A prospective observational study comparing conventional lateral border transfascial mesh fixation versus midline transfascial suturing in laparoscopic intraperitoneal onlay mesh repair for umbilical hernia- a pilot study

Abstract

Background

Conventional lateral border transfascial mesh fixation in laparoscopic intraperitoneal onlay mesh (IPOM) repair for umbilical hernia is associated with significant postoperative pain due to nerve entrapment in the lateral abdominal musculature. Midline transfascial suturing, targeting the less-innervated linea alba, may offer improved pain outcomes without compromising mesh stability.

Methods

This prospective observational study included 62 patients undergoing laparoscopic IPOM repair for primary umbilical hernia with defect size < 6 cm. Patients were allocated based on surgical unit protocol: 31 underwent midline transfascial suturing (Midline group) and 31 underwent conventional lateral border transfascial fixation (Lateral group). Primary outcomes were postoperative pain assessed by Visual Analogue Scale (VAS) at predetermined intervals (postoperative days 1, 2, 7, 14, and 60), operative time, and length of hospital stay. Secondary outcomes included recurrence, complications, and patient satisfaction using the Patient Satisfaction Questionnaire (PSQ).

Results

Baseline demographics including age, gender, body mass index, and defect size were comparable between groups (p > 0.05). The Midline group demonstrated significantly lower VAS scores at all time points: POD1 (2.81 ± 0.64 vs. 4.32 ± 0.60, p = 0.001), POD7 (2.13 ± 0.50 vs. 3.23 ± 0.72, p = 0.001), and POD60 (0.52 ± 0.51 vs. 1.36 ± 0.66, p = 0.001). Hospital stay was significantly shorter in the Midline group (2.48 ± 0.51 vs. 3.48 ± 0.51 days, p = 0.001). Patient satisfaction scores were higher with midline fixation (8.76 ± 0.25 vs. 6.76 ± 0.25, p = 0.001). Operative time was comparable between groups (80.19 ± 12.27 vs. 81.52 ± 10.80 min, p = 0.654). Recurrence rates were similar (9.7% vs. 12.9%, p = 0.688). The Midline group had no complications, while the Lateral group had 16.1% (seroma 9.7%, surgical site infection 6.5%; p = 0.066).

Conclusion

Midline transfascial suturing in laparoscopic IPOM repair for umbilical hernia significantly reduces postoperative pain, shortens hospital stay, and improves patient satisfaction compared to conventional lateral border fixation, with comparable operative time and recurrence rates. This technique represents a patient-friendly alternative that should be considered for small-to-medium umbilical hernias.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12893-026-04016-6.

Introduction

Umbilical hernia represents one of the most common anterior abdominal wall defects encountered in surgical practice, accounting for approximately 2–4% of all ventral hernias in the general population [1]. The condition arises from either congenital persistence of the umbilical ring or acquired weakening in adulthood due to factors such as obesity, multiparity, ascites, and chronic conditions that elevate intra-abdominal pressure [2]. While many small hernias remain asymptomatic, they can progress causing pain and potentially serious complications including incarceration and strangulation, requiring surgery [3]. The burden of umbilical hernia is particularly pronounced in high-risk groups, with females and multiparous women demonstrating higher prevalence, and obese individuals facing nearly twice the risk of developing clinically significant defects [4].

Hernia repair has evolved from tissue based techniques wit high recurrence rates to mesh based tension-free repairs, significantly improving outcomes. Historical techniques such as the Mayo repair, which involved overlapping fascial layers, were associated with recurrence rates exceeding 20% due to tension-related failure [5]. The introduction of synthetic meshes enabled tension-free repair, dramatically reducing recurrence rates to below 10% in most series [6]. Modern lightweight composite meshes have improved the biocompatibility and safety for intraperitoneal use [7]. Laparoscopic intraperitoneal onlay mesh (IPOM) repair emerged in the early 1990s as a minimally invasive alternative to open approaches, offering advantages including smaller incisions, superior visualization of the abdominal cavity, detection of occult contralateral defects, and reduced rates of surgical site infection [8]. Laparoscopic IPOM repair involves intraperitoneal mesh placement with adequate overlap and secure fixation [9]. Mesh fixation is critical to prevent migration, folding, and recurrence, with transfascial sutures traditionally serving as the gold standard for ensuring mechanical stability during the critical period of tissue ingrowth [10]. Conventional lateral border transfascial fixation, while biomechanically robust, carries significant drawbacks related to the anatomical characteristics of the lateral abdominal wall. Lateral transfacial sutures may cause pain due to entrapment of the intercostal nerves(T7-T12) within the abdominal wall musculature [11]. Transfascial sutures placed in this region risk direct nerve entrapment or irritation, leading to acute postoperative pain that may persist as chronic neuralgia in a subset of patients [12]. Several studies have shown that pain related to sutures can delay recovery, increase analgesic, length of hospital stay and reduce patient satisfaction after hernia repair [13–15]. The clinical significance of fixation-related pain has driven exploration of alternative strategies. Alternative fixation methods such as tacks and sealants have been explored, each with variable success in reducing pain while maintaining durable fixation [16]. However, concerns regarding long-term recurrence rates, additional costs other technical difficulties have limited widespread adoption of these alternatives [17]. Among the modifications gaining interest is midline transfascial suturing, which anchors the mesh along the relatively avascular and less-innervated linea alba [18]. Postoperative pain remains a central determinant of recovery quality after laparoscopic IPOM repair, directly influencing length of hospital stay, time to return to normal activity, and overall patient satisfaction [19]. As ERAS protocols focus on faster recover, fixation methods that reduce pain without increasing recurrences are important [20]. Furthermore, operative efficiency reflected in operating time carries implications for resource utilization, anaesthesia exposure, and healthcare costs, making it an important consideration when comparing surgical techniques [21].

