Modern Techniques in Hernia Repair Surgery

Overview of surgical procedures

Basic principles

A hernia is the protrusion of tissue through a weak spot in the surrounding wall of the cavity that normally contains it. Because of this opening of the wall, an organ or a part of an organ squeezes through and reaches another region of the body, forming kind of protruding 'sac' (hernia sac).

Several surgical approaches to hernia repair have been developed over the years. All of these different methods follow some basic common principles:

Inversion - Removal
The protruding tissue should get back to where it belongs. To achieve that, surgeons dissect the surrounding tissues and locate the hernia sac and its contents. The hernia sac can be then inverted (pushed or pulled back) or it can be opened and removed (herniotomy).

Closure - Reinforcement
The week spot - opening through which the hernia came out in the first place should be closed and reinforced, in order to remain closed. To achieve that, surgeons can stitch the defect or use a implant to fix the opening as a patch.


FAQ: I have been reading about hernia repair techniques and I am now quite confused. Can you help me understand the differences?

Main differences between hernia repair techniques

The main differences of the various hernia repair procedures can be classified according to the type of:

surgical approach
open access (single incision)
laparoscopic access (multiple very small incisions)
defect closure
stitching (herniorrhaphy, tension)
mesh implant (hernioplasty, tension-free)
mesh placement
above the muscle layers (onlay)
among the muscle layers (inlay)
below the muscle layers (sublay, preperitoneal)

Layers of the abdominal wall

The layers of the abdominal wall from superficial to deep are:

  • Skin
  • Subcutaneous tissue
  • Muscles
  • Peritoneum

is the membrane that forms the lining of the abdominal cavity, the deepest layer of the abdominal wall just above the intestines

Preperitoneal space
is the space between the peritoneum and the lower surface of the muscles of the abdominal wall

Important facts about hernia repair surgery

Surgical approach: open or laparoscopic

There are 2 surgical approaches in hernia repair surgery: the open and the laparoscopic one.

Open approach
An approach is called open, when the surgeon makes a single incision near the location of the hernia, dissects the surrounding tissues and repairs the hernia under direct vision. The length of the skin incision varies, depending on the chosen open repair technique. An open approach with a very small skin incision is often called mini-open.

"In our center we use both open and laparoscopic approaches for hernia repair, depending on the type and location of each hernia"

Laparoscopic approach
During laparoscopy or keyhole surgery the surgeon makes multiple very small incisions usually slightly away from the location of the hernia. The (abdominal) cavity is then inflated with gas (CO2), which creates the necessary working space for the operation. A thin, lighted tube connected to a camera - monitor system enables the view on the operating field. The dissection of the tissues and the repair of the hernia is done remotely with special long instruments.

Laparoscopically, the hernia repair is performed under general anesthesia with a mesh implant (tension-free) under the muscle layers (sublay).

Inversion or removal of the hernia sac

The protruding hernia tissue should get back to where it originally belongs or at least disappear from the area, it has squeezed into. To achieve that, the surrounding tissues are surgically prepared, in order to locate the protruding hernia sac and its contents. This can be done either open or laparoscopically. The hernia sac can be then inverted (pushed or pulled back) or it can be opened and removed (herniotomy).

"Inversion or removal of the hernia sac is essential during any hernia repair technique"

Closing the hernia defect: stitching or mesh implant

After getting the protruding tissue back to its original location, the surgeon needs to close the defect of the wall, in order to complete the hernia repair. This can be done either by directly stitching the 'hole' or by covering it with a mesh implant, in order to fix it as a patch.

"Depending on the surgical procedure chosen, significant differences in the clinical outcomes can be reported"

Stitching (herniorrhaphy)
The opening of the abdominal wall, where the hernia slided through at the first place, can be directly stitched and closed. A duplication of the muscle fascia can be also used, in order to strengthen the weak area around the hernia defect. No implants are used apart of typical surgical sutures.

However, stitching creates tension, which reduces the blood supply and the healing capability of an already weak muscle. Many studies have shown, that the recurrence rate of hernias repaired using tension was significant higher that hernias repaired tension-free.

