Awad SS, Fagan SP. Current approaches to inguinal hernia repair. Am J Surg. 2004 Dec. 188(6A Suppl):9S-16S. [QxMD MEDLINE Link].
Scott NW, McCormack K, Graham P, Go PM, Ross SJ, Grant AM. Open mesh versus non-mesh for repair of femoral and inguinal hernia. Cochrane Database Syst Rev. 2002. CD002197. [QxMD MEDLINE Link].
Hosgor M, Karaca I, Ozer E, Suzek D, Ulukus C, Ozdamar A. Do alterations in collagen synthesis play an etiologic role in childhood inguinoscrotal pathologies: an immunohistochemical study. J Pediatr Surg. 2004 Jul. 39(7):1024-9. [QxMD MEDLINE Link].
Junge K, Klinge U, Prescher A, Giboni P, Niewiera M, Schumpelick V. Elasticity of the anterior abdominal wall and impact for reparation of incisional hernias using mesh implants. Hernia. 2001 Sep. 5(3):113-8. [QxMD MEDLINE Link].
[Guideline] HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018 Feb. 22 (1):1-165. [QxMD MEDLINE Link]. [Full Text].
O'Dwyer PJ, Norrie J, Alani A, Walker A, Duffy F, Horgan P. Observation or operation for patients with an asymptomatic inguinal hernia: a randomized clinical trial. Ann Surg. 2006 Aug. 244(2):167-73. [QxMD MEDLINE Link].
Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, Dunlop DD, Reda DJ, McCarthy M Jr, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA. 2006 Jan 18. 295 (3):285-92. [QxMD MEDLINE Link].
Grosz CR. Iliohypogastric nerve injury. Am J Surg. 1981 Nov. 142(5):628. [QxMD MEDLINE Link].
Fingerhut A, Millet B, Veyrie N, et al. Inguinal hernia repair, update 2006. Edmund AM, Neugebauer S, Fingerhut A, et al. EAES Guidelines for Endoscopic Surgery. Springer; 2006. 1: 294-307.
Pisanu A, Podda M, Saba A, Porceddu G, Uccheddu A. Meta-analysis and review of prospective randomized trials comparing laparoscopic and Lichtenstein techniques in recurrent inguinal hernia repair. Hernia. 2015 Jun. 19 (3):355-66. [QxMD MEDLINE Link].
Chung L, O'Dwyer PJ. Treatment of asymptomatic inguinal hernias. Surgeon. 2007 Apr. 5(2):95-100; quiz 100, 121. [QxMD MEDLINE Link].
Chung L, Norrie J, O'Dwyer PJ. Long-term follow-up of patients with a painless inguinal hernia from a randomized clinical trial. Br J Surg. 2011 Apr. 98 (4):596-9. [QxMD MEDLINE Link].
Koch A, Edwards A, Haapaniemi S, Nordin P, Kald A. Prospective evaluation of 6895 groin hernia repairs in women. Br J Surg. 2005 Dec. 92(12):1553-8. [QxMD MEDLINE Link].
Woods B, Neumayer L. Open repair of inguinal hernia: an evidence-based review. Surg Clin North Am. 2008 Feb. 88(1):139-55, ix-x. [QxMD MEDLINE Link].
Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. The tension-free hernioplasty. Am J Surg. 1989 Feb. 157(2):188-93. [QxMD MEDLINE Link].
Malangoni MA, Rosen MJ. Hernias. Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed. Philadelphia: Elsevier; 2017. 1092-119.
Starling JR, Harms BA. Diagnosis and treatment of genitofemoral and ilioinguinal neuralgia. World J Surg. 1989 Sep-Oct. 13(5):586-91. [QxMD MEDLINE Link].
Wijsmuller AR, Lange JF, Kleinrensink GJ, van Geldere D, Simons MP, Huygen FJ, et al. Nerve-identifying inguinal hernia repair: a surgical anatomical study. World J Surg. 2007 Feb. 31 (2):414-20; discussion 421-2. [QxMD MEDLINE Link].