Against this background, the present prospective observational study was designed to compare conventional lateral border transfascial mesh fixation with midline transfascial suturing in laparoscopic IPOM repair for primary umbilical hernia. The primary objective was to evaluate differences in postoperative pain, length of hospital stays, and operative time between the two techniques. The secondary objective was to assess hernia recurrence, postoperative complications, and patient satisfaction. We hypothesized that midline transfascial suturing would provide equivalent mesh stability with significantly reduced pain scores and shorter hospitalization, thereby offering a patient-friendly refinement to standard laparoscopic hernia repair without increasing technical complexity or operative duration.

Materials and methods

Study design and setting

This prospective observational study was conducted at the Department of General Surgery, territory care centre, Chennai Tamil Nadu, India. The study duration extended over fourteen months, during which patient recruitment, surgical interventions, and postoperative follow-up at three and six months were completed. The study was designed and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Participants

Adult patients presenting to the General Surgery Outpatient Department with umbilical swelling suggestive of primary umbilical hernia were evaluated for eligibility. Inclusion criteria were: patients aged 18 years or older, with clinically and radiologically confirmed primary umbilical hernia, a defect size less than 6 cm in greatest dimension on preoperative ultrasonography, and an uncomplicated hernia (reducible, without obstruction or strangulation). While exclusion criteria were: patients younger than 18 years, those with complicated hernia involving obstruction, strangulation, or incarceration, defect size greater than 6 cm, incisional hernia at the umbilical site, or recurrent umbilical hernia following previous repair. Sample Size was total of 62 patients were required, with 31 patients in each group.

Sample size calculation

TOTAL SAMPLE SIZE – 62.

Where,

p1 = Patients with pain in lateral group.

p2 = Patients with pain in midline group.

q1 = Patients without outcome lateral group.

q2 = Patients without outcome in midline group.

Group allocation

The Department of General Surgery comprises eight independent surgical units, each staffed with faculty, residents, and trained nursing personnel. For this study, group allocation was determined by the surgical unit to which the patient was admitted, reflecting routine clinical practice without artificial manipulation of patient flow. Patients admitted to Units 3, 5, and 7 underwent midline transfascial suturing (Midline group), while those admitted to Units 1, 2, 4, and 8 underwent conventional lateral border transfascial mesh fixation (Lateral group). This pragmatic design preserved the observational nature of the study while enabling systematic comparison between the two fixation techniques.

Preoperative evaluation

All eligible patients underwent comprehensive preoperative evaluation including detailed clinical history, thorough physical examination, and radiological imaging. Ultrasonography of the abdomen was performed routinely to confirm the diagnosis, measure defect size in centimetres further imaging was done by means of a CT abdomen which was done selectively to assess hernia contents and to confirm defect size and other missed defects which were noted on clinical examination. Routine laboratory investigations included complete blood count, renal function tests, liver function tests, and coagulation profile. All patients underwent pre-anaesthetic evaluation to ensure fitness for general anaesthesia. Written informed consent was obtained from all participants after providing detailed information regarding the nature of the study, the surgical procedures involved, and potential risks and benefits.

Surgical technique: laparoscopic IPOM repair

All procedures were performed under general anaesthesia with the patient in supine position. A Foley catheter was inserted to decompress the bladder. Pneumoperitoneum was established using a Veress needle or open Hasson technique at the Palmer’s point or left upper quadrant, depending on surgeon preference and previous surgical history. Intra-abdominal pressure was maintained at 12–14 mmHg throughout the procedure.

Three ports were placed in a standardized configuration: a 10-mm optical port for the laparoscope (30-degree, Karl Storz, Tuttlingen, Germany), and two 5-mm working ports placed laterally on the left and right sides under direct visualization. Diagnostic laparoscopy was performed to evaluate the hernia defect, measure its dimensions, and identify any occult defects.

The hernia sac was reduced, and the fascial defect was closed primarily using a 1 − 0 polydioxanone suture (PDS II, Ethicon, Somerville, NJ, USA) with an Endo Close suture passing device (Medtronic, Dublin, Ireland) or intracorporeal suturing technique based on surgeon preference. Defect closure was confirmed laparoscopically based on the surgeons assessment for larger defects(> 5 cm) which is only 7 patients in each group. This was not done for all cases.