"In our center we still use stitching only in children hernia repair and other very special cases"

Mesh implant (hernioplasty)
Instead of closing the hernia defect under tension by stitching it together, a synthetic mesh implant can be used to fix the opening as a patch. This implant is designed as a fine structured mesh, in order to allow the surrounding tissue to grow through and fuse with it. Several mesh materials are used, the most common is polypropylene, which shows an excellent tissue compatibility.

The mesh implant allows a tension-free hernia repair, which provides a significant lower recurrence rate.

"In our center we use mesh for adult hernia repair in most cases"

Mesh implant placement

A mesh implant can be placed above, inside or below the muscle layers. Clinical trials have shown, that the placement of the mesh below the muscle layers (sublay or preperitoneal) seems to provide the best bio-mechanics, while the mesh placement above the muscle (onlay) the worst ones.

"The most important element for a successful hernia repair is the experience of the surgeon performing it"

Innovation in hernia repair surgery

Our method of choice for inguinal & femoral hernia repair

Mini-open inguinal and femoral hernia repair with preperitoneal mesh implant under local anesthesia

"This well-proven surgical approach is rapidly replacing worldwide all other surgical methods (open or laparoscopic) of inguinal and femoral hernia repair. The reason: it provides great clinical results combined with an unmatched patient comfort during and after surgery"

Mini-open hernioplasty with preperitoneal mesh implant
Anesthesia local, light sedation
Length of skin incision 3 - 4 cm
Duration of surgery 15 - 45 min.
Hospital stay after surgery 3 - 4 hours
Back to simple activities 3 - 4 hours
Back to full activities 3 - 12 days
Recurrence rate < 0.6%
Infection rate < 0.01%


Do you recommend mini-open hernioplasty with preperitoneal mesh over laparoscopy for inguinal hernia repair?

We definitely do. We are experienced surgeons in laparoscopic surgery and we apply laparoscopy almost daily for many different surgical procedures. We have been performing laparoscopic hernia repair for many years as well. Nevertheless, we now strongly recommend mini-open hernioplasty with preperitoneal mesh over laparoscopic inguinal or femoral hernia repair in most cases. It provides the same bio-mechanical results as a laparoscopic repair but it is simpler and easier to perform and it is much more comfortable for the patient. Please check also the discussion below.

What are the differences between mini-open hernioplasty with preperitoneal mesh and other widespread open methods in inguinal hernia repair surgery?

There are many open techniques available in inguinal hernia repair surgery. Some use sutures to repair the hernia defect, others use mesh (tension-free). We discuss the advantages and disadvantages of those methods below.

Mini-open hernioplasty with preperitoneal mesh, although an open method, is a different approach, the latest development in inguinal hernia surgery. The main difference is that the mesh implant is placed in the deepest layer of the abdominal wall and not between the muscles, as in any other open conventional method. This provides better bio-mechanics and increased stability for the hernia repair. As a result, patients do not have to avoid extensive physical load for long time, as necessary in other open methods. In addition, the preperitoneal mesh repair provides protection against femoral hernias, that may develop in the future. Conventional open repair methods do not.

What kind of anesthesia do you use?

We usually perform the procedure in local anesthesia in combination with a light sedation. In presence of an anesthesiologist, intravenous analgesic and anxiolytic medication is administered, so that the patient feels no pain or discomfort at all and remains awake during the procedure. This has the advantage, that we can examine the stability of the hernia repair directly on site, as we usually ask the patient to actively press after the mesh has been placed.

Of course, other forms of anesthesia (general, spinal etc.) are possible.

How long does the surgical procedure last?

The duration of the procedure depends on the size of the inguinal or femoral hernia, the presence of possible adhesions with the surrounding tissues and other anatomical conditions. We usually perform mini-open hernioplasty with preperitoneal mesh implant in 15 to 45 minutes. Longer operation times are very uncommon.

How long do I have to stay in hospital?

Mini-open hernioplasty with preperitoneal mesh implant is in most cases an ambulatory surgery, that does not require an overnight hospital stay. Our patients may go home on the same day of surgery, as they feel minimal or no discomfort at all and there is no medical reason for them to stay overnight. We usually discharge our patients 3 or 4 hours after the procedure.

When can I go back to work?

Much quicker than any other procedure in inguinal hernia repair, even laparoscopy. Patients are able to return to simple activities just hours after the procedure and drive a car on the following day. We usually recommend avoiding extensive physical load for just 3 to 12 days after surgery, depending on the type of hernia.

