A predictive nomogram for peritoneal injury during totally extraperitoneal inguinal hernia repair: A retrospective cohort study

ObjectivePeritoneal injury is a common complication during totally extraperitoneal inguinal hernia repair, potentially affecting surgical outcomes and patient recovery. Identifying risk factors associated with peritoneal injury is crucial to improving surgical techniques and optimizing patient care.MethodsThis retrospective study analyzed data from 334 patients who underwent totally extraperitoneal inguinal hernia repair between August 2019 and April 2024. Patients were divided into two groups based on the occurrence of peritoneal injury: injury group (<i>n</i> = 69) and noninjury group (<i>n</i> = 265). Univariate and multivariate logistic regression analyses identified independent risk factors for peritoneal injury. A predictive nomogram was constructed using significant variables from the multivariate analysis. The performance of the nomogram was evaluated using the area under the receiver operating characteristic curve (AUC), calibration plots, and decision curve analysis.ResultsPeritoneal injury occurred in 20.7% of the cases. Multivariate analysis identified the following five independent risk factors: anatomical misrecognition (odds ratio: 7.55; p = 0.005), insufficient peritoneal tension (odds ratio: 2.95; p = 0.007), hernial sac diameter ≥4 cm (odds ratio: 2.75; p = 0.008), prior infraumbilical surgery (odds ratio: 2.50; p = 0.021), and use of sharp medial hernia sac dissection techniques (odds ratio: 5.20; p = 0.006). Body mass index was a significant factor in univariate analysis (p = 0.004) but not in multivariate analysis (p = 0.180). The nomogram demonstrated good discriminative ability (AUC = 0.841) and calibration. The decision curve analysis indicated that the nomogram provided clinical utility across a range of threshold probabilities.ConclusionsThe study identified key risk factors for peritoneal injury during totally extraperitoneal inguinal hernia repair and developed a predictive nomogram with strong discriminative ability. Awareness of these factors enables surgeons to preoperatively stratify risk based on imaging-assessed hernia characteristics and patient history, thereby guiding technique selection.