Therefore, the present cohort included both conventional IPOM repairs and IPOM Plus repairs, depending on whether fascial defect closure was performed. Defect closure was selectively undertaken for larger defects based on surgeon assessment.

A composite mesh with anti-adhesive barrier (Parietex Composite, Medtronic, Dublin, Ireland; or Proceed, Ethicon, Somerville, NJ, USA) was selected based on availability and surgeon preference. Mesh size was determined to ensure a minimum of 5 cm overlap beyond the fascial defect margins in all directions. This 5 cm overlap is measured without the closure of the fascial defect. The mesh was introduced into the peritoneal cavity through the 10-mm port after careful rolling to prevent contamination.

Mesh fixation techniques: midline transfascial suturing group

In the Midline group, mesh fixation was achieved using transfascial sutures placed along the midline. A suture passer (Endo Close, Medtronic, Dublin, Ireland) was used to percutaneously pass 2 − 0 polypropylene sutures (Prolene, Ethicon, Somerville, NJ, USA) through the fascia at the midline, approximately 1 cm lateral to the linea alba on either side. Sutures were passed through the mesh at corresponding points and brought back through the fascia, creating a U-stitch configuration. Typically, two to three transfascial sutures were placed along the midline to secure the mesh along with circumferential tacking of the mesh by absorbable tackers. For the mesh size of 15 × 10 cm used in this study, approximately 12–16 absorbable tacks were used at 2 cm intervals. Sutures were tied in the subcutaneous tissue after deflating the abdomen to ensure proper mesh tension and apposition to the abdominal wall.

Lateral border transfascial fixation group

In the Lateral group, conventional lateral border transfascial fixation was performed. Transfascial sutures (2 − 0 polypropylene, Prolene, Ethicon, Somerville, NJ, USA) were placed circumferentially around the mesh periphery, penetrating the full thickness of the abdominal wall at the lateral borders. A suture passer was used to retrieve sutures through small skin incisions, and knots were tied in the subcutaneous tissue. Additionally, circumferential tack fixation was performed using absorbable tacks (AbsorbaTack, Medtronic, Dublin, Ireland) in a double-crown configuration. For the mesh size of 15 × 10 cm used in this study approximately 12–16 absorbable tacks were used to supplement suture fixation, consistent with standard practice in these units.

Postoperative care and outcome assessment

All patients received standardized postoperative care including intravenous fluids, antibiotics (single-dose preoperative cefazolin 2 g), and a uniform analgesic protocol consisting of a slow intravenous push of diclofenac 75 mg twice daily along with intravenous paracetamol 1gram given on an as needed(sos) basis. This protocol was applied consistently across both groups to minimize variability in pain management. For oral analgesia both groups were put on a combination of aceclofenac and paracetomol twice daily. Transition from intravenous to oral analgesics was guided by patient reported pain levels in clinical recovery. Pain was assessed using the Visual Analogue Scale (VAS), a 10-cm scale ranging from 0 (no pain) to 10 (worst possible pain). VAS scores were recorded at 6, 12, 24, and 48 h postoperatively, and at follow-up visits on postoperative days 7, 14, and 60. Analgesic requirements were documented.

Operative time was measured in minutes from the first skin incision to completion of skin closure and recorded immediately after surgery. Length of hospital stay was calculated in days from the date of surgery to the date of discharge, with discharge criteria including adequate pain control with oral analgesics, tolerance of oral intake, ambulation independently, and absence of complications.

Patient satisfaction was assessed at the 60-day follow-up using the Patient Satisfaction Questionnaire (PSQ), a validated instrument with scores ranging from 0 to 10, where higher scores indicate greater satisfaction with the surgical outcome and recovery experience.

Follow-up visits were scheduled at three months and six months postoperatively. At each visit, clinical examination was performed to assess for hernia recurrence, defined as a palpable or visible bulge at the umbilical site with or without cough impulse. Ultrasound was performed if clinical examination was equivocal or if recurrence was suspected.

Complications including seroma (defined as clinically detectable fluid collection at the surgical site), surgical site infection (SSI, defined per Centers for Disease Control and Prevention criteria), hematoma, and mesh-related complications were documented prospectively.

Statistical analysis

Data were analyzed using SPSS software version 25.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation and compared between groups using the independent samples t-test after confirming normal distribution. Categorical variables were presented as frequencies and percentages and compared using the chi-square test or Fisher’s exact test as appropriate. Repeated measures analysis of variance (ANOVA) was used to analyze VAS scores which is across multiple time points between groups. The within- subject factor was time (POD-1,2,7,14,60) and between-subject factor was group (Midline Vs lateral Fixation). The interaction between the group and time was also evaluated. Sphericity was assessed using Mauchly’s test, and where violated, Greenhouse–Geisser correction was applied. A p-value of less than 0.05 was considered statistically significant. All statistical tests were two-tailed.

