INGUINAL HERNIAS

Lecture by Wilfredo Tayag, M.D, FPCS

th
Schwartz Principle of Surgery 10 Edition

INTRODUCTION______________________________________________  The inguinal canal is an approximately 4-6 cm long cone shaped

 Inguinal hernia is the most commonly performed operation in the region situated in the anterior portion of the pelvic basin. The canal
United States, Given the success in most operations done, the begins on the posterior abdominal wall, where the spermatic cord
Quality of Life and the Avoidance of Chronic Pain have become the passes through the Deep inguinal ring (Internal Ring), a hiatus in
most important considerations in hernia repair the transversalis fascia. The canal concludes medially at the
 Approximately 75% of Abdominal Wall hernias occur in the Groin superficial inguinal ring (External Ring), the point at which the
 Lifetime risk of inguinal hernia is 27% in men and 3% in women, the spermatic cord crosses a defect in the external oblique
incidence of inguinal hernias in males has a bimodal distribution, aponeurosis.
with peaks before the first year of age and after the age 40.  BOUNDARIES of the INGUINAL CANAL
 The most common subtype of groin hernia in men and women is o ANTERIORLY - External Oblique aponeurosis
the indirect inguinal hernia o LATERALLY – Internal Oblique muscle
 Inguinal hernia is a defect in the groin and intra-abdominal wall and o POSTERIORLY – Transversalis fascia and Transversus
organs that protrudes in the inguinal area Abdominis muscle
 Imagine a “hole” then protrudes within the hole are the omentum o SUPERIORLY – Internal Oblique muscle
and intestine o INFERIORLY – Inguinal Ligament (Poupart’s ligament)
 ENDOABDOMINAL FASCIA (Transversalis Fascia) – layer in the  The Spermatic Cord traverses the inguinal canal, and it contains
abdominal wall that will prevent the protrusion of organs through Three (3) Arteries, Three (3) Veins, Two (2) Nerves, the
the abdominal wall; defect will result to hernia; takes it name to pampiniform plexus and the vas deferens.
adjacent structures, anterior to it is the Transversus Abdominis
muscle. TYPES OF HERNIAS
 Hernia = “luslus or loslos” – can either be an Inguinal Buldge or  Inguinal hernias are generally classified as Indirect, Direct and
Scrotal Enlargement Femoral Based on the site of herniation relative to surrounding
 Indirect Inguinal Hernia is the most common type in BOTH sexes structures.
 Most common predisposing factor is increased in abdominal  INDIRECT HERNIAS – Protrude lateral to the inferior epigastric
pressure vessels, through the deep inguinal ring.
 Femoral hernias occur more commonly in women but not the most  DIRECT HERNIAS – protrude medial to the inferior epigastric
common type vessels, with in the hasselbachs triangle.
ANATOMY__________________________________________________  FEMORAL HERNIAS – protrude through the small and
inflexible femoral ring.

HASSELBACH’S TRIANGLE ILLUSTRATION

BORDERS:

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 Inguinal Ligament: inferior
Lateral edge of the rectus sheath: medial
Inferior Epigastric Vessels: superolateral

 NYHUS Classification catergorizes hernia defects by location, size

and type.

 Two potential space exist within the preperitoneum.

 BOGRO’S (preperitoneal space) – between the peritoneum and
the posterior lamina of the transversalis fascia
 SPACE OF RETZIUS – the most medial aspect of the preperitoneal
space, that which lies superior to the bladder
 The posterior perspective also allows visualization of the
MYOPECTINEAL ORIFICE OF FRUCHAUD, a relatively weak portion
of the abdominal wall that is divided by the inguinal ligament.


 The laparoscopic approach to hernia provides a posterior
perspective to the peritoneal and preperitoneal spaces.

 BORDERS:
 SUPERIOR: Arch of the Transversus Abdominis
 MEDIAL: Lateral Rectus Abdominis/pubic bone
 INFERIOR: Cooper’s Ligament
 LATERAL: Illopsoas muscle
 VASCULAR SPACE – situated between the posterior and anterior
laminae of the transversalis fascia, and it houses the inferior
epigastric vessels. The inferior epigastric arteries supplies the
rectus abdominis, it is derived from the external iliac artery, and it
anastomoses with the superior epigastric, a continuation of the
internal thoracic artery.
 TRIANGLE OF DOOM – bordered medially by the vas deferens and
laterally by the vessels of the spermatic cord. The contents include
 Intraperitoneal points of reference are the five peritoneal folds,
bladder, inferior epigastric vessels and psoas muscle. the external iliac vessels, deep circumflex iliac vein, femoral nerve

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 and genital branch of the genitofemoral nerve.

