| CLINICAL REVIEW |

Surgical Techniques
In Primary Inguinal Hernia Repair
CHRISTOPHER G. ANDREW MD, FRCS(C); GERALD M. FRIED MD, FRCS(C), FACS

summary Tension-free hernia repair revolutionized inguinal hernia surgery, “plug-and-patch method,”4 is popular
and today surgeons use many variations of this approach.1–4 The introduction of
for its simplicity of technique. Other
advantages are its amenability to local
laparoscopy added a new dimension to herniorrhaphy. A full understanding of the
or regional anesthesia, and low peri-
benefits and drawbacks of each approach in treating primary inguinal hernias
operative morbidity and recurrence
enables the surgeon to use the appropriate procedure or seek consultation when rates.6 One drawback is that foreign
needed. This article explains the advantages and disadvantages of each proce- material heightens the risk of infec-
dure, reviews technique, and offers pearls for improving results. ■ tion, migration, or even fistulization
into nearby hollow viscera.7

T ension-free mesh herniorrhaphy is the most

popular technique for hernia repair, but even
this technique can be associated with problems,
mostly due to the introduction of foreign material.
Video-assisted inguinal herniorrhaphy, a controver-
sial alternative, is typically more expensive, requires
longer operative times, and can increase the difficul-
ty of a future radical prostatectomy.
Technical innovations have improved both peri-
operative and long-term morbidity of inguinal hernia
repair in the 118 years since Bassini popularized the
technique.5 However, tension-free and video-assisted
repairs have not rendered the traditional primary repair
obsolete. The surgeon must distinguish the role each
method has in treating the primary inguinal hernia. A
sound knowledge of inguinal anatomy and meticulous
attention to surgical technique will minimize perioper-
ative morbidity and long-term recurrence.
THE 3 APPROACHES
Tension-Free Mesh Repair
Tension-free mesh herniorrhaphy, utilizing either the
mesh patch, which Lichtenstein popularized,1 or the
The Traditional Approach
Because traditional tissue repair does not use foreign
material, it may be indicated in patients with local or
systemic infections or with a concomitant bowel
resection or other contaminated condition. Compared
with tension-free repairs, however, the traditional
approach results in greater postoperative pain and a
higher recurrence rate.6
Video-Assisted TAPP or TEP
Video-assisted inguinal herniorrhaphy involves either
KEY POINTS
• Tension-free mesh heniorrhaphy is amenable to
anesthesia, and has a low risk of recurrence.
• Traditional repair may be best for patients with a con-
tamination condition such as an infection or bowel
resection.
• Laparoscopic heniorrhaphy provides easy surgical
access to recurrent hernias and faster patient recov-
ery periods.

Drs Andrew and Fried are with Steinberg-Bernstein Centre for Minimally Invasive Surgery, Department of Surgery, McGill University,
Montreal, Quebec, Canada. Contact: Dr Fried at Department of Surgery, McGill University Health Centre, Montreal General Hospital
Campus, 1650 Cedar Avenue, #L9.309, Montreal, Quebec, Canada H3G 1A4; telephone (514) 934-8044; fax (514) 934-8438 (e-mail:
gerald.fried@mcgill.ca).