Results

Patient disposition and baseline characteristics

A total of 62 patients undergoing laparoscopic IPOM repair for primary umbilical hernia were included in this prospective observational study, with 31 patients in the Midline transfascial suturing group and 31 patients in the Lateral border transfascial fixation group. Both groups were comparable with respect to baseline demographic and clinical characteristics, as summarized in Table 1.

Table 1.

Baseline demographic and clinical characteristics of study groups (Data presented as mean ± standard deviation or number (percentage). p-values calculated using independent t-test for continuous variables and chi-square test for categorical variables)

Characteristic	Midline Group (n = 31)	Lateral Group (n = 31)	p-value
Age (years)
Mean ± SD	45.45 ± 8.91	43.00 ± 7.35	0.242
Range	27–64	28–53
Gender, n (%)			0.783
Female	21 (67.7%)	22 (71.0%)
Male	10 (32.3%)	9 (29.0%)
BMI (kg/m²)
Mean ± SD	27.13 ± 2.55	27.16 ± 2.54	0.96
Range	22.0–34.0	22.0–33.0
Defect size, n (%)			1.00
< 2 cm	8 (25.8%)	8 (25.8%)
2–5 cm	16 (51.6%)	16 (51.6%)
> 5 cm	7 (22.6%)	7 (22.6%)

The mean age in the Midline group was 45.45 ± 8.91 years (range 27–64 years) compared to 43.00 ± 7.35 years (range 28–53 years) in the Lateral group, with no statistically significant difference (p = 0.242). Although the distribution across age categories showed some variation (p = 0.043), with the Midline group having a higher proportion of patients in the 36–45 years category (45.2% vs. 32.3%) and the Lateral group predominating in the 46–55 years category (48.4% vs. 29.0%), the overall mean age difference was clinically negligible.

Females constituted the majority in both groups, reflecting the known epidemiological predilection of umbilical hernia in women. The Midline group comprised 67.7% females (21 patients) and 32.3% males (10 patients), while the Lateral group had 71.0% females (22 patients) and 29.0% males (9 patients). The gender distribution was not significantly different between groups (p = 0.783).

Body mass index (BMI) was closely matched between groups. The Midline group had a mean BMI of 27.13 ± 2.55 kg/m² (range 22.0–34.0), and the Lateral group had a mean BMI of 27.16 ± 2.54 kg/m² (range 22.0–33.0), with a mean difference of -0.03 (p = 0.96). This near-identical BMI distribution eliminates obesity-related confounding in outcome comparisons.

Defect size distribution was exactly identical between the two groups, representing a remarkable baseline balance. In both groups, defects measuring < 2 cm were observed in 8 patients (25.8%), defects of 2–5 cm in 16 patients (51.6%), and defects > 5 cm in 7 patients (22.6%). The Chi-square value was 0.00 with p = 1.00, confirming perfect comparability in this critical anatomical parameter that influences mesh selection and fixation requirements.

Primary outcomes

Postoperative pain (VAS Scores)

Pain assessment using the Visual Analogue Scale (VAS) at multiple postoperative intervals revealed consistently and significantly lower pain scores in the Midline group compared to the Lateral group at all time points measured (Table 2; Fig. 1).

Table 2.

Primary outcomes comparing midline and lateral fixation techniques (Data presented as mean ± standard deviation. p-values calculated using independent t-test. VAS: Visual Analogue Scale; POD: Postoperative day; PSQ: Patient Satisfaction Questionnaire)

Outcome	Midline Group (n = 31)	Lateral Group (n = 31)	Mean Difference	p-value
VAS Scores
POD 1	2.81 ± 0.64	4.32 ± 0.60	-1.51	0.001
POD 2	2.81 ± 0.64	4.32 ± 0.60	-1.51	0.001
POD 7	2.13 ± 0.50	3.23 ± 0.72	-1.09	0.001
POD 14	1.26 ± 0.44	2.19 ± 0.54	-0.94	0.001
POD 60	0.52 ± 0.51	1.36 ± 0.66	-0.84	0.001
Operative Time (minutes)	80.19 ± 12.27	81.52 ± 10.80	-1.32	0.654
Hospital Stay (days)	2.48 ± 0.51	3.48 ± 0.51	-1.00	0.001
Satisfaction Score (PSQ)	8.76 ± 0.25	6.76 ± 0.25	2.00	0.001

Fig. 1.

Pain trajectory over 60 days following laparoscopic IPOM repair. Line graph comparing mean VAS scores between Midline transfascial suturing group (blue line) and Lateral border transfascial fixation group (red line) at postoperative days 1, 2, 7, 14, and 60. The Midline group demonstrated significantly lower pain scores at all time points (*p < 0.001 for all comparisons)

On postoperative day (POD) 1 and POD 2, the Midline group recorded identical mean VAS scores of 2.81 ± 0.64 (range 2.0–3.5), while the Lateral group had significantly higher scores of 4.32 ± 0.60 (range 3.0–5.5). The mean difference of -1.51 was highly significant (p = 0.001). This difference of more than 1.5 points on the 10-point VAS scale represents clinically meaningful pain reduction in the immediate postoperative period (Fig. 2).