 Microscopic examination of skin of inguinal hernia patients

demonstrated significantly decreased ratios of type I to type III
 TRIANGLE OF PAIN – region bordered by the iliopubic tract and collagen. Additional analyses revealed disaggregated collagen
gonadal vessels, and it encompasses the lateral femoral cutaneous, tracts with decreased collagen fiber density in hernia patient’s skin.
femoral branch of the genitofemoral, and femoral nerves. Collagen disorders such as Ehler-Danlos syndrome are also
associated with an increased incidence of hernia formation

GROIN HERNIAS_____________________________________________
 Most common on the right side
 CONTENTS:
o INTRAPERITONEAL STRUCTURES
o RETROPERITONEAL STRUCTURES – Sliding Hernia e.g. Cecum –
Tx: do high ligation of the sac | Female – common sliding
hernia of the ovaries
o ANTI-MESENTERIC WALL – Richters Hernia – no sign of Bowel
Obstruction
o MECKEL’S DIVERTICULUM – Littre’s Hernia

 CIRCLE OF DEATH – is a vascular continuation formed by the

common iliac, internal iliac, obturator, inferior epigastric and
external iliac vessels.

PATHOPHYSIOLOGY__________________________________________
 Inguinal hernias may be congenital or acquired. Most adult inguinal
hernias are considered acquired defects in the abdominal wall
although collagen studies have demonstrated a heritable
predisposition. A number of studies have attempted to delineate
the precise causes of inguinal hernia formation; however, the best-
characterized risk factor is weakness in the abdominal wall
musculature
 Congenital hernias which make up the majority of pediatric
hernias, can be considered an impedance of normal development,
rather than an acquired weakness.
 During the normal course of development, the testes descend from Intestine ------ omentum contents (pic above)
the intra-abdominal space into the scrotum in the third trimester.
Their descent is preceded by the gubernaculum and a diverticulum  REDUCIBILITY
of peritoneum, which protrudes through the inguinal canal and o REDUCIBLE – can be pushed back (Pathognomonic of hernia)
becomes the Processus Vaginalis. During the 36 and 40 weeks of o INCARCERATED – cannot be pushed back; it can be Acute or
gestation, the processus vaginalis closes and eliminates the Chronic | ACUTE W/SIGNS OF BO = emergency | CHRONIC
peritoneal opening at the internal inguinal ring. Failure of the W/O SIGNS OF BO = omentum, do elective procedure
peritoneum to close results in a PATENT PROCESSUS VAGINALIS o STRANGULATED – Compromised Blood Supply; ischemic
(PPV), hence the high incidence of indirect inguinal hernias in necrosis of herniated contents = emergency
preterm babies.  Clinical Parameters of strangulation
 The presence of a PPV likely predisposes a patient to the o Fever
development of inguinal hernia. This likelihood depends on the o Tachycardia
presence of other risk factors such as inherent tissue weakness, o Exquisite tenderness
family history, and strenuous activity. o Erythema tenderness
o Erythema of underlying skin
o Leukocytosis
o Obstructive symptoms

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  Extrainguinal symptoms such as a change in bowel habits or urinary
CLASSIFICATION OF INGUINAL HERNIAS__________________________ symptoms are less common.
 Pressure or heaviness in the groin is a common complaint,
especially at the conclusion of the day or following prolonged
activity.
 Hernias will often increase in size and content over a protracted
time.
 Questions should also be directed to characterize whether the
hernia is reducible, thereby providing temporary relief. As the
defect size increases and more intra-abdominal contents fill the
hernia sac, the hernia may become harder to reduce

B. PHYSICAL EXAMINATION
 Essential for diagnosis
 Ideally, the patient should be examined in a standing position to
increase intra-abdominal pressure, with the groin and scrotum fully
exposed.
 Inspection is performed first, with the goal of identifying an
abnormal buldge along the groin or within the scrotum. If an
obvious buldge is not detected, palpation is performed to confirm
the presence of the hernia.
 Palpation is performed by advancing the index finger through the
scrotum toward the external inguinal ring. This allows the inguinal
canal to be explored.