Paajanen H, Varjo R. Ten-year audit of Lichtenstein hernioplasty under local anaesthesia performed by surgical residents. BMC Surg. 2010 Aug 4. 10:24. [QxMD MEDLINE Link]. [Full Text].
Wiese M, Kaufmann T, Metzger J, et al. Learning curve for Lichtenstein hernioplasty. Open Access Surg. 2010 Jul 2. 3:43-6. [Full Text].
Kark AE, Kurzer M, Waters KJ. Tension-free mesh hernia repair: review of 1098 cases using local anaesthesia in a day unit. Ann R Coll Surg Engl. 1995 Jul. 77 (4):299-304. [QxMD MEDLINE Link]. [Full Text].
Gianetta E, Cuneo S, Vitale B, Camerini G, Marini P, Stella M. Anterior tension-free repair of recurrent inguinal hernia under local anesthesia: a 7-year experience in a teaching hospital. Ann Surg. 2000 Jan. 231(1):132-6. [QxMD MEDLINE Link]. [Full Text].
Zhao G, Gao P, Ma B, Tian J, Yang K. Open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Ann Surg. 2009 Jul. 250(1):35-42. [QxMD MEDLINE Link].
Chung RS, Rowland DY. Meta-analyses of randomized controlled trials of laparoscopic vs conventional inguinal hernia repairs. Surg Endosc. 1999 Jul. 13 (7):689-94. [QxMD MEDLINE Link].
Espat NJ. Biomaterials in hernia repair. Fischer JE, Jones DB, Pomposelli FB, et al, eds. Fischer's Mastery of Surgery. 6th ed. Philadelphia: Wolters Kluwer; 2012. Chap 209.
Bringman S, Wollert S, Osterberg J, Smedberg S, Granlund H, Heikkinen TJ. Three-year results of a randomized clinical trial of lightweight or standard polypropylene mesh in Lichtenstein repair of primary inguinal hernia. Br J Surg. 2006 Sep. 93(9):1056-9. [QxMD MEDLINE Link].
Weyhe D, Belyaev O, Müller C, Meurer K, Bauer KH, Papapostolou G, et al. Improving outcomes in hernia repair by the use of light meshes--a comparison of different implant constructions based on a critical appraisal of the literature. World J Surg. 2007 Jan. 31(1):234-44. [QxMD MEDLINE Link].
Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. Cause and prevention of postherniorrhaphy neuralgia: a proposed protocol for treatment. Am J Surg. 1988 Jun. 155(6):786-90. [QxMD MEDLINE Link].
Wantz GE. Complications of inguinal hernial repair. Surg Clin North Am. 1984 Apr. 64(2):287-98. [QxMD MEDLINE Link].
Franklin ME Jr, Gonzalez JJ Jr, Glass JL. Use of porcine small intestinal submucosa as a prosthetic device for laparoscopic repair of hernias in contaminated fields: 2-year follow-up. Hernia. 2004 Aug. 8 (3):186-9. [QxMD MEDLINE Link].
Ferzli GS, Edwards E, Al-Khoury G, Hardin R. Postherniorrhaphy groin pain and how to avoid it. Surg Clin North Am. 2008 Feb. 88(1):203-16, x-xi. [QxMD MEDLINE Link].
Delikoukos S, Fafoulakis F, Christodoulidis G, Theodoropoulos T, Hatzitheofilou C. Re-operation due to severe late-onset persisting groin pain following anterior inguinal hernia repair with mesh. Hernia. 2008 Dec. 12(6):593-5. [QxMD MEDLINE Link].
Shamberger RC, Ottinger LW, Malt RA. Arterial injuries during inguinal herniorrhaphy. Ann Surg. 1984 Jul. 200(1):83-5. [QxMD MEDLINE Link].
Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibiotic prophylaxis for hernia repair. Cochrane Database Syst Rev. 2007 Jul 18. CD003769. [QxMD MEDLINE Link].
Shankar VG, Srinivasan K, Sistla SC, Jagdish S. Prophylactic antibiotics in open mesh repair of inguinal hernia - a randomized controlled trial. Int J Surg. 2010. 8(6):444-7. [QxMD MEDLINE Link].
Franneby U, Sandblom G, Nordin P, Nyren O, Gunnarsson U. Risk factors for long-term pain after hernia surgery. Ann Surg. 2006 Aug. 244(2):212-9. [QxMD MEDLINE Link].
Albo D, Awad SS, Berger DH, Bellows CF. Decellularized human cadaveric dermis provides a safe alternative for primary inguinal hernia repair in contaminated surgical fields. Am J Surg. 2006 Nov. 192(5):e12-7. [QxMD MEDLINE Link].
O'Dwyer PJ, Alani A, McConnachie A. Groin hernia repair: postherniorrhaphy pain. World J Surg. 2005 Aug. 29(8):1062-5. [QxMD MEDLINE Link].
Hair A, Duffy K, McLean J, Taylor S, Smith H, Walker A, et al. Groin hernia repair in Scotland. Br J Surg. 2000 Dec. 87 (12):1722-6. [QxMD MEDLINE Link].
Nilsson H, Stylianidis G, Haapamaki M, Nilsson E, Nordin P. Mortality after groin hernia surgery. Ann Surg. 2007 Apr. 245(4):656-60. [QxMD MEDLINE Link].
Taylor EW, Duffy K, Lee K, Hill R, Noone A, Macintyre I, et al. Surgical site infection after groin hernia repair. Br J Surg. 2004 Jan. 91 (1):105-11. [QxMD MEDLINE Link].
Earle DB, Mark LA. Prosthetic material in inguinal hernia repair: how do I choose?. Surg Clin North Am. 2008 Feb. 88(1):179-201, x. [QxMD MEDLINE Link].
Amid PK. How to avoid recurrence in Lichtenstein tension-free hernioplasty. Am J Surg. 2002 Sep. 184(3):259-60. [QxMD MEDLINE Link].
Sanders DL, Waydia S. A systematic review of randomised control trials assessing mesh fixation in open inguinal hernia repair. Hernia. 2014 Apr. 18 (2):165-76. [QxMD MEDLINE Link].
Akyol C, Kocaay F, Orozakunov E, Genc V, Kepenekci Bayram I, Cakmak A, et al. Outcome of the patients with chronic mesh infection following open inguinal hernia repair. J Korean Surg Soc. 2013 May. 84(5):287-91. [QxMD MEDLINE Link]. [Full Text].
van Veen RN, Mahabier C, Dawson I, Hop WC, Kok NF, Lange JF, et al. Spinal or local anesthesia in lichtenstein hernia repair: a randomized controlled trial. Ann Surg. 2008 Mar. 247 (3):428-33. [QxMD MEDLINE Link].
Nordin P, Zetterstrom H, Gunnarsson U, Nilsson E. Local, regional, or general anaesthesia in groin hernia repair: multicentre randomised trial. Lancet. 2003 Sep 13. 362(9387):853-8. [QxMD MEDLINE Link].
Nordin P, Haapaniemi S, van der Linden W, Nilsson E. Choice of anesthesia and risk of reoperation for recurrence in groin hernia repair. Ann Surg. 2004 Jul. 240(1):187-92. [QxMD MEDLINE Link].
Amid PK, Shulman AG, Lichtenstein IL. Local anesthesia for inguinal hernia repair step-by-step procedure. Ann Surg. 1994 Dec. 220(6):735-7. [QxMD MEDLINE Link].
Wagner JP, Brunicardi FC, Amid PK, Chen DC. Inguinal hernias. Brunicardi FC, Andersen DK, Billiar TR, et al, eds. Schwartz's Principles of Surgery. 10th ed. New York: McGraw-Hill; 2015. Chap 37.