Fig. 2.

a & b Schematic representation of midline transfascial mesh fixation showing a 15 × 10 cm mesh secured with 2–3 midline transfascial sutures placed along the linea alba represented by blue marks and conventional lateral border transfascial mesh fixation with red marks

By POD 7, pain scores had decreased in both groups, but the Midline group continued to demonstrate superior pain control with a mean VAS of 2.13 ± 0.50 (range 1.0–3.0) compared to 3.23 ± 0.72 (range 2.0–4.0) in the Lateral group (mean difference − 1.09, p = 0.001).

At POD 14, the Midline group’s mean VAS score had declined to 1.26 ± 0.44 (range 1.0–2.0), while the Lateral group still reported moderate pain with a mean of 2.19 ± 0.54 (range 1.0–3.0). The mean difference of -0.94 remained statistically significant (p = 0.001).

At the final assessment on POD 60, representing intermediate-term pain outcomes, the Midline group had near-minimal pain with a mean VAS of 0.52 ± 0.51 (range 0.0–1.0), whereas the Lateral group continued to report perceptible pain with a mean of 1.36 ± 0.66 (range 0.0–2.0). The mean difference of -0.84 was significant (p = 0.001), indicating that the pain benefit of midline fixation extends well beyond the acute recovery phase.

We also observed a clear difference in the postoperative analgesic requirements between the two groups. Patients who were put in the conventional lateral border mesh fixation group generally need intravenous analgesics up till post operative day 3 before they could be switched to oral analgesics. Whereas the patients who were put into the midline transfacial fixation group were able to transition earlier, usually by POD-2. This pattern aligns with the lower VAS pain scores seen in the midline group.

Operative time

The mean operative time was comparable between the two fixation techniques. In the Midline group, operative time ranged from 58.0 to 104.0 min with a mean of 80.19 ± 12.27 min. The Lateral group had operative times ranging from 65.0 to 104.0 min with a mean of 81.52 ± 10.80 min. The mean difference of -1.32 min was not statistically significant (p = 0.654), demonstrating that midline transfascial suturing does not prolong operative duration compared to conventional lateral fixation. This finding is clinically important as it indicates that the adoption of midline fixation does not impose additional time burden in the operating room.

Length of hospital stay

Patients in the Midline group experienced significantly shorter hospitalization compared to those in the Lateral group. The Midline group had hospital stays ranging from 2.0 to 3.0 days, with a mean duration of 2.48 ± 0.51 days. In contrast, the Lateral group required longer hospitalization ranging from 3.0 to 4.0 days, with a mean of 3.48 ± 0.51 days. The mean difference of -1.0 day was statistically significant (p = 0.001).

Patient satisfaction

Patient satisfaction, assessed using the Patient Satisfaction Questionnaire (PSQ) at the 60-day follow-up, was significantly higher in the Midline group. This was a simple assessment tool in which patient rated their overall satisfaction with the surgical outcome and recovery on a numerical scale from 0 to 10(0 = completely dissatisfied, 10 = highly satisfied. The Midline group reported satisfaction scores ranging from 8.5 to 9.0, with a mean of 8.76 ± 0.25. The Lateral group had lower scores ranging from 6.5 to 7.0, with a mean of 6.76 ± 0.25. The mean difference of 2.00 was highly significant (p = 0.001). This two-point difference on a 10-point scale reflects substantially greater patient-perceived quality of recovery and overall satisfaction with the surgical experience in the Midline group.

Secondary outcomes

Hernia recurrence

Recurrence was assessed clinically and radiologically at three months and six months postoperatively. In the Midline group, 3 out of 31 patients (9.7%) developed recurrence during the follow-up period. In the Lateral group, 4 out of 31 patients (12.9%) experienced recurrence. The overall recurrence rate for the entire cohort was 11.3%. The difference in recurrence rates between groups was not statistically significant (p = 0.688, Chi-square test). However this can be attributed to the relatively small sample size and low number of postoperative events and as this is only a single institute study, The study may be underpowered to detect meaningful differences in recurrence rates between the two techniques. Most recurrences occurred in patients with initial defect size > 5 cm (5 patients) or 2–5 cm (2 patients), with no recurrences in patients with defects < 2 cm. None of the recurrences required emergency intervention during the follow-up period, and all were managed electively.

Postoperative complications

The complication profile differed notably between the two groups. In the Midline group, there were no postoperative complications recorded (0%). All 31 patients in this group had an uneventful recovery without seroma, surgical site infection, hematoma, or mesh-related issues.

In contrast, the Lateral group experienced complications in 5 out of 31 patients (16.1%). Seroma formation occurred in 3 patients (9.7%), all of which were managed conservatively with observation and resolved spontaneously within 4–6 weeks without intervention. Surgical site infection (SSI) occurred in 2 patients (6.5%), both of whom were managed with oral antibiotics based on culture sensitivity reports; neither required mesh removal or surgical drainage. There were no cases of hematoma, mesh infection requiring explantation, or enterocutaneous fistula in either group.