80 ■ VOL 61, NO 2/FEB 2005 contemporary surgery

 Inguinal Hernia Repair

transabdominal preperitoneal repair (TAPP) or totally

Universal Principles in Herniorrhaphy
extraperitoneal repair (TEP). First described in 1990,8
laparoscopic inguinal hernia repair remains a contro- • Adequately identify pertinent landmarks.
versial option. It allows the surgeon to access recur- • Perform high dissection of the hernia sac.
rent hernias via “virgin” tissue and repair bilateral her- • Evaluate for the presence of an indirect hernia sac.
nias through the same small incisions. Laparoscopic • Identify and preserve the peri-inguinal nerves.
hernia repair results in less postoperative pain and • Reconstruct the area of Hesselbach’s triangle
gets patients back to vigorous physical activities more to avoid a direct recurrence.
quickly.9–11 • Avoid tension on the repair.
Disadvantages, besides increased cost and
longer operative time, include the need for general
FIGURE 1 Making the Incision
anesthesia. TAPP itself carries the potential for intra-
abdominal injury or subsequent adhesions.10 Authors
have also reported that laparoscopic inguinal hernia
repair can make it difficult if not impossible to per-
form a subsequent radical prostatectomy.12
We use the TEP procedure for bilateral or recur-
rent inguinal hernias, and reserve the TAPP approach
for patients who have had previous lower abdominal
surgery and for inguinal hernia repair concurrent
with another laparoscopic procedure—provided the
peritoneal cavity is not contaminated.
Whichever approach you choose, the principles
of primary inguinal repair remain the same (box at
right). In right inguinal hernia repair, the external oblique aponeurosis
(black arrow) is incised, exposing the ilioinguinal nerve (yellow
arrow).
OPEN INGUINAL HERNIA REPAIR
FIGURE 2 Landmark for Mesh Placement
Anesthesia
In most cases, local anesthetic, administered correct-
ly, is safe and effective.13 General or regional anes-
thetic are options.
Xylocaine 1% with epinephrine is injected into 3
sites:
• The first injection is made 1 cm inferomedial
to the anterior superior iliac spine.
• The second is at the level of the internal ring
(half the distance from the anterior superior
iliac spine to the pubic tubercle and 1 cm
medial to that line) to block the ilioinguinal
nerve.
• The third at the pubic tubercle. With the spermatic cord retracted medially (arrow), the forceps
points at the pubic tubercle, an essential landmark for correct
Inject further local anesthetic subcutaneously placement of the mesh prosthesis.
along the proposed line of incision. Save additional
solution for use during the procedure, if necessary. Divide Camper’s and Scarpa’s fascia, controlling
subcutaneous veins with fine absorbable suture or
Making the Incision electrocautery. Identify the external oblique aponeu-
A skin incision exposes the area of interest from the rosis and incise it from the external ring to the level
pubic tubercle just lateral to the internal ring. A hor- of the internal ring, taking care to protect the under-
izontal incision provides optimal cosmesis. lying ilioinguinal nerve.

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| CLINICAL REVIEW |
FIGURE 3 Dissecting the Sac and Cord
In right-indirect inguinal hernia repair, the indirect hernia sac (yel-
low arrow) is dissected from the spermatic cord (black arrow) to
the level of the internal ring.
FIGURE 4 Sac and Cord Dissection (Direct Hernia)
A direct hernia sac (black arrow) is visualized. The dissection pro-
ceeds proximally to expose the point at which the peritoneum
reflects onto the spermatic cord (yellow arrow), thus excluding an
indirect sac.
Performing the Dissection
During the dissection, the surgeon must identify and
preserve the ilioinguinal and iliohypogastric nerves.
If either nerve is damaged or accidentally incorpor-
ated into a stitch, it is best resected with the ends lig-
ated and buried within the internal oblique muscle
fibers. This may help avoid future neuroma forma-
tion and prevent involvement of the nerve in future
scarring of the surgical field. (Figure 1).
Blunt dissection creates the superior and inferior
flaps under the external oblique aponeurosis, mak-
ing a space for placement of the mesh onlay.
Expose the shelving border of the inguinal liga-
ment from the pubic tubercle to about 2 cm lateral to
82 ■ VOL 61, NO 2/FEB 2005 contemporary surgery
the internal ring. Blunt dissection isolates the cord
structures at the pubic tubercle (Figure 2). Encircle
them with the index finger and thumb, and retract
with either a Penrose drain or special ring clamp.
Cremasteric Muscle Division
Divide the cremasteric muscle over the cord near the
internal ring. Protect the cord structures and seek an
indirect sac in the anteromedial position.
Dissecting the Hernia Sac
Dissect the indirect sac away from the spermatic cord
(Figure 3). However, if the sac extends distal to the
pubic tubercle, it is usually divided rather than dis-
sected further. This avoids possible ischemic orchitis
that excessive dissection of the cord structures may
cause. Do not ligate the distal end of the sac, as this
may cause hydrocele formation.
Proximally dissect the cord and sac from one
another to above the level of the internal ring. If the
completely dissected sac is intact, invert it into the
preperitoneal space without dividing it.
When repairing a direct hernia, the surgeon
must still adequately explore the cord to rule out an
indirect sac. Visualizing the point of reflection of
peritoneum onto the cord can accomplish this
(Figure 4).
Making the Repair
‘Plug-and-patch’ repair. Insert a prosthesis resem-
bling a badminton shuttlecock via the internal ring
into the preperitoneal space (Figures 5, 6). Secure
the petals to the edges of the internal ring to prevent
the plug from extruding. Position a mesh patch pros-
thesis to cover the posterior wall of the inguinal
canal overlying Hesselbach’s triangle.
Secure the medial, rounded end to the fascia
overlying the pubis at least 2 cm medial to the pubic
tubercle. This will avoid a medial recurrence. Avoid
placing sutures through the periosteum as this may
cause persistent postoperative pain.14
Affix the mesh medially to the internal oblique
aponeurosis using interrupted 2-0 monofilament
stitches. Laterally, a continuous stitch attaches the
mesh to the iliopubic tract and shelving edge of
inguinal ligament, to a point at least 2 cm lateral to
the internal ring (Figures 7, 8).
Overlap the tails of the prosthesis and suture
them together laterally to the cord at the internal
 Inguinal Hernia Repair

