Inguinal hernia repair is among the most frequently performed procedures in general surgery worldwide. Over the past three decades, minimally invasive techniques—predominantly Totally Extraperitoneal (TEP) and Transabdominal Preperitoneal (TAPP) repair—have gained widespread adoption and are now endorsed by international hernia guidelines as first-line modalities alongside Lichtenstein repair. Laparoscopic approaches provide well-documented clinical benefits, including reduced postoperative pain, lower wound morbidity, early ambulation, and accelerated return to work and daily activities. Despite these advantages, the prevalence of overweight and obesity continues to rise globally, posing distinct perioperative challenges. In clinical and surgical research, Body Mass Index (BMI) is the standard metric used to quantify adiposity. Elevated BMI is characterized by abundant subcutaneous and preperitoneal fat, reduced working space in the retroperitoneal/extraperitoneal preperitoneal plane, obscure anatomical landmarks, and vascular engorgement. These factors make the dissection of the space of Retzius and the space of Bogros technically demanding, potentially increasing operative time, the incidence of inadvertent peritoneal laceration, nerve irritation, and conversion to open repair. Furthermore, while laparoscopic repair has been recommended to mitigate the higher wound infection rates often observed in obese patients undergoing open repair, there is conflicting evidence regarding whether elevated BMI independently drives intraoperative difficulty, prolonged hospital stay, or increased postoperative complications such as seroma formation, chronic groin pain, and early recurrence. In developing countries and public academic teaching settings, where patients present with variable hernia chronicity and anatomical characteristics, data systematically examining the graded association between BMI and objective laparoscopic hernia outcomes remain limited. Therefore, this prospective observational study was undertaken to evaluate the association between BMI categories and intraoperative technical difficulty, operative duration, perioperative complications, and short-term surgical outcomes following laparoscopic inguinal hernia repair at our tertiary-care teaching institution.

Study Design and Setting A prospective observational cohort study was conducted over an 18-month duration (February 2025 to July 2026) in the Department of General Surgery at Vilasrao Deshmukh Government Medical College and Hospital, Latur, Maharashtra, India. The institutional ethics committee reviewed and approved the study protocol prior to patient enrollment. Written informed consent was obtained from all participating patients. Inclusion and Exclusion Criteria Adult patients aged 18 to 75 years diagnosed with primary uncomplicated unilateral or bilateral inguinal hernia undergoing elective laparoscopic repair (TEP or TAPP) were consecutively recruited. Exclusion criteria comprised: (1) complicated hernias (strangulated, incarcerated, or obstructed hernia requiring emergency exploration); (2) recurrent inguinal hernias after previous preperitoneal or open repair; (3) history of extensive lower abdominal midline or Pfannenstiel incisions; (4) severe cardiopulmonary co-morbidities precluding general anesthesia or pneumoperitoneum (ASA physical status IV or V); and (5) refusal to participate. Patient Stratification and Operative Technique Patients' height and weight were measured at admission to calculate BMI (kg/m²). In accordance with the revised World Health Organization Asian-Indian criteria, participants were categorized into three cohorts: (1) Normal Weight: BMI < 23.0 kg/m²; (2) Overweight: BMI 23.0–27.4 kg/m²; and (3) Obese: BMI ≥ 27.5 kg/m². All procedures were performed under general anesthesia with endotracheal intubation by experienced laparoscopic surgeons or under direct faculty supervision. The choice between TEP and TAPP was based on standardized department protocol and surgeon discretion. For TEP repairs, preperitoneal space creation was achieved under direct vision using a telescopic dissection technique or balloon dissecting trocar. A three-midline port configuration was utilized. For TAPP repairs, pneumoperitoneum was established at 12–14 mmHg, and a peritoneal flap was created 4 cm cranial to the hernia defect extending from the medial umbilical ligament to the anterior superior iliac spine. In all cases, a macroporous polypropylene mesh (15 × 12 cm) was placed to achieve adequate overlap over the myopectineal orifice of Fruchaud, with tacker or suture fixation used selectively as indicated. Data Collection and Outcome Parameters Primary outcome variables included total operative duration (skin incision to skin closure in minutes) and subjective technical difficulty assessed by the operating surgeon immediately post-procedure on a 10-point Visual Analogue Scale (VAS: 1 = extremely facile, 10 = technically arduous). Intraoperative events recorded included peritoneal laceration, injury to epigastric vessels, nerve injury, and open conversion. Secondary outcome measures evaluated postoperative recovery: postoperative pain scores measured at 12 hours, 24 hours (POD 1), and 7 days using the 0–10 Numerical Rating Scale (NRS); time to unassisted ambulation; total postoperative hospital stay; and 30-day postoperative complications graded according to the Clavien-Dindo classification, specifically including seroma/hematoma formation, acute urinary retention, surgical site infection (SSI), and readmission rates. Statistical Analysis Data were entered into Microsoft Excel and analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables are presented as mean ± standard deviation (SD) and compared across the three BMI cohorts using one-way Analysis of Variance (ANOVA) followed by Tukey's post-hoc test. Categorical variables are expressed as numbers and percentages and analyzed using the Pearson Chi-Square test or Fisher's exact test. Multivariate linear and logistic regression models were applied to identify independent predictors of operative time and complications while controlling for age, hernia type, and operative approach. A two-tailed p-value < 0.05 was considered statistically significant.

