INTRODUCTION — Inguinal hernia repair is among the most common procedures performed by general surgeons. Many techniques have been used, and these can be categorized as tension-free repairs that typically use mesh and primary tissue approximation repairs that do not use mesh. The most commonly used open approaches include the Lichtenstein repair; the plug and patch repair; and the open, preperitoneal approach. When performed by experienced surgeons, each of these is associated with low recurrence rates.

Open techniques for the repair of inguinal and femoral hernia are reviewed here. The classification and diagnosis of inguinal and femoral hernias, management of inguinal and femoral hernia, and laparoscopic techniques for inguinal and femoral hernia repair are discussed elsewhere. (See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults" and "Overview of treatment for inguinal and femoral hernia in adults" and "Laparoscopic inguinal and femoral hernia repair in adults".)

ANATOMIC CONSIDERATIONS — Inguinal anatomy is illustrated in the figure (figure 1A). The inguinal canal is formed by the aponeurosis of the external oblique muscle anteriorly and the transversalis fascia and the transversus abdominis muscles posteriorly. The external inguinal ring is formed by the external oblique muscle. The internal inguinal ring is located in the transversalis fascia. The iliac vessels exit the abdomen posterior to the inguinal canal. The anatomy of the abdominal wall is discussed in detail elsewhere. (See "Anatomy of the abdominal wall".)

Hernia location — Indirect inguinal hernias develop at the internal ring, the site at which the spermatic cord in males and the round ligament in females enter the inguinal canal. Indirect inguinal hernias originate lateral to the inferior epigastric artery (figure 1A-B), in contrast to direct hernias (figure 2), which protrude through Hesselbach's triangle medial to the inferior epigastric vessels. Hesselbach's triangle is bounded by the rectus abdominis muscle medially, the inguinal ligament inferiorly, and the inferior epigastric vessels laterally.

Femoral hernias (figure 3) protrude through the femoral ring, which is bounded by the inguinal ligament anteriorly, the pectineus fascia posteriorly, the lacunar ligament medially, and the sheath of the femoral vein laterally.

Nerves of the groin region — The iliohypogastric, ilioinguinal, and genital branches of the genitofemoral nerves are encountered during anterior, open hernia repair (figure 1A).

●The ilioinguinal nerve can be identified as it passes between the external and internal oblique muscles and across the arching fibers of the internal oblique before joining the other cord structures. This location makes it prone to entrapment during mesh fixation laterally. The ilioinguinal nerve may also be injured more medially along the cord during incision of the external oblique or dissection of an indirect hernia sac. Freeing the nerve from the spermatic cord and retracting it may help protect it.

●The iliohypogastric nerve enters the groin, as does the ilioinguinal nerve, from between the external and internal oblique muscles. These two nerves can share elements and are variable in size. This nerve passes cephalad to the spermatic cord and crosses the conjoined tendon as it progresses medially. If the iliohypogastric nerve appears absent, it may be hidden within the fibers of the internal oblique muscle.

●The genital branch of the genitofemoral nerve, the third nerve in this area and the only one that accompanies the other cord structures through the internal ring, is behind the other cord structures out of the usual area of dissection and out of harm's way. It is virtually always sacrificed in women along with the round ligament without need for selective identification.

Pelvic anatomy — The configuration of the female pelvis and the musculoaponeurotic attachments may contribute to a higher incidence of femoral hernia but a lower incidence of direct hernia in females compared with males [1].

INDICATIONS FOR OPEN REPAIR — The definitive treatment of all hernias, regardless of their origin or type, is surgical repair. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Indications for surgical repair'.)

In general, the open approach remains preferred over a laparoscopic approach for primary, unilateral inguinal hernia repair in men [2-4]. Even so, the approach should be individualized on the basis of patient variables and surgeon skill set. The benefits and risks of each approach should be discussed with each patient and any misperceptions about the differences between the procedures determined and corrected [5,6]. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Inguinal hernia'.)

Factors that are relative contraindications to the laparoscopic approach, and that may thus favor an open approach, are listed below and discussed in detail elsewhere. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Patients precluded from laparoscopic repair'.)

●Inability to tolerate general anesthesia

●Prior pelvic surgery

●Strangulated or incarcerated inguinal hernia

●Large scrotal hernia

●Ascites

●Active infection

Contraindications to open repair — There are relatively few contraindications to the elective repair of inguinal or femoral hernia. Contraindications are discussed separately. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Contraindications to surgical repair'.)

CHOICE OF REPAIR — Once a decision has been made to perform an open groin hernia repair, the type of repair needs to be selected.

Many open techniques for groin hernia repair have been developed and are broadly categorized as tension-free mesh repairs, which include [7,8] (see 'Mesh repairs' below):

●Lichtenstein repair – Mesh onlay anterior to the transversalis fascia

●Bilayer mesh repair – Combined onlay and underlay (ie, bilayer) mesh placement (eg, Prolene hernia system)

●Preperitoneal mesh repair – Mesh placed behind transversalis fascia (eg, Nyhus, Rives, Stoppa, Read, Wants, Kugel repairs)

●Plug and patch repair – Mesh plug through the defect, mesh onlay anterior to the transversalis fascia

Repairs that do not use mesh, and generally create tension, are primary approximation repairs and include [7] (see 'Non-mesh repairs' below):

●Shouldice

●McVay

●Bassini

Mesh versus non-mesh repair — Based upon systematic reviews, large database reviews, and meta-analyses of randomized trials that have shown reduced recurrence rates for tension-free mesh repair [9,10], we agree with various hernia society guidelines that generally recommend a tension-free mesh technique (open or laparoscopic) over those non-mesh techniques that generate tension [2-4]. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Surgical techniques'.)