Sanabria A, Dominguez LC, Valdivieso E, Gomez G. Prophylactic antibiotics for mesh inguinal hernioplasty: a meta-analysis. Ann Surg. 2007 Mar. 245(3):392-6. [QxMD MEDLINE Link].
Terzi C. Antimicrobial prophylaxis in clean surgery with special focus on inguinal hernia repair with mesh. J Hosp Infect. 2006 Apr. 62(4):427-36. [QxMD MEDLINE Link].
Bay-Nielsen M, Thomsen H, Andersen FH, Bendix JH, Sørensen OK, Skovgaard N, et al. Convalescence after inguinal herniorrhaphy. Br J Surg. 2004 Mar. 91 (3):362-7. [QxMD MEDLINE Link].
Amid PK, Chen DC. Lichtenstein tension-free hernioplasty. Fischer JE, Jones DB, Pomposelli FB et al, eds. Fischer's Mastery of Surgery. 6th ed. Philadelphia: Wolters Kluwer; 2012. Chap 205.
Stylianidis G, Haapamäki MM, Sund M, Nilsson E, Nordin P. Management of the hernial sac in inguinal hernia repair. Br J Surg. 2010 Mar. 97(3):415-9. [QxMD MEDLINE Link].
New implant combined with bupivacaine hydrochloride approved for pain after hernia repair. Anesthesiology News. September 4, 2020. Available at https://www.anesthesiologynews.com/Online-First/Article/03-20/New-Implant-Combined-with-Bupivacaine-Hydrochloride-Approved-for-Pain-After-Hernia-Repair/59475.
Franklin ME Jr, Gonzalez JJ Jr, Michaelson RP, Glass JL, Chock DA. Preliminary experience with new bioactive prosthetic material for repair of hernias in infected fields. Hernia. 2002 Dec. 6(4):171-4. [QxMD MEDLINE Link].
Hakeem A, Shanmugam V. Inguinodynia following Lichtenstein tension-free hernia repair: a review. World J Gastroenterol. 2011 Apr 14. 17(14):1791-6. [QxMD MEDLINE Link]. [Full Text].
Chastan P. Tension-free open hernia repair using an innovative self-gripping semi-resorbable mesh. Hernia. 2009 Apr. 13(2):137-42. [QxMD MEDLINE Link].
Viscusi E, Minkowitz H, Winkle P, Ramamoorthy S, Hu J, Singla N. HTX-011 reduced pain intensity and opioid consumption versus bupivacaine HCl in herniorrhaphy: results from the phase 3 EPOCH 2 study. Hernia. 2019 Dec. 23 (6):1071-1080. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Anatomy of inguinal canal.
Anatomy of nerves of groin.
Open inguinal hernia repair. Skin incision.
Open inguinal hernia repair. Division of external oblique aponeurosis.
Open inguinal hernia repair. Cord structures and hernia sac encircled by Penrose drain.
Open inguinal hernia repair. Hernia sac separated from cord structures.
Open inguinal hernia repair. Development of preperitoneal space.
Open inguinal hernia repair. Deployment of Prolene Hernia System (PHS).
Open inguinal hernia repair. Final position of Prolene Hernia System (PHS) mesh.
Open inguinal hernia repair. Closure of external oblique aponeurosis.
Open inguinal hernia repair. Skin closure.
Open inguinal hernia repair. Draping and incision.
Open inguinal hernia repair. External oblique aponeurosis with external inguinal ring.
Open inguinal hernia repair. External oblique aponeurosis with external inguinal ring.
Open inguinal hernia repair. Reflected part of inguinal ligament exposed for fixing inferior edge of mesh.
Open inguinal hernia repair. Inferior flap of external oblique aponeurosis developed to expose inguinal ligament from pubic tubercle to midinguinal point.