 Then the patient is asked to do valsalva maneuver to protrude the

hernia contents. These maneuvers will reveal an abnormal buldge
and allow the clinician to determine whether the hernia is
reducible or not.
 Differentials include:

DIAGNOSIS_________________________________________________
A. HISTORY
 Can be an incidental discovery to surgical emergencies such as  Certain techniques have classically been used to differentiate
incarceration and strangulation of the hernia sac contents between direct and indirect
 Patients who present with a symptomatic groin hernia will  INGUINAL OCCLUSION TEST: entails the examiner blocking the
frequently report groin pain internal inguinal ring with a finger as the patient is instructed to

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 cough. A controlled impulse suggests an indirect hernia, while incarcerated hernias without sequelea of strangulation, and the
persistent herniation suggest a direct hernia option of surgical repair should be discussed prior to the
 Transmission of the cough impulse to the tip of the finger implies maneuver.
an indirect hernia, whie an impulse palpated on the dorsum of the  TO PERFORM TAXIS – Patient given analgesics and light sedatives,
finger implies a direct hernia. he is placed in the trendelenburg position, then the hernia is
 External groin anatomy is difficult to assess in obese patients, elongated with hands and the contents are compressed in a milking
making the physical diagnosis of inguinal hernia challenging. A fashing to ease their reduction into the abdomen.
further challenge to the physical examination is the identification  The indication for emergent inguinal hernia repair is impending
of a femoral hernia. Femoral hernias should be palpable below the compromise of intestinal contents. As such, strangulation of hernia
inguinal ligament, lateral to the pubic tubercle. In obese patients, a contents is a surgical emergency. CLINICAL SIGNS OF
femoral hernia may be missed or misdiagnosed as a hernia of the STRANGULATION INCLUDE:
inguinal canal. In contrast, a prominent inguinal fat pad in a thin o Fever
patient, otherwise known as a femoral pseudohernia, may prompt o Leukocytosis
an erroneous diagnosis of femoral hernia. o Hemodynamic instability
The hernia buldge is usually warm and tender, and the overlying
C. IMAGING skin may be erythematous or discolored. Symptoms of bowel
 Unnecessary and costly, used as adjunct only obstruction in patients with sliding or incarcerated inguinal hernia
 The most common modalities include Ultrasonography, Computed may also indicate strangulation.
Tomography, and Magnetic Resonance Imaging.  TAXIS SHOULD NOT BE PERFORMED when strangulation Is
 CT and MRIN provide static images that are able to delineate groin suspected, as reduction of potentially gangrenous tissue in the
anatomy, to detect groin hernias and to exclude potentially abdomen may result in an intra-abdominal catastrophe.
confounding diagnoses. Preoperatively, the patient should receive fluid resuscitation,
 INDICATIONS: Obese, equivocal physical examination, recurrent nasogastric decompression, and prophylactic intravenous
inguinal hernias antibiotics.
 Most of the time the diagnosis is based on History and Physical
Examination ~~~~~OPEN APPROACH~~~~~
Open inguinal hernia repairs are subdivided into techniques
that employ prostheses to create a Tension-free repair and those that
reconstruct the inguinal floor using native tissue. Tissue Repairs are
indicated when the use of Prosthetic material is contraindicated (e.g.
contamination or strangulation)
Exposure of the anterior inguinal region is common to open
approaches. An oblique or horizontal incision is performed over the
groin

CT SCAN {R} Large Inguinal Hernia {L} small inguinal hernia

TREATMENT________________________________________________
 Surgical repair is the definitive treatment of inguinal hernias;
however, operation is not necessary in a subset of patients. When
the medical condition confers an unacceptable level of operative
risk, elective surgery should be deferred until the condition
resolves, and operations reserved for life-threatening emergencies.
 Nonoperative management is an appropriate consideration in
minimally symptomatic patients.
 Non-operative inguinal hernia treatment targets pain, pressure,
and protrusion of abdominal contents in the symptomatic patient
population. The recumbent position aids in hernia reduction via the
effects of gravity and a relaxed abdominal wall.
 Femoral and symptomatic inguinal hernias carry higher
complication risks, and so surgical repair is performed earlier for A. layers of AW in
these patients. It is recommended that femoral hernias and anterior open
symptomatic inguinal hernias be electively repaired, when possible. approach
 Although there is no universal guideline regarding the
administration of prophylactic antibiotics for open elective hernia B. Identification of
repair, it is our experience that meticulous perioperative protocol Direct and Indirect
and surgical technique are more reliable countermeasures to hernia sacs with
prevent wound infection than antibiotics. Nevertheless, data retraction of
trends and quality improvement measures have resulted in routine spermatic cord and
administration of prophylactic perioperative antibiotics in inguinal illioinguinal nerve
hernia repairs.
 Incarceration occurs when hernia contents fail to reduce; however,
a minimally symptomatic, chronically incarcerated hernia may also
be treated non-operatively. TAXIS should be attempted for