However, clinical circumstances may favor one approach over another due to anatomic constraints or the need to avoid mesh (eg, wound infection from prior repairs). When mesh is deemed safe, we suggest a Lichtenstein repair. When mesh is not considered desirable by surgeon or patient, we suggest a Bassini repair with a relaxing incision in the anterior rectus fascia. (See "Wound infection following repair of abdominal wall hernia", section on 'Deep incisional surgical site/mesh infection' and 'Specific clinical circumstances' below.)

Non-mesh repair is felt to be the leading cause of failed hernia repair [9-14]. Although special maneuvers have been used (eg, relaxing incisions) to reduce tension associated with most primary tissue approximation repairs, a tension-free repair is arguably not achievable.

●A Cochrane systematic review of randomized trials comparing groin hernia repair with mesh versus without mesh found a significantly lower risk of recurrent hernia when mesh was used (21 studies, 5575 participants; relative risk [RR] 0.46, 95% CI 0.26-0.80, I² = 44%, moderate-quality evidence) [9]. Neurovascular and visceral injuries were less common with mesh repair (RR 0.61, 95% CI 0.49-0.76, I² = 0%, high-quality evidence). Compared with non-mesh repair, mesh repair was also associated with lower risks of hematoma (15 studies, 3773 participants; RR 0.88, 95% CI 0.68-1.13, I² = 0%, low-quality evidence) and urinary retention (eight studies, 1539 participants; RR 0.53, 95% CI 0.38-0.73, I² = 56%, moderate-quality evidence) but a higher incidence of seromas (14 studies, 2640 participants; RR 1.63, 95% CI 1.03-2.59, I² = 0%, moderate-quality evidence).

●The recurrence rate for primary hernia repair among 142,578 inguinal hernia repairs from the Swedish Hernia Registry was 4.3 percent [12]. Non-mesh repair, which was performed in 16 percent of the patients, was associated with an increased risk for recurrent hernia (hazard ratio [HR] 1.27, 95% CI 1.14-1.43).

●The EU Hernia Trialists Collaboration reviewed 58 trials (8221 patients) and also found a significantly higher recurrence rate for hernias repaired without mesh versus those performed with mesh using either open or laparoscopic techniques [10,13].

●A prospective study of 26,304 inguinal hernia repairs performed in Denmark (Danish Hernia Database) found that reoperation rates using anterior open mesh and laparoscopic (mesh) techniques were significantly lower compared with a sutured posterior wall (open, non-mesh) technique. This was true for both the repair of primary hernias (2.2 and 2.6 versus 4.4 percent) and recurrent hernias (6.1 and 3.4 versus 10.6 percent) [11].

Specific clinical circumstances

Elective inguinal hernia — When elective, tension-free mesh repair is performed by surgeons experienced with each technique, no significant differences have been identified in randomized trials for the incidence of recurrent hernia [9,11,15-19]. When an open technique is chosen over a laparoscopic approach for the initial repair of hernia (unilateral or bilateral), we prefer the Lichtenstein repair rather than other open, tension-free mesh techniques [20-22]. Although the preponderance of data do not clearly support one technique over another, the Lichtenstein technique is perhaps the most versatile, is easier to master, and is associated with an equally reliably low incidence of recurrent hernia [7,23].

For the elective repair of large scrotal inguinal hernias [24], hernias following major lower abdominal surgery, and when general anesthesia is not feasible, the Lichtenstein repair is especially well suited.

Prior to the introduction of tension-free hernia repairs, bilateral inguinal hernias were repaired one side at a time to avoid increased tension and high recurrence rates. This teaching lingers in many circles today, leading some to conclude that bilaterality is one of the few absolute indications for laparoscopic repair [25]. With the availability of tension-free, open techniques, this teaching has no basis in fact, and the approach should be individualized based upon patient and surgeon factors.

Incarcerated or strangulated inguinal hernia — The use of mesh for repair of complicated inguinal hernia (incarcerated, strangulated) may increase the risk for subsequent mesh infection. If the use of mesh is deemed safe in a patient who presents early with incarcerated inguinal hernia manifesting only edema without gangrene or severe ischemia, we suggest a Lichtenstein repair, rather than a laparoscopic repair, although a laparoscopic approach has been used. (See 'Indications for open repair' above and "Overview of treatment for inguinal and femoral hernia in adults", section on 'Patients with complicated hernia'.)

When mesh is contraindicated, we suggest a Shouldice repair or a Bassini repair with a McVay relaxing incision. This is especially true when treating patients who require bowel resection for an incarcerated or strangulated hernia to avoid the risk of subsequent mesh infection.

Whether or not to avoid use of mesh for all circumstances of complicated inguinal hernia is controversial. Several reviews have reported acceptable outcomes for mesh repair of complicated hernia. A systematic review identified two randomized trials comparing the use of mesh versus a non-mesh technique for the repair of strangulated hernias [26]. In the first of these trials, 54 patients with strangulated inguinal hernia were randomly assigned to tension-free mesh repair (Lichtenstein) or repair using a Bassini technique [27]. Mesh hernioplasty was not attempted in patients with preoperative peritonitis, inflammatory hernia, or for those in whom bowel resection was performed for ischemic necrosis as a result of strangulated hernia. The incidence of surgical complications did not differ significantly between the groups, but postoperative hospital stay was significantly longer in those who underwent mesh compared with non-mesh repair (five versus three days). Over a mean follow-up period of 22 months, no hernia recurrences occurred in the Lichtenstein repair group, compared with three in the Bassini repair group. In the second trial, 42 patients with strangulated inguinal hernia were randomly assigned to preperitoneal mesh or Lichtenstein mesh repair [28]. Throughout the study period, there were no complications related to the presence of the mesh, and no recurrences were encountered in either group. A separate review reported no significant difference in outcomes for repair of acutely or chronically strangulated hernia using a laparoscopic technique (transabdominal preperitoneal [TAPP] repair) compared with TAPP repair for reducible hernias [29].