Although fewer complications were observed in the midline group (0% vs. 16.1%) this difference did not reach statistical significance (p = 0.066, Chi-square test), Although no complications were observed in the Midline group compared to the lateral border group, this difference did not reach statistical significance. Therefore, no definitive conclusions can be drawn regarding differences in complication rates between the two technique. Also the p-value approaching significance suggests that with a larger sample size, this difference might become statistically significant.

Subgroup analysis

Given the identical distribution of defect sizes between groups, Exploratory subgroup analysis by defect size category was performed to assess whether the pain benefit of midline fixation was consistent across all hernia sizes. The reduction in VAS scores favoring the Midline group was observed across all defect size categories (< 2 cm, 2–5 cm, and > 5 cm), However, no statistically robust conclusions can be drawn due to the small sample size within each subgroup.

Discussion

This prospective observational study comparing midline transfascial suturing with conventional lateral border transfascial fixation in laparoscopic IPOM repair for umbilical hernia demonstrates that midline fixation offers significant advantages in patient-centered outcomes while maintaining equivalent surgical efficacy. The Midline group exhibited consistently and significantly lower postoperative pain scores at all measured intervals from postoperative day 1 through day 60, with mean differences exceeding one point on the Visual Analogue Scale throughout the early recovery period. This substantial pain reduction translated into clinically meaningful benefits, including a one-day reduction in hospital stay (2.48 vs. 3.48 days, p = 0.001) and significantly higher patient satisfaction scores (8.76 vs. 6.76, p = 0.001). Importantly, these improvements were achieved without prolonging operative time (80.19 vs. 81.52 min, p = 0.654) or compromising hernia durability, as recurrence rates were comparable between groups (9.7% vs. 12.9%, p = 0.688). Furthermore, the Midline group demonstrated a trend toward fewer postoperative complications (0% vs. 16.1%, p = 0.066), with complete absence of seroma and surgical site infection, suggesting potential safety advantages that warrant further investigation.

The observed pain reduction with midline transfascial suturing has a sound anatomical rationale. The lateral abdominal wall comprises three muscle layers external oblique, internal oblique, and transversus abdominis through which course the segmental intercostal nerves (T7-T12) supplying sensory innervation to the abdominal wall and overlying skin [16]. Conventional lateral border transfascial sutures traverse these muscle planes, creating potential sites for direct nerve entrapment, irritation, or ischemia from suture tension. The resulting pain can be both acute, manifesting as sharp localized discomfort at suture sites, and chronic, presenting as neuropathic pain persisting beyond normal tissue healing [17]. In contrast, the midline approach targets the linea alba, a tendinous raphe formed by the fusion of the aponeuroses of the lateral abdominal muscles. This structure is relatively hypovascular and contains minimal nerve fibers, making it an anatomically privileged site for suture placement [18]. By concentrating fixation along this median fibrous structure, midline suturing achieves secure mesh anchorage while avoiding the richly innervated lateral musculature. The progressive and sustained pain reduction observed in our Midline group from the immediate postoperative period to day 60 supports this anatomical explanation. The benefit was not merely an early phenomenon but persisted throughout recovery, suggesting that midline fixation may also reduce the risk of chronic neuralgia, a recognized complication of lateral suturing reported in up to 5–20% of patients in some series [19]. The one-day reduction in hospital stay observed in the Midline group carries substantial implications for both patients and healthcare systems. Prolonged hospitalization after hernia repair is multifactorial, with pain being a primary determinant limiting early mobilization, resumption of oral intake, and achievement of discharge criteria [20]. The significantly lower VAS scores in the Midline group likely facilitated earlier ambulation and reduced opioid requirements, accelerating recovery along enhanced recovery after surgery (ERAS) pathways. From a health economics perspective, reducing average hospital stay by one day translates to significant cost savings, improved bed turnover, and increased surgical throughput particularly relevant in publicly funded healthcare systems managing high hernia volumes [21].

The higher satisfaction scores in the Midline group (8.76 vs. 6.76) reflect the cumulative impact of reduced pain, shorter hospitalization, and fewer complications on patient-perceived quality of recovery. Satisfaction is increasingly recognized as a critical metric in value-based healthcare models, and our findings demonstrate that technical refinements in mesh fixation can meaningfully improve this patient-centered outcome [22]. The two-point difference on a 10-point scale represents a substantial improvement that patients can appreciate, likely influencing their overall perception of surgical success beyond mere recurrence prevention.

Our findings align with and extend the existing evidence base on fixation techniques in laparoscopic hernia repair. Kumar and colleagues (2020), in a prospective comparative study of 69 patients undergoing totally extraperitoneal (TEP) inguinal hernia repair, reported significantly lower pain scores at 1 week, 1 month, and 3 months with transfascial suture fixation compared to tack fixation, with VAS scores at 3 months of 0.07 vs. 0.42 (p < 0.05) [12]. Although their study addressed inguinal hernias in a different anatomical plane, the principle that suture-based fixation can achieve durable results with acceptable pain profiles supports our findings. Notably, their suture technique avoided lateral nerve entrapment, similar to our midline approach.