A total of 120 eligible patients undergoing laparoscopic inguinal hernia repair were enrolled and completed the prospective observational study. Patients were distributed into three groups based on BMI: Normal Weight (n = 42, 35.0%), Overweight (n = 46, 38.3%), and Obese (n = 32, 26.7%). Baseline patient demographic and clinical characteristics are summarized in Table 1. Table 1: Baseline Demographics and Clinical Characteristics Across BMI Categories Characteristic Normal (<23 kg/m²) (n = 42) Overweight (23–27.4) (n = 46) Obese (≥27.5 kg/m²) (n = 32) p-value Age in years (Mean ± SD) 44.6 ± 12.8 47.2 ± 13.5 48.9 ± 11.9 0.324 Male / Female sex, n (%) 40 (95.2%) / 2 (4.8%) 43 (93.5%) / 3 (6.5%) 30 (93.8%) / 2 (6.2%) 0.941 Mean BMI, kg/m² (Mean ± SD) 20.8 ± 1.4 25.1 ± 1.2 29.7 ± 2.1 <0.001 ASA Class I / II / III, n 25 / 15 / 2 22 / 20 / 4 11 / 16 / 5 0.312 Hypertension, n (%) 8 (19.0%) 12 (26.1%) 11 (34.4%) 0.314 Diabetes Mellitus, n (%) 6 (14.3%) 9 (19.6%) 10 (31.3%) 0.207 Hernia Laterality, n (%) 0.862 • Unilateral (Right / Left) 37 (22 / 15) 39 (24 / 15) 27 (17 / 10) • Bilateral 5 (11.9%) 7 (15.2%) 5 (15.6%) Hernia Type, n (%) 0.789 • Indirect 26 (61.9%) 27 (58.7%) 17 (53.1%) • Direct 13 (31.0%) 15 (32.6%) 12 (37.5%) • Combined / Pantaloon 3 (7.1%) 4 (8.7%) 3 (9.4%) Surgical Approach, n (%) 0.875 • TEP repair 28 (66.7%) 30 (65.2%) 20 (62.5%) • TAPP repair 14 (33.3%) 16 (34.8%) 12 (37.5%) Operative duration and technical difficulty scores demonstrated a clear, statistically significant stepwise increase with higher BMI strata (Table 2). Total operative time averaged 52.4 ± 10.2 minutes in normal weight individuals compared to 78.5 ± 15.4 minutes in the obese cohort (p < 0.001). The subjective operative difficulty score on the 10-point VAS was more than double in obese patients compared to normal weight counterparts (6.8 ± 1.5 vs 3.4 ± 1.1; p < 0.001). Inadvertent peritoneal tear occurred predominantly in obese patients undergoing TEP (31.3% vs 7.1% in normal weight, p = 0.012). Conversion to open Lichtenstein repair occurred in 1 patient in the obese cohort due to dense adhesions and loss of preperitoneal space. Table 2: Intraoperative Parameters and Technical Difficulty Metrics Parameter Normal (<23 kg/m²) (n = 42) Overweight (23–27.4) (n = 46) Obese (≥27.5 kg/m²) (n = 32) p-value Total Operative Time, min (Mean ± SD) 52.4 ± 10.2 63.8 ± 12.6 78.5 ± 15.4 <0.001 • Unilateral hernia repair, min 48.2 ± 8.6 58.5 ± 9.8 72.4 ± 12.1 <0.001 • Bilateral hernia repair, min 78.6 ± 11.4 94.2 ± 14.8 112.5 ± 18.2 <0.001 Subjective Difficulty Score (VAS 1–10) 3.4 ± 1.1 4.9 ± 1.3 6.8 ± 1.5 <0.001 Peritoneal Tear during TEP, n (%) 2 / 28 (7.1%) 5 / 30 (16.7%) 6 / 20 (30.0%) 0.038 Inferior Epigastric Vessel Bleed, n (%) 0 (0.0%) 1 (2.2%) 2 (6.3%) 0.245 Mesh Fixation Performed, n (%) 12 (28.6%) 20 (43.5%) 22 (68.8%) 0.002 Conversion to Open Repair, n (%) 0 (0.0%) 0 (0.0%) 1 (3.1%) 0.354 Evaluation of postoperative recovery parameters revealed marked differences among the groups (Table 3). Pain scores on POD 1 were significantly higher in obese patients (4.2 ± 0.9 vs 2.8 ± 0.8; p < 0.001), which translated into prolonged time to unassisted mobilization (21.4 ± 5.2 hours vs 14.6 ± 3.8 hours; p < 0.001). Hospital stay was slightly longer in the obese group (2.4 ± 0.8 days vs 