Discussion about widespread methods in inguinal hernia repair surgery

What is an inguinal and femoral hernia?

A hernia is the protrusion of tissue through an opening in the surrounding wall of the cavity that normally contains it. Because of this weak spot of the wall, an organ or a part of an organ squeezes through and reaches another region of the body. If this region is the groin, the area between the abdomen and the upper thigh on either side of the body, we call the hernia inguinal (inner groin) or femoral (outer groin).

In case of an inguinal hernia, the protrusion of abdominal-cavity contents occurs through the inguinal canal, a condition very common in men. Femoral hernias develop underneath the inguinal canal into the upper thigh, through a naturally occurring weakness called the femoral canal. They occur more frequently in women.

There are two types of inguinal hernias, indirect and direct. Indirect inguinal hernias protrude through the deep inguinal ring (the natural entrance to the inguinal canal) and are often the result of the failure of embryonic closure / narrowing of this entrance after the testicle passes through it. Direct inguinal hernias develop through a weak spot of the back (posterior) wall of the inguinal canal, the transversalis fascia.

Inguinal canal

The inguinal canal is an approximately 4 cm long natural passage among the muscle layers of the abdominal wall in the groin, the area between the abdomen and the upper thigh. It connects the abdominal cavity with the scrotum (the protuberance that contains the testicles in men) or the labia majora (in women). During development the testicles descend through the inguinal canal on each side into the scrotum.

The inguinal canal contains various anatomical structures: blood vessels, lymphatics, nerves, ductus deferens etc., forming the spermatic cord in men. In women the inguinal canal contains the round ligament of the uterus, instead of the spermatic cord.

Femoral canal

The femoral canal is an approximately 2 cm long conical shaped area underneath the inguinal canal in the outer groin. It's located next (medial) to the major blood vessels of the leg, the femoral vein and the femoral artery. It usually contains lymphatic vessels and a lymph node embedded in connective tissue.

Inguinal hernia repair: a very common procedure with controversial management

Inguinal hernia repair is one of the most commonly performed surgical procedure in the world, as inguinal hernias occur in about 15% of the population. Despite the fact, that inguinal hernia repair is an essential part of a general surgeon's repertoire of operations, the definitive operative management still remains controversial. Numerous different surgical techniques have been developed over the years, some are today very popular, while others are considered obsolete.

Tension-free mesh repair is today gold standard in adult inguinal hernia repair

Multiple studies have confirmed that surgical techniques using tension-free mesh repair have significant advantages over techniques using stitching under tension, such as Bassini and Shouldice suture repairs. So, the question about the best way to close and reinforce an inguinal hernia defect seems to have been resolved and most surgeons, including us, prefer to perform a tension-free mesh repair to our adult patients.

Lichtenstein repair: widespread open tension-free method in inguinal hernia repair

Method description
The Lichtenstein technique is an open, tension-free inlay mesh repair for indirect and direct inguinal hernias.

Under general, regional, or local anesthesia a single 5-7 cm long skin incision is made above the hernia in the groin. After dissection, inversion or removal of hernia sac, a synthetic mesh implant is placed among the muscle layers, that form the inguinal canal, on top of the abdominal wall defect to fix it as a patch.

A reliable method
Lichtenstein belongs nowadays to the standard procedures, that most surgeons learn during their surgical training and perform later on their patients. Soon after this technique was introduced, it became very popular and practically replaced older procedures, that use sutures under tension to fix the hernia defect, as the hernia recurrence rate was significantly lower and the patient comfort after surgery significantly higher. We have been performing Lichtenstein for many years and we can confirm, that it is a reliable technique with good clinical results.

However, as mentioned above, Lichtenstein is an inlay technique: the mesh is placed and fixed among the muscles of the abdominal wall, that form the inguinal canal. Unfortunately, there are some nerves in exactly the same area, where the mesh is usually placed. As a result, an annoying, long-lasting pain can rarely occur after Lichtenstein repair, because of a chronic irritation of those nerves. Moreover, the mesh inside the inguinal canal provides no protection for future femoral hernias, that can occur underneath the canal (and the mesh) into the outer groin / thigh.