Campbell and Mills (2017), in their series of 152 patients undergoing laparoscopic ventral hernia repair with circumferential transfascial suture fixation, reported low recurrence rates (1.97%) and minimal postoperative pain, with most patient’s pain-free by 6 weeks [14]. Their average hospital stay of 2 days closely aligns with our Midline group’s mean of 2.48 days, suggesting that suture-based techniques, when carefully executed, can facilitate rapid discharge. However, their circumferential approach included lateral sutures, whereas our midline technique specifically avoids lateral placement, potentially explaining the even lower pain scores in our cohort.

Agrawal and colleagues (2022) prospectively studied 40 patients undergoing laparoscopic ventral hernia repair with totally transfascial suture mesh fixation and defect closure, reporting a mean hospital stay of 2.85 days, return to daily routine at 4.65 days, and excellent quality-of-life outcomes on the Carolina Comfort Scale, with postoperative mesh sensation scoring only 0.30 [23]. Their results parallel our findings and reinforce that transfascial suture fixation, when performed with attention to anatomical considerations, can optimize recovery without compromising outcomes. Mitura (2021), evaluating laparoscopic transabdominal preperitoneal (TAPP) repair in 25 patients with small and medium umbilical hernias, reported discharge on postoperative day one for all patients and no significant pain complaints during follow-up [24]. While TAPP represents a different technical approach (preperitoneal rather than intraperitoneal mesh placement), the principle of avoiding lateral trauma aligns with our midline fixation strategy. The comparable operative times in our study (approximately 80 min) are consistent with Mitura’s reported range of 55–120 min, indicating that midline fixation does not introduce technical inefficiency. Shetty and colleagues (2015), comparing IPOM and TAPP for umbilical and paraumbilical hernias in 120 patients, found IPOM to be significantly faster (p = 0.021) with comparable pain outcomes and no recurrences [25]. Their IPOM technique utilized lateral fixation, yet our midline approach achieved superior pain scores without increasing operative time, suggesting that modifying fixation location within the IPOM framework can enhance outcomes while preserving the efficiency advantage of IPOM over TAPP.

The recurrence rates in our study (9.7% in Midline, 12.9% in Lateral) are higher than some published series, such as Campbell’s 1.97% [14], but remain within acceptable ranges for pilot data and reflect our inclusion of defects up to 6 cm, including 22.6% with > 5 cm defects where recurrence risk is inherently elevated. Importantly, the comparable recurrence rates between groups confirm that midline fixation does not compromise mesh stability a critical safety finding supporting its continued use. The trend toward reduced complications in the Midline group (0% vs. 16.1%, p = 0.066) is noteworthy, though statistical significance was not achieved due to sample size limitations. Sieda and Khalil (2020), in their randomized controlled trial comparing standard IPOM with IPOM Plus (fascial closure with transfascial sutures), similarly found lower seroma rates and improved outcomes with suture-based fascial closure, supporting the biological plausibility that reducing lateral dissection and suture passes may decrease fluid accumulation and infectious complications [26]. Gopalakrishnan (2024), in a retrospective analysis of 74 patients comparing IPOM and IPOM Plus, reported significantly higher seroma formation in the IPOM group (p = 0.021), consistent with our observed trend [27].

Clinical implications

The findings of this study have several practical implications for surgeons performing laparoscopic umbilical hernia repair. First, midline transfascial suturing should be considered a viable alternative to conventional lateral fixation, particularly for small-to-medium defects where the anatomical benefits can be fully realized without compromising mesh overlap. The technique is technically straightforward, utilizes familiar instrumentation (suture passer, standard polypropylene sutures), and does not require specialized mesh or fixation devices, making it accessible to surgeons with basic laparoscopic skills.

Second, the significant pain reduction and shorter hospital stay associated with midline fixation support its integration into ERAS pathways for hernia surgery. By addressing one of the primary barriers to early discharge postoperative pain this technique aligns with the principles of multimodal analgesia and early mobilization that underpin modern perioperative care [28].

Third, the comparable operative times between groups indicate that adopting midline fixation does not impose efficiency costs, addressing a common concern when modifying established surgical techniques. Surgeons can transition to this approach without prolonging operating room time or disrupting surgical workflow.

Fourth, the higher patient satisfaction scores in the Midline group underscore the importance of considering patient-reported outcomes when evaluating surgical techniques. In an era of increasing emphasis on patient-centered care, technical modifications that improve the patient experience without compromising safety or efficacy should be prioritized.

Strengths and limitations

This study has several strengths. The prospective observational design allowed systematic data collection with real-time recording of outcomes, minimizing recall bias. The groups were well-matched at baseline for critical variables including age, gender, BMI, and defect size, as demonstrated in Table 1, enabling attribution of outcome differences to fixation technique rather than confounding factors. The comprehensive assessment of pain at multiple time points up to 60 days provided a nuanced understanding of recovery trajectories rather than a single-point snapshot. The inclusion of patient-reported satisfaction scores added a valuable dimension beyond traditional clinical outcomes.

