Inguinal Hernia Repair (IHR)

Inguinal Hernia Repair (IHR)

David Ray Velez, MD

Table of Contents

General Principles
Open Inguinal Hernia Repair
Minimally Invasive Surgery (MIS) – Laparoscopic/Robotic
Complications

See Also:
*See Inguinal Hernia

General Principles

Definition: Surgical Repair of an Inguinal Hernia with Reconstruction or Reinforcement of the Abdominal Wall Defect Using a Tissue Repair or Prosthetic Mesh Through an Open or Minimally Invasive Approach

Indications for Repair

Tissue vs Mesh Repair

  • Tissue Repair: Reconstructs the Inguinal Floor Using the Patient’s Native Tissues without a Prosthetic Mesh
    • Avoids Mesh Related Complications
    • Preferred in Contaminated Fields
    • Appropriate for Select Pediatric Patients with Small Hernias
    • Higher Recurrence Rate and More Highly Dependent on Surgeon Experience
  • Mesh Repair: Reinforces the Myopectineal Orifice Using a Prosthetic Mesh
    • Lower Recurrence Rate
    • Risk for Mesh Infection that Could Require Mesh Explanation
    • Avoided in Contaminated Fields
    • Can Cause a Foreign Body Sensation and Chronic Groin Pain
  • Recurrence Rates:
    • Mesh Repair: 3-4%
    • Tissue Repair: 10-30%
      • Exception: The Shouldice Repair Has Been Reported as Low as 2% at High Volume Centers Such as the Shouldice Hospital in Ontario, Canada but it Has Been Less Reproducible Elsewhere

Open vs Minimally Invasive Surgery (MIS)

  • Open IHR:
    • Technically More Straight Forward with a Shorter Learning Curve
    • Can Be Performed Under Local Anesthetic if Necessary
    • Larger Incision
    • Increased Early Postoperative Pain and Higher Risk of Chronic Groin Pain
    • Longer Recovery
  • MIS IHR:
    • Technically More Challenging with a Longer Learning Curve
    • Requires General Anesthesia
    • Increased Operative Cost
    • Smaller Incisions
    • Less Postoperative Pain and Lower Risk of Chronic Groin Pain
    • Shorter Recovery
    • Can Provide Excellent Visualization of Bilateral Groins – Particularly Beneficial in Bilateral Hernias
  • Generally Comparable Risk of Recurrence

Choice of Technique

  • Mesh Repairs are Generally Preferred Over Tissue Repairs Unless the Field is Contaminated
  • MIS is Generally Preferred for Bilateral Inguinal Hernias
  • Both Open IHR and MIS Remain Excellent Options for Unilateral Hernias
  • Repair Recurrent Hernias Through Virgin Tissue Planes
    • Previous Posterior Repair (MIS or OPP): Repair Recurrence Anteriorly (Lichtenstein)
    • Previous Anterior Repair (Lichtenstein): Repair Recurrence Posteriorly (MIS or OPP)

Primary Techniques to Be Familiar with as a Student/Resident:

Tissue Repairs: Bassini, Shouldice, and McVay

Mesh Repairs: Lichtenstein, Plug and Patch, Kugel, and Bilayer

MIS Repairs: TAPP and TEP

Open Inguinal Hernia Repair

NOTE: Terminology is Inconsistent in the Literature with Many Variations of Different Repairs Rather than Truly Distinct Operations

Tissue Repairs

  • Bassini Repair: Approximate the Conjoined Tendon to the Inguinal Ligament
  • Shouldice Repair: A Subtype of a Bassini Repair Done in Multiple Layers (x4)
  • McVay Repair: Approximate the Conjoined Tendon to Cooper’s Ligament
  • Marcy Repair: “High Ligation” of the Hernia Sac with Narrowing of the Internal Ring
    • Used Only for Small Indirect Hernias with a Normal Posterior Wall
    • Particularly Used in Children or Young Adults
  • Halsted Repair: Approximate the Conjoined Tendon to the Inguinal Ligament (Similar to Bassini) with the Spermatic Cord Placed Subcutaneously
    • Historical and Largely Abandoned Due to Cord Complications
  • LaRoque Repair: Reconstruction/Narrowing of the Deep Inguinal Ring
    • *Generally Considered an Approach/Modification Rather than a Distinct Tissue Repair
    • Emphasized High Dissection and Complete Removal of the Hernia Sac as the Critical Step Rather than a Specific Canal Reconstruction
    • Procedure:
      • Intraabdominal Muscle-Splitting Incision Superior to the Deep Inguinal Ring to Enter the Peritoneal Cavity
      • Hernia Sac Completely Reduced and Resected
      • After Reduction, Definitive Inguinal Repair Can Be by Any Other Technique
    • In Particular it Assisted in Reduction of Large Sliding Hernias Under Direct Visualization
    • Historical and Largely Abandoned