In summary, mesh repair techniques appear to be safe for the repair of complicated hernias provided the tissues appear normal or only mildly edematous [26-28]. Profound edema and/or dusky tissue are relative contraindications to the use of mesh, even if the tissue regains a normal color with observation. Any nonviable or gangrenous tissue should be resected/debrided to a healthy margin prior to considering the use of mesh [30-34]. Although others have used mesh after resection of gangrenous tissue, this is not our practice [35].

Elective and complicated femoral hernias — Femoral hernias account for <10 percent of all groin hernias but represent 40 percent of hernia emergencies [36-38]. (See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults".)

Although it is the preferred repair for inguinal hernias, the Lichtenstein repair is not applicable to femoral hernias, since it does not address the femoral ring. (See 'Lichtenstein repair' below.)

Traditional surgical repair of femoral hernias used the McVay repair, but this tissue approximation technique has an increased risk of recurrence due to tension at the suture line. Mesh repair decreases recurrence rates, and in observational studies, both mesh plug and flat mesh techniques have been used successfully for the repair of femoral hernia [9,39-42]. Among the available techniques, we prefer a bilayer mesh repair (figure 4). (See 'Bilayer mesh repair' below.)

However, for complicated femoral hernia repair, if mesh is not deemed to be safe, we suggest a McVay repair [9,40]. (See 'McVay repair' below.)

Recurrent inguinal and femoral hernia — In general, an anterior, open hernia repair is chosen for the repair of recurrent hernia previously repaired using a laparoscopic technique. For most recurrent hernias following a prior open repair, a laparoscopic repair is often advised [43]. (See "Recurrent inguinal and femoral hernia", section on 'Suggested approach'.)

If an open approach is chosen for a recurrence after a prior open, anterior repair, we suggest the Lichtenstein repair [44]. But, because the anatomy of recurrent hernias is highly variable, innovative hybrid procedures are commonly used. The options are more varied when the original repair included mesh. If the recurrence is limited to a small, 1 to 2 centimeter defect, as is sometimes seen next to the pubic tubercle, a plug and patch repair can be used. If multiple direct defects are found, the fibrous bridges between should be transected, providing access for an open, bilayer mesh preperitoneal repair. (See 'Bilayer mesh repair' below.)

A preperitoneal repair can be used when a recurrent direct hernia involves the entire floor of the canal [45]. We avoid taking down or destroying portions of the previous repair that are intact, except in the case of multiple defects. If the recurrence is indirect, a high ligation of the sac is performed. Alternatively, the indirect sac can be freed and reduced into the preperitoneal space without high ligation.

PREOPERATIVE EVALUATION AND PREPARATION — Preoperative evaluation and preparation prior to inguinal and femoral hernia repair, including thromboprophylaxis, prophylactic antibiotics, initial management of complicated hernia, and choice of anesthesia, is discussed in detail elsewhere. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Preoperative preparation'.)

GENERAL PRINCIPLES OF HERNIA REPAIR — Inguinal and femoral hernia repair is performed in a stepwise fashion that includes making an appropriate incision for the specific repair planned, exposing the relevant anatomy to identify and mobilize the hernia sac, protecting associated nerve structures to prevent post-herniorrhaphy neuralgia, proper placement and fixation of mesh, and wound closure.

General principles for specific hernia repair, including the management of large hernias, sliding hernias, incarcerated hernias, and strangulated hernias, are described in the next sections. (See 'Hernia repair techniques' below and 'Approach to complicated hernias' below.)

Incision and exposure — The groin incision should be of adequate length to provide exposure for the specific type of repair. Incisions for specific repairs are discussed below. The incision for an open repair, although longer than the incisions for laparoscopic repairs, may be more cosmetically appealing for females since it is entirely below the "bikini line" (figure 5).

Once the incision has been made, the groin is explored to identify the hernia. If operative exploration of the internal inguinal ring and Hesselbach's triangle fails to identify an inguinal hernia, the preperitoneal space should be explored to allow inspection of the femoral canal. This can be accomplished by incising the transversalis fascia over Hesselbach's triangle.

Mobilizing the hernia sac — The hernia sac is mobilized from surrounding structures.

●Indirect hernia – The indirect sac is normally mobilized from the adjacent cord structures. Indirect inguinal hernia sacs are frequently much more intimately attached to the round ligament in women than are indirect sacs to the cord structures in males. In the case of large indirect hernia sacs, the distal elements of the sac can be left in place to prevent ischemic orchitis associated with damage to the spermatic structures that can occur with excessive dissection, although this sometimes leads to hydrocele formation.

●Direct hernia – Direct hernia sacs (figure 2) usually have a broader base compared with indirect hernia sacs. The attenuated transversalis fascia associated with these hernias may be mistaken for the peritoneal sac.