FIGURE 5 Plug and Patch FIGURE 6 Securing the Mesh

The polypropylene mesh plug and patch prosthesis. After the mesh prosthesis (arrow) is inserted into the internal
inguinal ring in right-indirect inguinal hernia repair, sutures
secure it to the edges of the ring.
ring, allowing adequate space for passage of the
spermatic cord. FIGURE 7 Running Suture
Mesh patch repair. The mesh patch repair is identical
to the plug and patch repair, except that a mesh
patch is placed without first inserting the mesh plug
into the internal inguinal ring.
Primary tissue repair (modified Shouldice repair).
Dissecting and managing the hernia sac are identical
to the tension-free repair. Start by incising the post-
erior floor of the inguinal canal from the internal ring
to the pubic tubercle down to the peritoneum,
exposing the cut edges of the transversalis fascia.
Take care to avoid injuring the inferior epigastirc ves-
sels at the internal ring
Use continuous monofilament stitches to repair 3 In right inguinal hernia repair, a running suture affixes the lateral
separate layers: edge of the prosthesis to the shelving edge of the inguinal liga-
ment (arrow).
• The edge of the lateral flap of transversalis fas-
cia to the undersurface of the medial flap of FIGURE 8 Securing Mesh to Fascia
transversalis fascia.
• The edge of the medial flap of transversalis
fascia to the iliopubic tract laterally.
• The medial edge of conjoint tendon to the
shelving edge of inguinal ligament.

Closure
To close the incision, approximate the external
oblique aponeurosis to re-create the external ring.
Take care not to strangulate the cord nor to entrap the
ilioinguinal nerve.

VIDEO-ASSISTED APPROACHES The apex of the mesh patch onlay is sutured (arrow) to the fascia
overlying the pubis approximately 2cm medial to the pubic tuber-
The totally extraperitoneal repair was first described cle. Additional interrupted sutures fix the prosthesis to the inter-
in 1992 (box, p 84).15 The advantages this approach nal oblique muscle medially.

