SURGICAL MANAGEMENT OF THE PSEUDOSAC IN LAPAROSCOPIC INGUINAL HERNIA REPAIR: A SYSTEMATIC REVIEW WITH META-ANALYSIS

Abstract

Background: When a direct inguinal hernia is approached laparoscopically, the tissue bulging through the defect is, more often than not, attenuated transversalis fascia rather than genuine peritoneum — a structure widely termed the “pseudosac.” Its importance is not limited to seroma: surgeons also rely on it as a dissection landmark, and in re-operative hernia surgery it can mark the site of the original defect. Reported approaches to handling it span simple blunt reduction, suture or tacker fixation, plication (via Endoloop or a figure-of-eight stitch to Cooper's ligament), fenestration, and, occasionally, excision — yet no prior work has pulled this literature into one systematic account. Objective: This review sought to map the definition, clinical relevance, and operative handling of the pseudosac during laparoscopic inguinal hernia surgery, and to pool comparative data on active management strategies — fixation, plication, or fenestration — set against simple passive reduction. Methods: Following PRISMA 2020 methodology, we searched PubMed/MEDLINE, Embase, Cochrane CENTRAL, Scopus, and Google Scholar from database inception through August 2026, adding hand searches of hernia-focused journals and citation lists. We admitted two categories of study: comparative work (randomised or otherwise) weighing any active pseudosac intervention against passive reduction, and single-arm or narrative papers offering anatomical, technical, or clinical-relevance detail without a comparator. Bias in the comparative studies was appraised with RoB 2.0 for trials and ROBINS-I for non-randomised designs, and binary seroma outcomes were combined via Mantel-Haenszel weighting under a DerSimonian-Laird random-effects framework. Results: Eight papers satisfied the eligibility criteria — four comparative studies (356 patients or hernia units combined) and four single-arm or narrative papers supplying anatomical and technique-spectrum background. Pooling the two studies that used a directly matched fixation-type intervention (n=120) gave a random-effects odds ratio for seroma of 0.37 with fixation relative to non-fixation (95% CI 0.03–4.33, p=0.43, I²=54.9%). Widening this to a three-study sensitivity analysis spanning both fixation and fenestration (n=150) produced an odds ratio of 0.31 (95% CI 0.07–1.33, p=0.11, I²=35.3%); all three studies pointed the same direction in favour of active management, though the result still fell short of significance. Pain and operative-time findings varied in direction from study to study, and no study recorded a recurrence during its follow-up window. The non comparative literature characterised the pseudosac as invaginated transversalis fascia rather than true peritoneum, noted its use as a landmark in redo surgery, and put forward a size- and redundancy-based framework for deciding when to intervene. Conclusion: Although the pseudosac is anatomically well described, its operative handling in direct inguinal hernia repair remains inconsistent. Only four small, heterogeneous comparative studies address the question directly, and both the primary and sensitivity pooled analyses lean toward fewer seromas with active intervention without crossing the threshold for significance — a benefit that in some series may trade off against a longer operation and more pain in the early postoperative period. Given the very low certainty of this evidence base, larger multicentre trials using a standardised technique definition are warranted.