Hernia repair — Once the hernia has been mobilized and the sac separated from surrounding structures and reduced, tissue repair is accomplished using one of the specific hernia repair techniques. The main principle of inguinal hernia repair is to reinforce the floor of the inguinal canal and, for men, to tighten the internal inguinal ring without creating undue tension on the repair [10,46]. Tension-free repair usually involves the placement of an appropriate mesh material.

The type of mesh used and the method of fixation are implicated as potential causes of persistent groin pain and post-herniorrhaphy neuralgia. (See "Post-herniorrhaphy groin pain".)

Mesh for open hernia repair — Mesh is a standard component of modern techniques for the open repair of primary and recurrent inguinal and femoral hernias [47]. (See 'Mesh versus non-mesh repair' above.)

Macroporous polypropylene meshes are preferred to other prosthetic materials. These products have large pores (>75 micrometers) allowing permeation of the material with fibroblasts, collagen fibers, new blood vessels, and macrophages, all of which are essential for creating a strong repair [7]. Microporous materials, which have pores <10 micrometers, do not promote a sufficient inflammatory response and also do not provide sufficient tissue incorporation. Lightweight monofilament materials are generally preferable since they are pliable and more easily sterilized in cases involving postoperative infections. Lightweight meshes may also have some advantages with respect to long-term discomfort and foreign body sensation.

Several systematic reviews and meta-analyses have compared heavy versus lightweight mesh [48-51]. The risk of chronic pain was significantly less for lightweight mesh. The magnitude of risk reduction was similar in each of the meta-analyses (eg, odds ratio [OR] 0.61, 95% CI 0.50-0.74) [50]. Patients reported significantly less foreign body sensation for the lightweight mesh regardless of whether the mesh was partially absorbable or nonabsorbable. No significant differences were identified for postoperative complications such as seroma, hematoma, wound infection, urine retention, and testicular atrophy or hernia recurrence.

In resource-limited settings, low-cost alternatives to commercial meshes have been used to repair groin hernias with good clinical outcomes. As an example, in a randomized trial conducted in Uganda, open groin hernia repairs using a mesh made from sterilized mosquito netting resulted in similar rates of hernia recurrences (0.7 versus 0 percent) and postoperative complications (31 versus 30 percent) compared with surgery performed with commercial mesh [52]. The low-cost mesh used in this study was a lightweight macroporous material made from polyethylene. When prepared and sterilized at the local surgical facility, the cost of the mesh was less than 1 US dollar, which is substantially less expensive than a commercial mesh (approximately 125 US dollars). However, a follow-up report cautioned that the mosquito nettings currently available in Uganda, Sierra Leone, and Ghana are made from material that does not withstand autoclaving and therefore cannot be used off-label as hernia mesh [53].

Mesh fixation — Mesh fixation using sutures or tacking devices is common. However, the increasing prevalence of post-herniorrhaphy neuralgia has stimulated interest in finding alternative methods with the intention of reducing the potential for persistent postoperative pain. These include absorbable suture and various sutureless techniques, such as self-fixing mesh and tissue glue [54-63].

A systematic review identified six trials and two prospective studies comparing self-fixing and conventional mesh for Lichtenstein inguinal hernia repair [55]. No significant differences were identified in the incidence of chronic pain, acute postoperative pain, hematoma or seroma, wound infection, or recurrence. The self-gripping mesh group was associated with a minor reduction in operating time (one to nine minutes). Although a large cohort study of the Swedish Hernia Registry did not associate self-gripping mesh with less chronic pain or more recurrences, repair with a self-gripping mesh took less time than sutured repair (43 versus 70 minutes) [64]. A later trial comparing self-gripping mesh with sutured lightweight mesh found improved early postoperative pain scores for the self-gripping mesh but no reduction in chronic pain [54].

A meta-analysis of eight trials found a significantly reduced incidence of chronic pain with glue fixation compared with suture fixation (relative risk 0.46, 95% CI 0.22-0.97) [65]. No differences were seen in the duration of the operation or hernia recurrence during the period of follow-up, which varied between the studies.

Minimizing post-herniorrhaphy neuralgia — Chronic pain following inguinal hernia repair is often due to neuralgia [66,67]. Neuralgia can be due to injury or entrapment of any of the named sensory nerves that innervate the groin, including the ilioinguinal, iliohypogastric, genital branch of the genitofemoral, and the lateral femoral cutaneous nerves (table 1) [66]. The type of mesh used and the method of fixation are potential causes of persistent groin pain and post-herniorrhaphy neuralgia [68]. (See 'Mesh for open hernia repair' above and 'Mesh fixation' above.)

Post-herniorrhaphy neuralgia can be minimized by avoiding manipulation of the nerves during dissection and hernia repair or by neurectomy [69-72]. Some surgeons routinely sacrifice one or more nerves prophylactically at the time of hernia repair in patients [73-81]. (See "Post-herniorrhaphy groin pain".)

We use neurectomy selectively for cases involving inadvertent trauma to a nerve or when the location of a nerve would make entrapment with sutures during mesh fixation a necessity for adequate repair. Prophylactic neurectomy leaves an area of relative sensory deprivation on the thigh or hemiscrotum but is generally well tolerated and is a minor nuisance compared with the significant dysfunction that can occur if neuralgia develops.

Some data suggest that preperitoneal mesh repair may result in fewer cases of chronic post-herniorrhaphy neuralgia compared with traditional onlay open repair. In a randomized trial of 302 patients, preperitoneal repair resulted in a lower rate of chronic groin pain at one year after surgery than Lichtenstein repair (3.5 versus 12.9 percent) [82]. At five years, however, groin pain had spontaneously resolved in all but one patient in both groups [83]. The recurrence rates were similarly low (1.7 percent preperitoneal versus 3.8 percent Lichtenstein). Open preperitoneal repair is essentially an open version of the laparoscopic totally extraperitoneal (TEP) repair. (See 'Preperitoneal repair' below.)