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| CLINICAL REVIEW |
Equipment for Laparoscopic
Inguinal Hernia Repair
• 30° 5- or 10-mm laparoscope.
• Graspers.
• Scissors or hook cautery (for TAPP repairs).
• Suction-irrigation device.
• A blunt 12-mm trocar.
• Two 5-mm trocars.
• Multi-fire tacking device (for TAPP repairs).
• Preperitoneal distention balloon.
(optional for TEP repair).
FIGURE 9 Identifying Structures in TEP
After attaining a preperitoneal work space and bluntly dissecting
away the fibroareolar tissue, the spermatic cord (forceps), the
inferior epigastric vessels (above forceps), and Cooper’s ligament
(arrow) are identified.
has over the transabdominal preperitoneal repair are
that it allows the surgeon to stay outside the abdom-
inal cavity, carries a lower risk of adhesions (in theo-
ry), keeps the peritoneal layer between the mesh and
intra-abdominal contents intact, and forgoes the use
of tacks to secure the mesh.
However, TEP requires a greater learning curve
than TAPP,16 and the technique is contraindicated in
patients who have had previous lower abdominal
surgery.
Before attempting either TEP or TAPP proce-
dure, the surgeon must be proficient in laparoscopic
techniques and possess a working knowledge of the
“inside view” of the inguinal anatomy.
Totally Extraperitoneal Repair
Patient preparation. The patient is positioned in the
supine Trendelenburg position with arms tucked at
84 ■ VOL 61, NO 2/FEB 2005 contemporary surgery
the sides. The surgeon stands opposite the side of
the hernia.
Creating the preperitoneal space. Through a 1-cm
infraumbilical incision just off midline toward the
side of the hernia, incise the anterior rectus sheath
transversely and retract the muscle laterally to expose
the posterior rectus sheath.
Slide blunt curved forceps into the preperitoneal
space, developing the space in the midline either
with the finger, the curved forceps, the laparoscope,
or a specially designed balloon.
Insert a blunt 10/12-mm trocar and insufflate the
preperitoneal space to 10–12 mm Hg. Insert two 5-
mm working ports in the midline, taking care to not
puncture the peritoneum.
Dissection. Bluntly dissect the peritoneum off the
undersurface of the rectus abdominus to view the
pubis, Cooper’s ligament, and inferior epigastric ves-
sels—each a key landmark (Figure 9).
Identify the hernia sac and bluntly dissect it
away from the spermatic cord (Figures 10, 11). The
surgeon may ligate a long sac and divide it with the
distal portion left in situ, but should dissect the indi-
rect sac away from the cord structures well proximal
to the internal ring.
Mesh placement. Various polypropylene and poly-
ester materials are available.17 We use a specially
designed large polypropylene mesh shaped to the
contour of the inguinal region (Bard 3D Max mesh,
Davol, Inc, Providence, RI).
The mesh should cover the pubic tubercle medi-
ally, internal ring laterally, Cooper’s ligament/iliopu-
bic tract inferiorly, and posterior aspect of the rectus
muscle superiorly. Usually one can position the mesh
without sutures or staples, but a few tacks, if neces-
sary, can affix the mesh to these structures. Do not
place tacks inferior to the inguinal ligament (vascular
injury) or inferolateral to the internal ring (nerve
entrapment).
Slowly release C02 so that the mesh can be visu-
alized as the preperitoneal space collapses back
upon itself.
Peritoneal defects. Small peritoneal defects created
during the course of the procedure may be ignored.
If these defects are large, the resulting pneumoperi-
toneum may make visualization of the preperitoneal
space difficult. In these cases, place a Veress needle
intraperitoneally in the upper abdomen and attach it
to suction. If this technique fails to re-establish ade-
 Inguinal Hernia Repair

F I G U R E 1 0 Dissecting the Sac, Spermatic Cord

quate preperitoneal exposure, the procedure may be
converted to a TAPP.

Transabdominal Preperitoneal Repair

Patient preparation. Patient preparation and position-
ing for the TAPP technique is identical to that of the
TEP procedure.
Trocar placement. Using an open-insertion tech-
nique, insert a blunt 10/12-mm trocar intraperitone-
ally at the umbilicus and establish 12-mm Hg pneu-
moperitoneum.
Place an additional 5-mm trocar just lateral to
each rectus muscle, at the level of the umbilicus.
Peritoneal incision and dissection. Before creating the
peritoneal flap, the surgeon must visualize these land- In right TEP, an indirect hernia sac (arrow) is bluntly dissected
marks: medial umbilical ligament, inferior epigastric away from the spermatic cord.