1.6 ± 0.6 days; p < 0.001). Table 3: Postoperative Pain Trajectory, Recovery Milestones, and Hospital Stay Outcome Parameter Normal (<23 kg/m²) (n = 42) Overweight (23–27.4) (n = 46) Obese (≥27.5 kg/m²) (n = 32) p-value Pain Score at 12 hours (NRS 0–10) 3.8 ± 0.9 4.6 ± 1.1 5.4 ± 1.2 <0.001 Pain Score on POD 1 (24 h) 2.8 ± 0.8 3.5 ± 0.9 4.2 ± 0.9 <0.001 Pain Score on POD 7 1.2 ± 0.5 1.6 ± 0.6 2.1 ± 0.8 <0.001 Time to Unassisted Ambulation, hours 14.6 ± 3.8 17.8 ± 4.4 21.4 ± 5.2 <0.001 Postoperative Hospital Stay, days 1.6 ± 0.6 1.9 ± 0.7 2.4 ± 0.8 <0.001 Time to Return to Normal Activities, days 7.4 ± 2.1 9.6 ± 2.8 12.8 ± 3.5 <0.001 Overall 30-day postoperative morbidity was significantly greater in the obese group compared to normal weight patients (31.3% vs 9.5%, p = 0.038; Table 4). The primary contributor to this increase was the development of early postoperative seroma (21.9% in obese vs 4.8% in normal weight, p = 0.027), all of which resolved conservatively within 4–6 weeks without surgical intervention. Acute urinary retention occurred in 4 (12.5%) obese patients, managed by temporary Foley catheterization. No cases of mesh infection, bowel injury, deep venous thrombosis, or early recurrence were recorded during the 30-day follow-up. Table 4: 30-Day Postoperative Complications Categorized by BMI Complication Category Normal (<23 kg/m²) (n = 42) Overweight (23–27.4) (n = 46) Obese (≥27.5 kg/m²) (n = 32) p-value Overall Morbidity (Clavien-Dindo I–II) 4 (9.5%) 8 (17.4%) 10 (31.3%) 0.038 Postoperative Seroma, n (%) 2 (4.8%) 5 (10.9%) 7 (21.9%) 0.027 Inguinoscrotal Hematoma, n (%) 1 (2.4%) 2 (4.3%) 2 (6.3%) 0.684 Acute Urinary Retention, n (%) 1 (2.4%) 3 (6.5%) 4 (12.5%) 0.198 Superficial Port-Site Infection, n (%) 0 (0.0%) 1 (2.2%) 1 (3.1%) 0.582 Transient Neuralgia / Paresthesia, n (%) 1 (2.4%) 2 (4.3%) 3 (9.4%) 0.354 Deep Mesh Infection, n (%) 0 (0.0%) 0 (0.0%) 0 (0.0%) — 30-Day Re-admission, n (%) 0 (0.0%) 0 (0.0%) 1 (3.1%) 0.354 30-Day Recurrence, n (%) 0 (0.0%) 0 (0.0%) 0 (0.0%) —

Laparoscopic inguinal hernia repair has firmly established itself as a preferred approach in modern surgical practice due to its minimally invasive benefits. However, surgical technical execution can be significantly constrained by patient anthropometric factors. In this prospective observational cohort study, we observed a significant, graded relationship between increasing BMI and operative difficulty, operative duration, postoperative pain trajectory, and the rate of early seroma formation. The primary finding of our study is the substantial prolongation of operative time in overweight and obese cohorts, averaging 26.1 minutes longer in obese individuals compared to normal weight patients. Several anatomical mechanisms explain this difference. In overweight and obese patients, the abundance of retroperitoneal and preperitoneal adipose tissue substantially limits operative working space. During TEP repair, dissecting through a thick preperitoneal adipose layer obscures the crucial landmarks—such as the pubic ramus, Cooper's ligament, and the epigastric vessels—demanding more meticulous, cautious blunt and sharp dissection. This also accounts for the substantially higher rate of peritoneal fenestration in obese patients (30.0% vs 7.1%), which leads to gas leakage into