Closure — Once the hernia defect is repaired, the subcutaneous layer can be approximated with a running suture of 3-0 absorbable suture. For Lichtenstein repairs, this has the theoretic value of protecting the mesh from superficial wound problems, including infection. The skin is typically approximated using running subcuticular sutures. Infiltration of the wound with a local anesthetic results in less postoperative pain [84]. Additionally, opioid use, abuse, and addiction may be reduced.

HERNIA REPAIR TECHNIQUES

Mesh repairs — The two most common open tension-free mesh repairs are the Lichtenstein repair [85] and the "plug and patch" repair, each of which places the mesh anteriorly in onlay fashion [86,87]. By contrast, the preperitoneal repairs place mesh posteriorly in the underlay fashion [88]. (See 'Lichtenstein repair' below and 'Plug and patch' below and 'Preperitoneal repair' below.)

Lichtenstein repair — The Lichtenstein repair can be used to repair most inguinal hernias [85,89]. However, the Lichtenstein repair is not applicable to femoral hernias, since it does not cover the femoral ring.

To obtain exposure for Lichtenstein inguinal hernia repair:

●Incise the skin over the inguinal canal and angle slightly cephalad as the incision progresses laterally (figure 5).

●Divide the subcutaneous layer and ligate the superficial epigastric vein. Sharply dissect the subcutaneous tissue from the external oblique aponeurosis to expose the external inguinal ring. Incise the aponeurosis of the external oblique muscle in the direction of its fibers extending laterally from the external inguinal ring. Take care to protect the ilioinguinal nerve, which frequently lies in proximity to the undersurface of the external oblique muscle in this area. The incision should expose the internal oblique muscle as it engages the inguinal ligament laterally, which allows clear identification of the ilioinguinal nerve between the internal and external oblique muscles before it joins the other cord structures more medially. This facilitates protection of the nerve during dissection and subsequent fixation of mesh laterally.

●In men, dissect the spermatic cord from the underlying transversalis fascia in the region of Hesselbach's triangle and retract it using a Penrose drain. In creating a window deep to the spermatic cord, protect the underlying transversalis fascia by first dissecting medially in the area of the pubic tubercle. Doing so will avoid loss of containment of bothersome preperitoneal fat and additionally facilitate repair should the hernia be of the direct type. In women, the procedure can be altered slightly by removing the segment of the round ligament lying within the inguinal canal along with the indirect hernia sac. This eliminates the need to keyhole the mesh. If a direct hernia is present and of sufficient size that it obscures the operative field, place a pursestring stitch at the base of the direct hernia in the transversalis fascia, invert the attenuated fascia, and tie the pursestring (figure 6). Reinforce the pursestring with a figure-of-eight stitch. This maneuver inverts the direct sac and facilitates exposure during additional dissection and mesh placement.

●Explore the spermatic cord for an indirect hernia sac or cord lipoma. The cord should not be routinely "skeletonized," because testicular ischemia can result. Even so, removal of redundant cremaster and fat may be required to facilitate repair. Remove the indirect sac and close the peritoneum at the level of the internal ring. Alternatively, it is acceptable to free the sac at the internal ring and place it within the adjacent preperitoneal space. If the neck of the hernia sac is large, a running closure or pursestring suture may be needed. Smaller necks can be transfixed. Remove any cord lipomas or appendages of preperitoneal fat passing through the internal ring that extend along the cord structures.

To perform a Lichtenstein hernia repair (figure 6):

●Fashion a patch of polypropylene mesh to cover the inguinal region from a sheet of the chosen mesh product. The specific measurements depend upon the anatomy of the hernia. Tailor its shape and size to the patient's anatomy, leaving at least 2 cm of overlap on the pubic tubercle and anterior rectus sheath medially.

●Suture the inferior margin of the mesh with a running nonabsorbable suture (eg, 2-0) to the shelving edge of the inguinal ligament. Start at the pubic tubercle medially and run it laterally to a point that is at least 1 cm lateral to the insertion of the internal oblique muscle into the inguinal ligament.

●Similarly, suture the superior margin of the mesh to the rectus sheath medially and internal oblique muscle laterally to the point at which the internal oblique meets the inguinal ligament.

●Slit the lateral aspect of the mesh to encircle the spermatic cord, and reconstruct the internal ring by suturing the medial tail to the lateral tail and the inguinal ligament at a point lateral to the internal ring. This suture is placed in such a fashion that the "neo-internal ring" will just admit the tip of the needle driver alongside the spermatic cord.

●This "neo-internal inguinal" ring is slightly medial to the true internal ring, creating obliquity to the cord in the inguinal canal, which may help prevent recurrence of indirect hernias. In women, if the round ligament has been removed with an indirect sac, the need to slit the mesh is eliminated.

The key technical points in mesh placement are [7]:

●Medially, the pubic tubercle must be covered with mesh.

●The lateral extent of the mesh must cover the arch of the internal oblique as it extends laterally past the conjoined tendon (the fused aponeuroses of the internal oblique and transverse abdominis) to insert on the inguinal ligament.

●Sutures must not entrap the ilioinguinal, iliohypogastric, or genital branch of the genitofemoral nerves.

●The tails of the mesh should be sutured together lateral to the spermatic cord to avoid recurrence lateral to the internal ring.