vessels, spermatic vessels, and vas deferens. F I G U R E 1 1 Visualizing the Sac in TEP
An indirect sac will be apparent as a peritoneal
out-pouching just lateral to the junction of the inferi-
or epigastric vessels and vas deferens. A direct sac
will appear medial to this site.
Incise the peritoneum from a point 2 cm super-
ior and lateral to the internal inguinal ring to a point
just above the pubic tubercle. Bluntly dissect this flap
away from the anterior abdominal wall.
Identify the pubic tubercle, Cooper’s ligament,
iliopubic tract, spermatic cord, and inferior epigastric
vessels (Figure 12). If a hernia sac is present, blunt
dissect it away from surrounding tissues and reduce
it into the abdominal cavity.
A direct right inguinal hernia defect is easily visualized medial to
Mesh placement. Insert a polypropylene mesh and the inferior epigastric vessels. The hernia contents (arrow) are dis-
position it to cover Hesselbach’s triangle medially, sected until the hernia defect is empty.

the internal inguinal ring laterally, and the femoral

F I G U R E 1 2 Flap in TAPP Repair
space inferiorly.
With a multi-fire tacking device, secure the mesh
to the pubic tubercle and Cooper’s ligament infero-
medially, and the rectus muscle superiorly. As with
the TEP procedure, one should not place tacks or
staples inferior to the inguinal ligament or inferolat-
eral to the internal ring.
Reapproximate the cut peritoneal edges to com-
pletely exclude the mesh from the abdominal cavity.
Decreasing the pneumoperitoneum may facilitate
this task.

POSTOPERATIVE CARE
After both open tension-free repairs and video-assist-
A peritoneal flap has been created, and the cut edge is visible (yel-
ed repairs, patients may return to normal physical
low arrow). The hernia contents have been bluntly dissected from
activities as soon as they are capable. With primary the spermatic cord, revealing a direct hernia defect (white arrow).

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| CLINICAL REVIEW |
Chronic Pain Syndromes After Heniorrhaphy
Hernia recurrence rates are acceptably low today,
but chronic inguinal pain can still be a significant
problem. Recent studies have shown that 16%–69%
of patients complain of chronic inguinal pain after
anterior herniorrhaphy.14,18,19
In a randomized study, 6% of patients who
underwent “plug-and-patch” repair required subse-
quent removal of the plug because of chronic pain.20
Video-assisted techniques have diminished chronic
postoperative inguinal pain.10,14
Authors have described 3 chronic pain syn-
dromes:
1. Somatic pain may be related to damage to the
pubic tubercle after placement of either sutures
or metallic tacks in the periosteum.18
2. Neuropathic pain is probably attributable to
ilioinguinal, iliohypogastric, or genitofemoral
nerve trauma.19 This pain develops in the senso-
ry distribution of the injured nerve. Surgical
handling, partial division, stretching, contusion,
crushing, electrical damage, or suture compres-
sion of sensory nerves may cause chronic neu-
ralgia. Another potential cause is irritation or
compression by an adjacent inflammatory
process.
3. Visceral pain may be due either to injury to
somatic sacral or sympathetic nerves, or to
stricture of the spermatic duct from scar tissue
or twisting of the cord.14
Preventing chronic pain begins with knowing the
inguinal sensory nerve anatomy. Avoid suture or tack
insertion at the pubic tubercle. Do not staple below
the iliopubic tract when stapling lateral to the internal
spermatic vessels (or avoid staples altogether).
Protect the sensory nerves during anterior
repairs. Intentional division of sensory nerves in the
groin may avoid neuralgia at the expense of causing
an insensate area above the pubis.
tissue repairs, a 4–6-week healing period is recom-
mended before patients attempt heavy lifting or
strenuous physical activity.
Disclosure: Tyco Healthcare Canada provides an
unrestricted grant to McGill University Department of
Surgery, with which both authors are affiliated.
86 ■ VOL 61, NO 2/FEB 2005 contemporary surgery
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