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 The incision begins two fingerbreadths inferior and medial to the preperitoneal fat is bluntly dissected to permit adequate tissue
anterior superior iliac spine. It is then extended medially for approximately 6 – 8 mobilization.
cm. the Subcutaneous tissue is dissected using electrocautery. Scarpa’s fascia is  A triple Layer repair is then performed, the internal oblique,
divided to expose the external oblique aponeurosis. A small incision is made in the
transversus abdominis and transversalis fascia are fixed to the
external oblique aponeurosis parallel to the direction of the muscle fiber.
Metzenbaum Scissors are introduced and spread beneath the fibers to separate shelving edge of the inguinal ligament and pubic periosteum
adhesion to the underlying ilioinguinal nerve. The scissors are then used to incise with interrupted sutures. The lateral aspect of the repair
the aponeurosis superior to the inguinal ligament, splitting the external inguinal reinforces the medial border of the internal inguinal ring.
ring. The flaps of the external oblique aponeurosis are elevated with hemostat
clamps, the internal oblique fibers are dissected bluntly from the overlying
external oblique flaps. Dissection of the inferior flap reveals the shelving edge of
the inguinal ligament.
An Indirect hernia sac will generally be found on the anterolateral
surface of the spermatic cord after division of the cremasteric muscle in the
direction of its fibers. The floor of the inguinal canal is fully assessed for direct
hernias, if a hernia is not visualized upon entry into the inguinal canal, the
preperitoneal canal space is assessed should be explored for a femoral hernia. In
addition to sac identification, the vas deferens and vessels of the spermatic cord
must be identified to allow dissection of the sac from the cord. At the leading
edge of the sac, the two layers of peritoneum will fold upon themselves and
reveal a white edge, which may help in the identification of the sac. The sac can
then be grasped with a tissue forceps and bluntly dissected from the cord. The
dissection is carried proximally toward the deep inguinal ring.
In cases where the viability of sac contents is in question, the sac
should be incised, and hernia contents should be evaluated for signs of ischemia.
The defect should be enlarged to augment blood flow to the sac contents. Viable
contents may be reduced into the peritoneal cavity, while nonviable contents
should be resected, and synthetic prostheses should be avoided in the repair. In
elective cases, the sac may be amputated at the internal inguinal ring or inverted
into the preperitoneum. Both methods are effective; however, patients
undergoing sac excision had significantly increased postoperative pain in a
prospective trial.33 Dissection of a densely adherent sac may result in injury to
cord structures and should be avoided; however, sac ligation at the internal
inguinal ring is necessary in these cases. A hernia sac that extends into the
scrotum may require division within the inguinal canal, as extensive dissection
and reduction risks injury to the pampiniform plexus, resulting in testicular
atrophy and orchitis.
At this point, the inguinal canal is reconstructed, either with native
tissue or with prostheses. The following sections describe the most commonly
performed types of tissue-based and prosthetic-based reconstructions.
(note: nice to read only from Schwartz)