●Interrupted suture may be preferred when continuous sutures across the internal oblique muscle place nerves at risk for entrapment.

●The lower edge of mesh must be in apposition to the inguinal ligament from the pubic tubercle medially to at least 1 cm past the edge of the internal oblique muscle laterally.

●The upper edge of mesh must cover a generous portion of the anterior rectus sheath medially and the internal oblique muscle over the upper edge of Hesselbach's triangle.

●There must be no tension on the mesh.

●The anatomic margins for mesh attachment must be clearly identified by clearing all fat, which sometimes requires cauterizing vessels that lie within the loose connective tissue in the area of the pubic tubercle.

Plug and patch — Plug and patch repair was originally conceived for repair of femoral hernia and expanded to include direct hernia repair. After freeing and inverting the hernia sac, a rolled-up or prefabricated piece of mesh is placed into the hernia defect, followed by placement of a flat piece of mesh overlying the inguinal floor.

Preperitoneal repair — The open, preperitoneal procedure can be used to repair primary or recurrent direct and indirect inguinal hernias and femoral hernias [15,16,39].

The preperitoneal approach to open hernia repair is essentially an open version of the laparoscopic totally extraperitoneal (TEP) repair [90,91]. The main points of the preperitoneal technique include:

●The incision is transversely oriented and is usually placed a little higher than for other techniques of open groin hernia repair, and cephalad to the inguinal canal, not directly over the canal (figure 7).

●The external inguinal ring is identified and the anterior rectus sheath is incised from the lateral to the medial edge for approximately 4 to 5 cm.

●The rectus abdominis muscle is retracted medially and the transversalis fascia is opened, taking care not to enter the peritoneum (figure 8).

●The peritoneum is dissected from the abdominal wall, exposing Cooper's ligament and the pubic tubercle.

●The inferior epigastric vein should be ligated prior to the dissection to avoid avulsion.

●For a direct or femoral hernia repair, reduction of the hernia is facilitated by placing the patient in the Trendelenburg position and applying direct pressure on the hernia.

●For indirect hernia repair, the cord structures should be bluntly isolated and retracted away from the hernia sac.

●Small hernia sacs are reduced into the preperitoneal space.

●Larger sacs are transected at the neck of the hernia and ligated at the proximal end of the sac to avoid excessive dissection below the level of the external inguinal ring.

●The hernia is repaired by suturing an 8 x 15 cm sheet of polypropylene mesh to the pubic tubercle medially and Cooper's ligament inferiorly.

●A keyhole is fashioned for the spermatic cord and sutured closed lateral to the cord.

Bilayer mesh repair — Bilayer mesh repair combines components of the Lichtenstein repair and preperitoneal repair with one layer of mesh placed in a preperitoneal position and a second layer overlying the transversalis fascia (figure 4) [92]. It can be used for any groin hernia and is our preferred technique for uncomplicated femoral hernia. Prefabricated mesh is available for this type of repair. (See 'Mesh for open hernia repair' above.)

To perform a bilayer mesh repair, follow the same steps as outlined above for the Lichtenstein repair, up to and including freeing the cord structures from the inguinal floor and retracting them with a Penrose drain.

●Access to the preperitoneal space can be accomplished through a dilated internal ring or an incision in transversalis fascia over Hesselbach's triangle.

●Dissect the preperitoneal space using the index finger to separate the peritoneum and preperitoneal fat from the inner aspect of the muscular components of the abdominal wall anteriorly, and extending as far as the linea alba medially and the anterior superior iliac spine laterally. Continue the dissection posteriorly, exposing the symphysis pubis, Cooper's ligament, femoral ring, cord structures, psoas muscle, and internal iliac vessels. Take care to leave the deep epigastric vessels anteriorly with the anterior abdominal wall.

●If a femoral hernia is present, reduce the herniated tissues in the femoral ring under direct vision through the incised transversalis fascia. Do not remove the sac. If an indirect hernia sac is present, it may be highly ligated and removed or simply left in the preperitoneal space.

●Insert the preperitoneal component of the mesh into the preperitoneal space, using the index finger to ensure that it is fully deployed without wrinkles.

●Suture the anterior component of the bilayer mesh into place just as described for the Lichtenstein technique.

Non-mesh repairs

Shouldice repair — The Shouldice technique is an anterior approach for open repair of inguinal hernias [93]. Among the non-mesh repairs, the Shouldice technique is the technique associated with the lowest hernia recurrence, although case selection may taint these data [94]. Recurrence rates are very low (<2 percent) in reports from Shouldice and specialized clinics [95]. Their results have not been equaled by any other non-mesh repair. However, in general practice, these low recurrence rates have not been achieved by other surgeons. The recurrence rate depends upon the level of surgical expertise and patient selection. In one report of 183 inguinal hernias repaired under local anesthesia, the recurrence rates for beginners (less than six repairs under local anesthesia) were significantly higher compared with those of experienced surgeons (9.4 versus 2.5 percent) [96].

This technique involves division of all of the layers of the floor of the inguinal canal and reduction of the hernia, followed by reconstruction of the inguinal canal with a four-layer overlap technique using continuous fine wire sutures to obliterate the hernia defect [97]. Because the defect is closed with multiple layers, none of them is placed under undue tension, according to reports.

Desarda repair — The Desarda repair is a primary tissue repair that does not use mesh. A flap of the external oblique muscle aponeurosis is used to "patch" the defect in a manner similar to a Lichtenstein repair, but without prosthetic material. (See 'Lichtenstein repair' above.)