Open Anterior Mesh (OAM) Repairs

  • Lichtenstein Repair: Flat Mesh Sutured to the Posterior Wall of the Inguinal Canal (Anterior Tension-Free Repair)
  • Plug and Patch (Rutkow-Robbins) Repair: A Conical Mesh Plug Inserted into the Hernia Defect and an Additional Flat Onlay Mesh Patch is Secured
    • Generally Discouraged Due to Complications (Contraction, Migration, and Chronic Pain)
  • Gilbert Repair: A Tailored Anterior Mesh Repair (Multiple Versions) Based on Hernia Type
    • May Use a Flat Mesh Alone or a Mesh Plug Depending on the Defect
    • Early Predecessor of the Plug and Patch (Rutkow-Robbins) Repair
    • An Early Tension-Free Method Prior to the Standardized Lichtenstein Repair
    • Largely of Historical Interest
  • Trabucco Repair: A Sutureless Anterior Mesh Repair
    • Largely of Historical Interest

Open Preperitoneal (OPP) Mesh Repairs

  • Transinguinal Preperitoneal (TIPP) Repair: Large Mesh Placed in the Preperitoneal Space Through a Standard Anterior Inguinal Incision
    • Inguinal Canal is Opened to Access the Preperitoneal Plane
    • Provides Broad Posterior Reinforcement without Laparoscopy
  • Kugel Repair: Large Mesh Placed in the Preperitoneal Space Through a Small Suprainguinal Incision
    • Direct Access to the Preperitoneal Space without Opening the Inguinal Canal
    • Uses a Self-Expanding Memory-Ring Mesh
  • Minimal Open Preperitoneal (MOPP) Repair: Large Mesh Placed in the Preperitoneal Space Using a Small (2.5-4.0 cm) Incision Immediately Over the Deep Inguinal Ring
    • Small Anterior Incision with Limited Dissection
    • Emphasizes Minimally Invasive Open Access
  • Transrectus Preperitoneal (TREPP) Repair: Large Mesh Placed in the Preperitoneal Space Through a Transrectus Approach
    • Preperitoneal Space Entered Medially to the Inguinal Canal
    • Avoids Opening the Inguinal Canal
  • Nyhus Repair: Large Mesh Placed in the Preperitoneal Space Through a Suprainguinal Incision
    • Was Primarily Used for Recurrent or Complex Hernias
    • Kugel is Essentially a Modern Evolution of the Nyhus Repair with a More Limited Dissection
    • Largely of Historical Interest
  • Stoppa (GPRVS) Repair: Giant Bilateral Mesh Placed Through a Lower Midline Incision into the Preperitoneal (Retzius) Space
    • Also Known as a Giant Prosthetic Reinforcement of the Visceral Sac (GPRVS)
    • Covers the Entire Myopectineal Orifice Bilaterally
    • Primarily Used for Bilateral, Recurrent, or Complex Hernias
  • Wantz Repair: Large Unilateral Mesh Placed Through a Lower Midline Incision into the Preperitoneal (Retzius) Space
    • Essentially a Unilateral Modification of the Stoppa (GPRVS) Repair

Open Anterior and Preperitoneal Mesh (OAPM) Repairs

  • Bilayer Mesh Repair: A Specialized Mesh is Used to Fix a Layer in the Preperitoneal Space (Underlay) and Another Layer (Onlay) in a Lichtenstein Fashion
    • Combines Features of Both Anterior and Preperitoneal Repairs
    • Often Uses a Prolene Hernia System (PHS)

Minimally Invasive Surgery (MIS) – Laparoscopic/Robotic

There are Essentially Two Fundamental MIS Approaches and Either Can Be Done Laparoscopically or Robotically