Open inguinal hernia repair. Superior flap of external oblique aponeurosis is developed as high as possible to provide ample space for mesh placement.
Open inguinal hernia repair. Lifting up cord with hernia sac medial to external inguinal ring.
Open inguinal hernia repair. Avascular plane between posterior inguinal wall and cord structures.
Open inguinal hernia repair. Cord structures and hernia sac looped along with ilioinguinal and genitofemoral nerves.
Open inguinal hernia repair. Cremaster muscle picked up to be incised longitudinally between hemostats.
Open inguinal hernia repair. Indirect hernia sac dissected and being separated from lipoma of cord and cord structures.
Open inguinal hernia repair. Lipoma of cord dissected free and excised.
Open inguinal hernia repair. Indirect hernia sac separated from cord structures in midinguinal region toward neck of sac.
Open inguinal hernia repair. Voluminous indirect hernia sac separated from cord structures in midinguinal region up to neck of sac.
Open inguinal hernia repair. Hernia sac being divided near neck.
Open inguinal hernia repair. Contents of hernia sac reduced and proximal end to be sutured closed.
Open inguinal hernia repair. Anterior wall of distal sac incised to prevent hydrocele formation.
Open inguinal hernia repair. Fixation of lower edge of mesh.
Open inguinal hernia repair. First medialmost stitch in mesh, fixed about 2 cm medial to pubic tubercle, where anterior rectus sheath inserts into pubis.
Open inguinal hernia repair. Same suture is utilized as continuous suture to fix lower edge of mesh to reflected part of inguinal ligament up to internal ring.
Open inguinal hernia repair. Lower edge of mesh sutured to inguinal ligament up to internal inguinal ring. To accommodate cord structures, lateral end of mesh is divided into wider upper (two thirds) tail and narrower lower (one third) tail.
Open inguinal hernia repair. Wider upper tail of mesh is passed underneath cord, and mesh is placed posteriorly in inguinal canal behind spermatic cord.
Open inguinal hernia repair. Fixation of upper edge of mesh.
Open inguinal hernia repair. Slit made in mesh to accommodate iliohypogastric nerve. Two interrupted sutures are taken under vision to fix upper edge of mesh while safeguarding iliohypogastric nerve.
Open inguinal hernia repair. Upper tail is crossed over lower tail around spermatic cord, thus creating internal ring. Lower edges of two tails are tucked together to inguinal ligament just lateral to internal ring.
Open inguinal hernia repair. Tails are then passed underneath external oblique aponeurosis to give overlap of about 5 cm beyond internal ring.
Open inguinal hernia repair. External oblique aponeurosis sutured with 2-0 polypropylene.
Open inguinal hernia repair. Subcutaneous tissue approximated with 3-0 plain catgut.
Open inguinal hernia repair. Skin approximated with 2-0 polypropylene subcuticular suture.
Hesselbach triangle. Image courtesy of Wikimedia Commons.

of 41

Author

Vinay K Kapoor, MBBS, MS, FRCSEd, FICS, FAMS Professor of HPB Surgery, Mahatma Gandhi Medical College and Hospital (MGMCH), Jaipur, India

Vinay K Kapoor, MBBS, MS, FRCSEd, FICS, FAMS is a member of the following medical societies: Association of Surgeons of India, Indian Association of Surgical Gastroenterology, Indian Society of Gastroenterology, Medical Council of India, National Academy of Medical Sciences (India), Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Associate Professor, Division of Bariatric and Minimally Invasive Surgery, Department of Surgery, Yale University School of Medicine; Chair, Department of Surgery, Saint Francis Hospital, Trinity Health of New England Medical Group

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoscopic and Robotic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

Harry L Adler, MD Assistant Clinical Professor of Surgery, Mount Sinai Hospital; Assistant Director and Consulting Physician, Maimonides Medical Center

Harry L Adler, MD is a member of the following medical societies: American College of Physician Executives, American College of Surgeons, and Association for Academic Surgery