Bassini repair — The Bassini repair is a primary tissue approximation approach to inguinal hernia repair in which the weakened inguinal floor is strengthened by suturing the conjoined tendon to the inguinal ligament from the pubic tubercle medially to the area of the internal ring laterally.

The original operation was introduced in 1887 and was modified many times [46]. In the mid-20^th century, a procedure based upon the original Bassini procedure was described by Shouldice. (See 'Shouldice repair' above.)

The Bassini repair is applicable to only inguinal hernias [98]. It may be more frequently applied to those women who have a less strenuous lifestyle. With removal of the round ligament, the internal ring is totally obliterated. However, long-term recurrence rates associated with the Bassini repair have been high.

McVay repair — The McVay repair is the only open, non-mesh repair that can be used for the repair of either inguinal or femoral hernias [98].

The McVay repair is somewhat more technically challenging than the Bassini repair and involves incising the transversalis fascia in the region of Hesselbach's triangle to enter the preperitoneal space to expose the pectineal ligament (Cooper's ligament). The conjoined tendon is then sutured to Cooper's ligament from the pubic tubercle laterally as far as the vicinity of the femoral sheath as it crosses Cooper's ligament. At that point, a transition stitch is placed incorporating the conjoined tendon, Cooper's ligament, the femoral sheath at the medial aspect of the femoral vein, and the inguinal ligament (occasionally the femoral sheath cannot be identified and can be excluded).

The remainder of the inguinal floor is repaired by approximating the conjoined tendon to the inguinal ligament extending laterally to the area of the internal ring. This repair generates considerable tension and requires a relaxing incision. To do this, the anterior rectus sheath behind the external oblique aponeurosis should be exposed from the pubic tubercle cephalad for several centimeters, and it is then incised from the pubic tubercle extending cephalad for approximately 6 centimeters along the fusion of the external oblique aponeurosis with the sheath's other components. This type of relaxing incision can also be used with other non-mesh repairs.

Approach to complicated hernias

Sliding hernias — If all contents of the sac cannot be reduced, adhesions of viscera to the sac or a sliding component may be present.

A sliding hernia is one in which a portion of the wall of the hernia sac is composed of the mesentery of viscera or viscera itself. The visceral component can be ovary, fallopian tube, cecum, appendix, sigmoid colon, bladder, ureter, or only the preperitoneal fat associated with any of these structures. When the cecum, terminal ileum, appendix, or sigmoid colon contributes to the sac, it presents laterally and posteriorly. The urinary bladder and ovary present as medial components of the sac. Ovaries frequently incarcerate without truly sliding. When a true slide is encountered, the sliding component must still be separated from the rest of the sac. When the appendix contributes as a sliding component of a hernia sac, we do not recommend removal of the appendix.

Sliding hernias are rarely direct except in the case of the urinary bladder. Direct sliding hernias require no special techniques, since the sac, including the sliding component, can be inverted behind a pursestring suture.

The essence of the repair of sliding indirect inguinal hernias is the peritonealization of the sliding component. Peritonealizing the extraperitoneal surface is not required as long as the base at the level of the internal ring is incorporated in the high ligation of the sac. Regardless of the size or source of the sliding component of the sac, the approach described below, a modification of either the Bevan or the LaRoque technique, is always applicable [99-101].

The sliding hernia sac should be opened with caution (figure 9). The surface of the enteric organ inside the peritoneal sac is covered with serosa. The sliding component of the outer surface of the sac has no peritoneal or serosal layer. Once the hernia sac is entered, the serosalized surface of the sliding organ will be seen. The sliding component is separated from the rest of the sac, leaving a 1 centimeter circumferential cuff of adjacent peritoneal component of the sac attached, which will be used to peritonealize the extraperitoneal surface of the sliding component (figure 9). This peritonealization is accomplished by everting the cuff and approximating its everted margins edge-to-edge with a running suture beginning at the apex and continuing to the level of the internal ring. The sliding component is thereby totally peritonealized and ready to assume its intraperitoneal location (figure 9). The organ is reduced through the internal ring into the abdominal cavity. Keep in mind that if the sliding viscus is the urinary bladder, it will remain outside of the abdomen in the preperitoneal space. On rare occasions, ligation of the deep epigastric vessels medially and/or enlargement of the internal ring superiorly by incising the conjoined tendon may be required to enable intra-abdominal placement of a bulky sliding component. Beginning at the termination of the previously completed peritonealizing suture, the remaining peritoneal defect is closed at the level of the internal ring while, at the same time, any remaining redundant sac is excised. The procedure is then completed in typical Lichtenstein fashion.

Incarcerated and strangulated hernias — For incarcerated and strangulated inguinal hernias, the operating table can be placed in reverse Trendelenburg position during induction of anesthesia to decrease the likelihood that the hernia will reduce spontaneously. Should spontaneous reduction of the hernia occur in spite of this maneuver, the bowel must be retrieved for inspection to assure viability, which can typically be accomplished through the opened hernia sac. Alternatively, laparoscopy can be used. On laparoscopy, the presence of bloody fluid in the abdomen increases the suspicion of strangulated, gangrenous tissues. Although clear, yellow peritoneal fluid is reassuring, it does not rule out gangrene or adhesive obstruction. When intestinal gangrene is present, bowel resection and an anastomosis will be needed and can frequently be performed through the groin incision; however, if the groin incision does not provide adequate exposure, an abdominal exploration (open or laparoscopic) will be needed.