However, several limitations must be acknowledged. First, the sample size of 62 patients, while adequately powered for primary outcomes, was relatively small and may have been insufficient to detect statistically significant differences in low-frequency events such as specific complications or recurrence. The subgroup analysis performed in this study should be interpreted with caution. The number of patients within each defect size category was small, limiting the statistical power to detect meaningful differences. As such, these findings are exploratory in nature and cannot be used to draw definitive conclusions. Larger studies are required to validate whether the observed benefits of midline fixation are consistent across different defect sizes. The trend toward fewer complications in the Midline group (p = 0.066) suggests that a larger study might demonstrate significant differences. Second, the follow-up duration of six months, while adequate for assessing acute pain and early recurrence, is insufficient to evaluate long-term recurrence rates, mesh-related complications, or chronic pain syndromes that may manifest beyond this period. Third, the observational, non- randomized design with the allocations of patients based on surgical units leaves room for potential selection and performance bias, including surgeon-related variability. Although baseline characteristics were comparable between the two groups and the surgeries were performed by surgeons with similar expertise, unmeasured confounders related to intraoperative technique and perioperative care may influence the outcomes, none the less the residual confounding factors cannot be excluded. Therefore, causal inference from the present findings remains limited and the results should be interpreted as demonstrating association rather than definitive causation. Further randomized controlled trials are required to validate these findings. Fourth, pain assessment using VAS, while widely validated, remains subjective and may be influenced by patient expectations, cultural factors, and prior pain experiences. Fifth, the study did not include objective measures of physical function or quality of life beyond satisfaction scoring, which could have provided additional insights into functional recovery. Sixth, the absence of blinding (surgeons and patients were aware of the fixation technique) may have introduced performance or detection bias, though the use of standardized protocols and objective outcome measures reduces this risk. Seventh, the single-center design limits generalizability to other settings with different patient populations or surgical expertise. Eight, No multivariable regression analysis was performed to adjust for potential confounders.

Future directions

The findings of this pilot study provide a strong foundation for future research. Large-scale, multicenter randomized controlled trials are needed to confirm these results in more diverse populations and to detect differences in low-frequency outcomes such as recurrence and specific complications with adequate statistical power. Longer follow-up extending to 2–5 years would clarify whether the pain benefits of midline fixation translate into reduced rates of chronic neuralgia and whether recurrence rates remain comparable over time. Incorporation of validated quality-of-life instruments such as the Carolina Comfort Scale or Hernia-Related Quality of Life Survey (HerQLes) would provide richer patient-reported outcome data. Cost-effectiveness analyses comparing midline fixation with conventional techniques, accounting for differences in hospital stay, analgesic requirements, and complication rates, would strengthen the economic case for adopting this approach. Future studies might also explore hybrid strategies combining midline sutures with selective lateral tacking for larger defects or high-risk patients, potentially optimizing both pain outcomes and biomechanical security. Finally, investigations into the biomechanical properties of midline-anchored meshes using computational modeling or cadaveric studies would provide engineering validation for the clinical observations reported here.

Conclusion

This study demonstrates that midline transfascial suturing significantly reduces postoperative pain compared to conventional lateral border fixation in laparoscopic IPOM repair for umbilical hernia. Patients undergoing midline fixation also experience shorter hospital stays and report higher satisfaction scores. Importantly, these benefits are achieved without any compromise in operative time or hernia recurrence rates. Overall, Midline transfascial suturing is associated with reduced postoperative pain and improved patient satisfaction. While no significant differences were observed in recurrence or complication rates, these findings should be interpreted with caution given the study’s observational design and limited sample size. Larger randomized studies are required to confirm these results. Based on the results provided by our study midline transfacial suturing can be considered for patients undergoing laparoscopic IPOM repair for small to medium umbilical hernia’s.

Authors’ contributions

Author A: Data collection, Managed the patients, wrote the main manuscript, reviewed the revisions, and submitted the manuscriptAuthor B: Data interpretation and supervised the writing of the manuscript.Author C: Supervised the writing of the manuscript and submitted the manuscript.Final approval of the article: All authors.

Funding

Open access funding provided by SRM Institute of Science and Technology for SRMIST – Medical & Health Sciences. No funding received. APC is covered by SRM Institute of Science and Technology of SRMIST- medicine and health sciences.

Data availability

All data supporting the findings of this study are included in the article.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Approval was obtained from the Institutional Ethics Committee of SRM Medical College Hospital and Research Centre prior to study commencement (IEC approval number: SRMIEC-ST1124-1826). Written informed consent was obtained from all participants after providing detailed information about the study. Patients were assured of confidentiality, and data were anonymized to protect patient identity. Participation was voluntary, and patients could withdraw at any time without affecting the quality of care received.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.