the peritoneal cavity, secondary loss of preperitoneal workspace, and the need for Veress needle or cannula decompression. These technical challenges directly correspond to the subjective difficulty scores reported by operating surgeons, which rose from 3.4 in normal-weight patients to 6.8 in obese individuals. In TAPP repair, while the intra-abdominal workspace is generally maintained, handling bulky, fat-laden peritoneal flaps and achieving adequate parietalization of the spermatic cord and gonadal vessels requires elevated dexterity, increased port torque, and longer operative duration. Regarding postoperative recovery, obese patients experienced higher pain intensity scores across the first postoperative week and required longer periods to achieve unassisted ambulation (21.4 hours vs 14.6 hours). This difference is largely attributable to greater tissue traction, higher port torquing force exerted through a thick abdominal wall, and more frequent utilization of mechanical tacker fixation in obese patients to prevent mesh displacement in extensive preperitoneal space defects. The 30-day complication rate was significantly higher in obese patients, predominantly driven by seroma formation (21.9%). Obesity is widely recognized to be associated with larger hernia defects, extensive dead space remaining after hernia reduction, and copious devascularized preperitoneal fibrofatty tissue that undergoes inflammatory transudation. Fortunately, almost all post-laparoscopic seromas represent Clavien-Dindo Grade I events that resolve spontaneously with watchful waiting and scrotal support. Critically, despite the increased operative complexity and prolonged surgical duration, the overall safety profile of laparoscopic repair was well preserved. There were no mesh infections, visceral or vascular emergencies, and only a single conversion to open repair occurred. Furthermore, hospital stay remained within 2.4 days even among obese patients, which compares favorably to historical data on open Lichtenstein repair in obese individuals who frequently encounter higher wound infection and hematoma rates. LIMITATIONS This study has certain limitations. It was conducted at a single tertiary-care government teaching hospital with a modest sample size of 120 patients. Both TEP and TAPP procedures were included, which, while reflective of daily clinical practice, introduces operative heterogeneity. Furthermore, surgeon subjective difficulty assessment on VAS is inherently susceptible to inter-operator variability. Finally, long-term follow-up beyond 30 days is necessary to ascertain chronic inguinal pain, nerve entrapment, and late recurrence rates across BMI cohorts.

Body Mass Index is an important determinant of operative complexity in laparoscopic inguinal hernia repair. Elevated BMI is significantly associated with prolonged operative time, higher technical difficulty, increased incidence of peritoneal tears, and elevated rates of early postoperative seroma formation and initial pain. Nevertheless, laparoscopic repair remains a safe, reproducible, and effective surgical modality in overweight and obese patients when executed with strict anatomical vigilance, careful preperitoneal dissection, and adequate mesh overlap.

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