Occasionally, an incarcerated or strangulated femoral hernia cannot be reduced in spite of traction from above within the preperitoneal space and pressure from below the femoral ring on the anterior thigh. In such cases, the lacunar ligament can be incised to enlarge the femoral ring. If this is still not adequate, the inguinal ligament can be transected just above the femoral ring; however, this maneuver is rarely needed. Once the repair is completed, the inguinal ligament should be repaired.

Recurrent hernia — Open repair of recurrent hernia is most often performed in the context of a prior posterior repair (open or laparoscopic).

In the absence of infection, no effort should be made to identify or remove the prior mesh unless it interferes with the surgeon's ability to complete an adequate tension-free repair. In our experience, it is unlikely that the mesh from a prior posterior repair will be encountered.

POSTOPERATIVE CARE AND FOLLOW-UP — Following open inguinal or femoral hernia repair, postoperative care is individualized.

In general, the length of stay is dictated by comorbidities, complications, and the elective or emergent nature of the hernia. Elective cases are usually discharged the same day. Nausea and urinary retention are the most common problems that require an overnight stay. (See "Overview of complications of inguinal and femoral hernia repair", section on 'Perioperative complications'.)

Although there are no uniformly accepted standards, the author's practice allows patients who have mesh repairs to return to full activity as postoperative discomfort abates [102]. Patients who undergo non-mesh repairs are advised to limit activity for four to six weeks to allow the repair to strengthen.

The time period before the patient can return to work following open hernia repair is typically brief but depends upon many factors, including type of procedure, motivation, and employment status [103,104].

Patients in sedentary employment generally may return to work within 10 days of surgery; those involved in manual labor should refrain from heavy lifting (>25 pounds) for approximately four to six weeks [104]. One small study that examined reaction times in an emergency stop simulation suggested that driving can resume 10 days following surgery [105].

OUTCOMES — Hernia recurrence after open inguinal hernia repair is generally low, and rates are similar to those occurring after laparoscopic inguinal hernia repair. Population-based studies indicate that open mesh procedures are associated with lower recurrence rates than non-open-mesh procedures [9]. However, many laparoscopic surgeons have equally good results, and recurrence rates for all types of repair are surgeon dependent. In the randomized trial of surgery versus watchful waiting, less than 2 percent of patients had a recurrence at two-year follow-up after an open mesh repair [106]. These outcomes and morbidity and mortality associated with inguinal and femoral hernia repair are discussed elsewhere. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Morbidity and mortality'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Groin hernia in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Inguinal and femoral (groin) hernias (The Basics)")

SUMMARY AND RECOMMENDATIONS

●The main goals of groin hernia repair are to reinforce the floor of the inguinal canal without creating tension and, for indirect inguinal hernias, to provide a snug, neo-internal ring. Open hernia repairs can be described as tension-free repairs that use mesh (hernioplasty) or as primary tissue approximation repairs (herniorrhaphy), which generally create tension. For tension-free repairs, equivalent surgical results can be obtained, regardless of approach, for surgeons experienced with the specific technique. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Surgical techniques' and 'Mesh versus non-mesh repair' above.)

●When an open repair is chosen, our recommendations are as follows (see 'Choice of repair' above and "Overview of treatment for inguinal and femoral hernia in adults", section on 'Choosing a surgical approach'):

•For initial repair of elective (uncomplicated) hernia, we recommend tension-free hernia repair, which typically requires the use of mesh, rather than repairs that are known to produce tension (ie, most primary approximation repairs) (Grade 1B). For complicated hernias, the approach depends upon whether there are contraindications to the placement of mesh. (See 'Mesh versus non-mesh repair' above and "Overview of treatment for inguinal and femoral hernia in adults", section on 'Surgical techniques' and "Wound infection following repair of abdominal wall hernia", section on 'Deep incisional surgical site/mesh infection' and "Recurrent inguinal and femoral hernia" and "Overview of treatment for inguinal and femoral hernia in adults", section on 'Treat hernia complications if present'.)

•Among the available open mesh repairs, we suggest the Lichtenstein repair for elective, uncomplicated inguinal hernia (Grade 2B). The Lichtenstein repair has a low recurrence rate, can be technically mastered with ease, and can be performed in the outpatient setting using local anesthetic. Key elements of the Lichtenstein repair include avoiding tension on the mesh; crossing the tails of the mesh lateral to the cord; overlapping the pubic tubercle with the mesh; securing the mesh on all edges; and protection of the ilioinguinal, iliohypogastric, and genital nerves. (See 'Elective inguinal hernia' above and 'Lichtenstein repair' above.)

•The use of mesh for repair of complicated hernia (incarcerated, strangulated) may increase the risk for subsequent mesh infection, and thus, open hernia repair is generally suggested rather than laparoscopic repair (requires mesh). However, whether avoidance of mesh is mandatory under all circumstances is controversial. When the use of mesh is deemed safe in a patient who presents with incarcerated or strangulated inguinal hernia, we suggest a Lichtenstein repair (Grade 2C). When mesh is contraindicated, we suggest a Bassini repair with a relaxing incision in the anterior rectus fascia for inguinal hernia (Grade 2C). (See 'Incarcerated or strangulated inguinal hernia' above and "Overview of treatment for inguinal and femoral hernia in adults", section on 'Patients with complicated hernia'.)

•For repair of femoral hernia, we suggest bilayer mesh repair for uncomplicated hernia repair or the McVay repair for complicated repair (Grade 2C). (See 'Elective and complicated femoral hernias' above.)

•Repair of recurrent inguinal and femoral hernias is individualized based upon the nature of the original repair (anterior, posterior) and the anatomy of the recurrence. (See 'Recurrent inguinal and femoral hernia' above.)