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Different methods of managing the distal hernia sac to prevent seroma after laparoscopic repair of large indirect inguinal hernias: a real-world study - Hernia Objective To evaluate the efficacy and safety of different methods of managing the distal hernia sac in preventing seroma after laparoscopic transabdominal preperitoneal repair (TAPP) for large indirect inguinal hernias. Methods A retrospective analysis was conducted on 163 male patients with unilateral large indirect inguinal hernias (hernia sac diameter > 5 cm) who underwent TAPP at the Department of Gastrointestinal Surgery, Fuling Hospital of Chongqing University between January 2020 and January 2025. Based on the method of hernia sac management, patients were divided into three groups: Group A (n = 38) underwent complete dissection of the hernia sac; Group B (n = 61) underwent transection and abandonment of the distal sac; Group C (n = 64) underwent midline transection of the lateral hernia sac combined with lateral fixation of the residual stump. Perioperative indicators, postoperative VAS scores, and complication rates were compared among the groups. Results All 163 patients successfully completed the surgery. Operative time was significantly longer in Group A (94.16 ± 21.93 min) compared to Groups B (80.59 ± 27.00 min) and C (93.97 ± 23.49 min) (P = 0.027), whereas no significant difference was detected between Groups B and C. The time required for hernia sac management also differed significantly across groups (P < 0.001), being longest in Group A, followed by Group C, and shortest in Group B. In terms of hospital stay, Group B (6 [5, 7] days) stayed significantly longer than both Group A and Group C (both 5 [4, 7] days) (P = 0.005). The incidence of seroma was significantly higher in Group B (18.03%) than in Group A (5.26%) and Group C (4.69%) (P = 0.035). Multivariable logistic regression further identified the surgical technique used in Group B as an independent risk factor for seroma (aOR: 5.47, 95% CI: 1.35–22.13, P = 0.017). The incidences of scrotal hematoma and ischemic orchitis were significantly higher in Group A than in the other two groups (P = 0.012 for both). There were no significant differences among the three groups in postoperative VAS scores, intraoperative blood loss, urinary retention, infection, recurrence, or chronic pain rates. Conclusion In this study, midline transection of the lateral hernia sac combined with lateral stump fixation was associated with a lower incidence of seroma after TAPP for large indirect inguinal hernias, without a significant increase in the risks of postoperative pain, scrotal hematoma, ischemic orchitis, infection, recurrence, or other complications. https://link.springer.com/article/10.1007/s10029-025-03535-0