison of Direct and Indirect Inguinal Hernias Between the Two Groups

Indirect inguinal hernia was the most common type in both groups. No significant difference was observed in the distribution of hernia type between the sutured and non-sutured groups (p = 0.6023) (table 5).

Comparison of Operative Time Between the Study Groups

Table 6: Comparison of Operative Time Between the Study Groups

No significant difference was observed in the duration of surgery between the sutured and non-sutured groups (p = 0.6597), suggesting that subcutaneous tissue closure had no measurable impact on operative time. (table 6).

Postoperative Pain Assessment Using Visual Analogue Scale (VAS)

Table 7: Postoperative Pain Assessment Using Visual Analogue Scale (VAS)

Postoperative pain scores declined progressively in both groups during follow-up. Pain was comparable on postoperative days (POD) 1 and 7 (p > 0.05). However, patients in the non-sutured group reported significantly lower pain scores on POD 3 than those in the sutured group (p = 0.0175).

Incidence of Postoperative Wound Complications During Follow-up

Table 8: Incidence of Postoperative Wound Complications During Follow-up

Postoperative wound complications were observed only during the first postoperative week. Although the incidence was slightly higher in the non-sutured group than in the sutured group, the difference was not statistically significant (p = 0.6404). No wound complications were recorded in either group during the subsequent follow-up period of six months (Table 8).

Duration of Hospital Stay in the Sutured and Non-Sutured Groups

Table 9: Duration of Hospital Stay in the Sutured and Non-Sutured Groups

The mean hospital stay was marginally longer in the sutured group than in the non-sutured group; however, the difference was not statistically significant (p = 0.4707), suggesting comparable postoperative recovery in both groups (table 9).

Patient Satisfaction Following Elective Inguinal Hernia Repair

Table 10: Patient Satisfaction Following Elective Inguinal Hernia Repair

Overall patient satisfaction was comparable between the two groups, with most patients expressing satisfaction and no reports of dissatisfaction. The difference in satisfaction levels was not statistically significant (p = 0.6404) (table 10).

DISCUSSION

Overall, the findings of the present study suggest that routine subcutaneous tissue closure during elective inguinal hernia repair does not offer a significant advantage in improving postoperative wound outcomes. Baseline demographic and clinical characteristics, including age, gender, BMI, hernia side, and hernia type, were comparable between the two groups, ensuring a reliable comparison of postoperative outcomes. No significant differences were observed in operative duration, postoperative wound complications, length of hospital stay, or patient satisfaction between patients who underwent subcutaneous tissue suturing and those in whom the subcutaneous layer was left unsutured. The only significant finding was a lower postoperative pain score on the third postoperative day in the non-sutured group, suggesting that omission of subcutaneous suturing may reduce tissue handling and the associated inflammatory response during the early phase of recovery [17].

These findings are consistent with those reported by Bawa et al. [8], who demonstrated that omission of subcutaneous tissue closure did not increase wound infection or dehiscence while reducing operative time and suture use. Similarly, Bayrak et al. [9] found no significant differences in surgical site infection, wound dehiscence, or seroma formation between closure and non-closure groups in obese patients undergoing gynecological surgery. Dwivedi et al. [10] also observed that subcutaneous suturing did not significantly reduce wound complications despite increasing operative time. Furthermore, the Cochrane systematic review by Gurusamy et al. [11] concluded that the available evidence is insufficient to support or discourage routine subcutaneous tissue closure in clean non-caesarean surgeries. Although Husslein et al. [5] and Madathil et al. [12] reported certain benefits of subcutaneous closure in specific surgical settings, these findings were influenced by differences in patient characteristics, wound type, and surgical procedures. Moreover, evidence suggests that patients with obesity or increased subcutaneous fat thickness may derive greater benefit from subcutaneous closure because of the higher risk of seroma and surgical site complications [9,14].

Taken together, the present study supports a selective rather than routine approach to subcutaneous tissue closure in elective inguinal hernia surgery [18]. In uncomplicated patients with normal BMI and clean surgical wounds, omission of subcutaneous suturing appears to be a safe and effective alternative without compromising wound healing or patient satisfaction. Therefore, the decision to close the subcutaneous layer should be individualized based on patient-related risk factors, wound characteristics, and the surgeon's intraoperative judgment. Further large-scale, multicentric randomized controlled trials with longer follow-up are recommended to establish definitive evidence and refine clinical guidelines for subcutaneous wound closure in elective inguinal hernia repair [19-27].

CONCLUSION

The present study found that suturing and non-suturing of the subcutaneous tissue during elective inguinal hernia repair resulted in similar postoperative outcomes. Both groups were comparable at baseline, with no significant differences in operative time, wound complications, hospital stay, or patient satisfaction. Although patients in the non-sutured group reported less pain on the third postoperative day, this difference was not observed by the seventh postoperative day.

Overall, omitting subcutaneous tissue suturing did not compromise wound healing or increase postoperative complications. These findings suggest that routine subcutaneous closure may not be necessary in uncomplicated elective inguinal hernia repair, and the decision should be guided by individual patient characteristics and the surgeon's clinical judgment.

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