Transabdominal Preperitoneal (TAPP) Repair: Enters the Peritoneal Cavity, Creates a Peritoneal Flap, and Places a Mesh in the Preperitoneal Space

  • Requires Peritoneal Entry and Closure
  • Allows Inspection of the Contralateral Groin and Intra-Abdominal Pathology
  • Provides a Larger Working Space and Easier Anatomic Orientation
  • Generally Considered Significantly Easier Robotically with Improved Ergonomics and Suturing
  • *See Transabdominal Preperitoneal (TAPP) Hernia Repair

Totally Extraperitoneal (TEP) Repair: Places Mesh in the Preperitoneal Space without Entering the Peritoneal Cavity

TAPP vs TEP Outcomes

  • Choice is Primarily Based on Surgeon Experience, Training, and Patient Factors
  • Overall Similar:
    • Recurrence
    • Complications
    • Chronic Pain
    • Operative Time
    • Return to Normal Activity
  • Possible Trends:
    • TAPP: Slightly Higher Risk of Visceral Injury and Port-Site Hernia
    • TEP: Slightly Higher Risk of Peritoneal Tears, Conversion to TAPP/Open Repair, and Vascular Injury Due to the Smaller Working Space

Complications

Recurrence

Seroma

  • Risk Factors:
    • Large Hernias or Large Residual Dead Space
    • Extensive Dissection
    • MIS Repair
  • Primarily Managed by Observation and Compression
  • Aspiration:
    • Generally Avoided Due to Risk of Seeding Infection
    • Consider if Persistent of Symptomatic

Hematoma

  • Risk Factors:
    • Anticoagulation or Antiplatelet Therapy
    • Coagulopathy
    • Extensive Dissection
    • Inadequate Hemostasis
  • Primarily Managed by Observation and Compression
  • Indications for Surgical Evacuation:
    • Expanding
    • Significant Pain
    • Infection
    • Hemodynamic Instability

Surgical Site Infection

  • Risk Factors:
    • Diabetes
    • Obesity
    • Smoking
    • Immunosuppression
    • Contaminated or Emergency Operation
  • Generally Managed by Antibiotics and Incision and Drainage
  • Mesh Infection:
    • May Present Weeks to Years Later with Persistent Drainage and Chronic Pain
    • Can Often Trial a Prolonged Course of Antibiotics and Percutaneous Drainage of Any Abscess First
    • Often Requires Surgical Mesh Explantation if Persistent or Chronic

Ischemic Orchitis

  • Caused by Vessel Injury and Venous Thrombosis
  • Risk Factors:
    • Extensive Dissection of a Large Distal Hernia Sac
    • Most Common After an Indirect Repair
  • Prevention:
    • Divide Large Sacs and Leave In-Situ
    • Do Not Dissect the Cord Past the Pubic Tubercle
  • Presentation:
    • Pain and Swelling for Several Days After Surgery
    • Rarely Progresses to Testicular Atrophy
  • Management: NSAIDs for Pain Control

Neuralgia/Pain

  • Intraoperative Concern for Nerve Injury: Preform a Neurectomy Proximal to the Injury
  • Immediate Severe Pain: Should Prompt Concern for Compression or Tacking of Nerves and May Consider Immediate Return to the OR
  • Chronic Postoperative Inguinal Pain (CPIP): Most are Self-Limiting and Resolve within 6 Months
    • Primary Treatment: NSAIDs for Pain Control
    • Secondary Treatments: Consider Steroid Injections or Peripheral Nerve Blocks
    • Refractory Cases: Triple Neurectomy and Mesh Explantation

Mesh Migration/Fistula

  • Rare Complication with Migration of the Mesh into Adjacent Structures (Bladder or Bowel)
  • Causes:
    • Erosion
    • Fistula Formation
    • Chronic Infection
    • Obstruction
  • Generally Requires Surgical Mesh Explantation with Repair of the Involved Organ

Other Complications

  • Postoperative Urinary Retention (POUR) – The Most Common Early Complication (0.4-2.2%)
  • Bladder Injury – More Common During MIS Repairs with Dissection of the Preperitoneal Plane
  • Bowel Injury
  • Vascular Injury