TENSION or TISSUE REPAIRS TENSION FREE or MESH REPAIRS

(non prosthetic) (prosthetics)
Apposition of one tissue plane to With mesh, not for infected A2. SHOULDICE REPAIR
another {internal oblique and hernias (strangulated hernias),  “MULTIPLE LAYER CONTINOUS”
transversus abdominis muscle to mesh effect on vas deferens, may  Recapitulates principles of the bassini repair, and its distribution
inguinal ligament} cause azospermia of tension over several layers results in lower recurrence rates.
Approximation of tissues No approximation of tissues,  The genital branch of the genitofemoral nerve is routinely divide
stronger and recurrence rate is resulting in ipsilateral loss of sensation to the scrotum in men or
low the mons pubis and labium major in women
1. BASSINI REPAIR 1. LICHTENSTEIN REPAIR
2. SHOULDICE REPAIR 2. MESH PLUG AND PATCH
A. The iliopubic tract is
3. McVAY REPAIR 3. STOPPA TECHNIQUE
sutured to the medial
4. PROLENE HERNIA SYSTEM (PHS) flap of the transversalis
fascia and the internal
A. TENSION or TISSUE REPAIRS (non prosthetic) oblique
 Tissue-based herniorrhaphy is a suitable alternative when and transverse
prosthetic materials cannot be used safely. Indications for tissue abdominis muscles.
B. The second of the
repairs include operative field contamination, emergency surgery,
four suture lines,
and the viability of the hernia contents is uncertain. reversing toward the
pubic tubercle
A1. BASSINI REPAIR approximating the
 Most common: “3-layer technique” internal oblique and
 Dissection of the spermatic cord, dissection of the hernia sac transversus muscles to
with high ligation and extensive reconstruction of the floor of the inguinal ligament.
Two more suture lines
the inguinal canal
affix the internal
 After exposing the inguinal floor, the transversalis fascia is oblique and transversus
incised from the pubic tubercle to the internal inguinal ring, muscles medially.

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A3. McVAY REPAIR
 “Coopers ligament Repair”
 Addresses both the inguinal and femoral ring defects.
 Indicated for femoral hernias and in cases where the use of
prosthetic material is contraindicated.
 ~~~~~~~~using either interrupted or continuous suture, the
superior transversalis flap is then fastened to cooper’s ligament,
and the repair is continued laterally along cooper’s ligament to
occlude the femoral ring.

B2. PLUG AND PATCH TECHNIQUE

 Modification of the Lichtenstein repair, the plug and patch
technique was developed by Gilbert and later popularized by
Rutkow and Robbins.
B. TENSION FREE or MESH REPAIRS (prosthetics)
 Prior to placing the prosthetic mesh patch over the inguinal
 INVENTION OF THE PROLENE MESH: a thin, strong, lightweight, floor, a three dimensional prosthetic plug is placed in the space
place at tissues, tissues will adhere to it, it will gain the strength of previously occupied by the hernia sac.
the mesh
 INDIRECT HERNIA : plug placed alongside the spermatic cord
 Mesh-Based hernioplasty is the most commonly performed general through the internal ring
surgical procedure, owing to the technique’s efficacy and improved
 DIRECT HERNIA: Sac is first reduced, and then the plug is sutured
outcomes.
to cooper’s ligament and the internal oblique aponeurosis
B1. LICHTENSTEIN REPAIR
 Expands the domain of the inguinal canal by reinforcing the
inguinal floor with a prosthetic mesh, thereby minimizing tension
in the repair.
 Initial exposure and mobilization of cord structures is identical to
other open approaches. The inguinal canal is dissected to expose
the shelving edge of the inguinal ligament, the pubic tubercle,
and sufficient area for mesh. The mesh is a 7 × 15 cm rectangle
with a rounded medial edge, and it must be large enough to
extend 2 to 3 cm superior to Hesselbach’s triangle. The lateral
portion of the mesh is split such that the superior tail comprises
two thirds of its width, and the inferior tail comprises the
remaining one third. The medial edge of the mesh is affixed to
the anterior rectus sheath such that it overlaps the pubic
tubercle by 1.5 to 2 cm. This refinement to the original
Lichtenstein technique minimizes medial recurrence

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B3. STOPPA TECHNIQUE repair should be considered if a hernia patient is scheduled to undergo
 GIANT PROSTHETIC RECONSTRUCTION OF THE VISCERAL SPACE another clean laparoscopic procedure, such as prostatectomy.
{SAC in Schwartz} (GPRVS) The patient is place on a trendelenburg position and video screens are
 Very Large prolene mesh placed at the foot of the bed. The surgeon stand contralateral to the
 Used in recurrent and bilateral hernias hernia and the assistant stands opposite the surgeon.
 A broad prosthetic mesh is placed in the preperitoneal space
from an anterior approach. 1. TAPP
 Confers the advantage of an intraperitoneal perspective, which is
useful for bilateral hernias, large hernia defects and scarring from
previous lower abdominal surgery
 Enter the intraabdominal cavity

2. TEP
 Advantage of the TEP repair is the access to the preperitoneal
space without intraperitoneal infiltration. Consequently, this
approach minimizes the risk of injury to intra-abdominal organs
and port site herniation through an iatrogenic defect in the
abdominal wall.
 TEP is indicated for repair of bilateral inguinal hernias or for
unilateral hernias when scarring makes the anterior approach
challenging
 Enter the preperitoneal space only
B4. PROLENE HERNIA SYSTEM (PHS)
3. IPOM
 Provides reinforcement to the anterior and posterior aspects of
 Permits the posterior approach without preperitoneal dissection.
the abdominal wall
 An attractive procedure in cases where the anterior approach is
 Exposure of the inguinal canal is identical to that of other open
unfeasible, in recurrent hernias that are refractory to other
approaches. With an indirect hernia, the sac is dissected from
approaches, or where extensive preperitoneal scarring would make
the spermatic cord, and the preperitoneal space is bluntly
TAPP or TEP challenging
dissected through the internal ring. With a direct hernia, the
 Do not dissect the peritoneum anymore
transversalis fascia is opened at the defect, and the
preperitoneal space is bluntly dissected to create space for the  Just patch the mesh
mesh. The mesh has an underlay flap and an onlay flap, joined by  The mesh is special
a short cylindrical connector (Fig. 37-20). The underlay portion of o One side is prolene (side of the Abdominal Wall)
the mesh is then placed through the hernia defect into the o Other side is PTFP – prevents adhesions of intestines
preperitoneal space. The advantage of the preperitoneal mesh to the mesh, at the side of the Abdominal Cavity)
position is that increased intra-abdominal pressure pushes the
Complications of groin hernia repairs
mesh into closer apposition to the abdominal wall. The overlay Recurrence Laparoscopic
flap reinforces the inguinal floor similar to a tension-free repair. Chronic groin pain Vascular injury
The spermatic cord is placed through a slit in the onlay portion of Nociceptive Intra-abdominal
Somatic Retroperitoneal
the mesh. Three to four circumferential interrupted sutures
Visceral Abdominal wall
anchor the anterior layer of the mesh to the inguinal canal floor. Neuropathic Gas embolism
Iliohypogastric Visceral injury
Ilioinguinal Bowel perforation
Genitofemoral Bladder perforation
Lateral cutaneous Trocar site complications
Femoral Hematoma
Cord and testicular Hernia
Hematoma Wound infection
Ischemic orchitis Keloid
Testicular atrophy Bowel obstruction
Dysejaculation Trocar or peritoneal closure site hernia
Division of vas deferens Adhesions
Hydrocele
Testicular descent
Miscellaneous
Bladder injury Diaphragmatic dysfunction
Hypercapnia
Wound infection General
~~~LAPAROSCOPIC APPROACH~~~ Seroma Urinary
Hematoma Paralytic ileus
Laparoscopic inguinal hernia repairs reinforce the abdominal wall via a Wound Nausea and vomiting
Scrotal Aspiration pneumonia
posterior approach. Principal laparoscopic methods include the
Retroperitoneal Cardiovascular and respiratory
insufficiency
 TRANSABDOMINALPREPERITONEAL (TAPP) repair Osteitis pubis
 TOTALLY EXTRAPERITONEAL (TEP) repair Prosthetic complications
Contraction
 INTRAPERITONEAL ONLAY MESH (IPOM) repair Erosion
Infection
Indications are similar to those of open repair, most surgeons would Rejection
agree that laparoscopic approach to bilateral or recurrent inguinal Fracture
hernias is superior to the open approach. Concurrent inguinal hernia

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OUTCOMES from Schwartz____________________________________

Among tissue repairs, the Shouldice operation is the

most commonly performed technique, and it is most frequently
executed at specialized centers A 2012 meta-analysis from the
Cochrane Database demonstrated significantly lower rates of
hernia recurrence (OR 0.62, CI 0.45–0.85) in patients undergoing
Shouldice operations when compared with other open
tissue-based methods

Hernia recurrence is drastically reduced as a result of the

Lichtenstein tension-free repair.83 Compared with open elective
tissue-based repairs, mesh repair is associated with fewer
recurrences (OR 0.37, CI 0.26–0.51) and with shorter hospital
stay and faster return to usual activities

Among other tension-free repairs, the Lichtenstein

technique remains the most commonly performed procedure
worldwide.

The Stoppa technique results in longer operative

duration than the Lichtenstein technique. Nevertheless, postoperative
acute pain, chronic pain, and recurrence rates are similar
between the two methods.

Because laparoscopic surgery requires specialized instruments

and longer operative times, its cost is higher than conventional
open repair; however, the potential financial benefit
of shorter recovery and decreased pain may offset these costs
in the long term.

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