Laparoscopy found its place also in inguinal hernia repair

Two different laparoscopic procedures for inguinal hernia repair haven been established: TAPP and TEP.

FAQ: I heard that keyhole surgery is usually better than open surgery. What about inguinal hernia repair?

The TAPP (TransAbdominal PrePeritoneal) approach allows the inguinal hernia repair through the abdominal cavity (transabdominal). Under general anesthesia the abdomen is inflated with CO2 gas and a camera (laparoscope) is inserted through an incision in or just below the navel. The necessary special instruments to repair the hernia are inserted through other small incisions in the lower abdomen. The peritoneum, the membrane that forms the lining of the abdominal cavity, is then opened so that the surgeon can repair the hernia. After placing the mesh implant above it (preperitoneal), the peritoneum is closed again.

The TEP (Totally ExtraPeritoneal) approach allows the inguinal hernia repair without accessing the abdominal cavity (extraperitoneal). Through an incision just below the navel under general anesthesia, the surgeon reaches the preperitoneal space (the space between the peritoneum and the muscles of the abdominal wall), inflates it with CO2 gas and inserts a camera (laparoscope). The necessary instruments are also inserted to the inflated preperitoneal space, through smaller incisions in the lower abdomen. This way, the surgeon can repair the hernia and place the mesh implant above the peritoneum (preperitoneal), without entering the abdominal cavity.

Advantages of laparoscopic hernia repair
We always felt, that the placement of a mesh below the muscle layers (sublay or preperitoneal) provides the best bio-mechanics for a hernia repair. This fact has already been proven for other types of hernias by clinical trials. Therefore, we were delighted as laparoscopic approaches to hernia repair were developed and implemented. The do namely just that: they allow the preperitoneal (sublay) placement of the mesh implant, which results in an increased stability of the hernia repair during physical load. Patients are able to return to their full activities much more quickly than they would after open Lichtenstein repair. As the mesh is placed preperitoneal and the area, where the inguinal nerves run, is avoided, the risk of chronic pain may decrease. Moreover, the laparoscopic inguinal hernia repair is at the same time suitable for femoral hernias, that develop underneath the inguinal ligament into the outer groin / thigh. Furthermore, the TEP and TAPP procedures seem to be better for repairing a recurrent inguinal hernia after open surgery and they are preferred for bilateral (two-sided) inguinal hernias, as the repair of both sides can be performed at once.

Those are the main advantages of the laparoscopic inguinal hernia repair techniques over the open Lichtenstein procedure. Other well known benefits of the laparoscopy over open surgery are in case of inguinal hernia repair, unlike other surgical procedures, not as significant: the pain and discomfort after surgery may be in case of laparoscopic inguinal hernia repair slightly less; it may also be more appealing for cosmetic reasons but also the incision made during open Lichtenstein mesh repair is small anyway and it heals well without a particularly visible scar in most cases.

Disadvantages of laparoscopic hernia repair
Laparoscopic inguinal hernia repair techniques, especially the TEP procedure, are technically demanding for the surgeon and require high experience and expertise. The duration of the operation is always longer compared with open inguinal hernia repair.

In fact, the advantages mentioned above only apply, if a well-trained laparoscopic surgeon performs the operation in a surgical department, specialized in laparoscopic hernia repair. Otherwise, the results can be much worse and the consequences serious: increased risk of major organ damage or bleeding, much higher risk of an early recurrence of the hernia, prolonged operation times under general anesthesia etc.

We have been performing TEP for years and we can confirm, that the learning curve for a surgeon is several hundred procedures indeed.

Another disadvantage of laparoscopic inguinal hernia repair, is the fact that the procedure is only possible under general anesthesia. On the other hand, open inguinal hernia repair can be performed under general, regional or local anesthesia. Although general anesthesia is nowadays very safe, it still carries risks on its own.

Open preperitoneal mesh repair: combining the advantages of open and laparoscopic procedures

Latest development
Several years ago, we too joined forces with many other surgeons around the world, in order to improve the inguinal and femoral hernia repair, by combining the advantages of the open and the laparoscopic procedures available and leaving out their downsides. The result was the development of safe and simple (to learn and apply) tension-free surgical techniques, which allow the placement of a mesh into the preperitoneal space behind the transversalis fascia (sublay), just like the laparoscopic methods, but not necessarily in general anesthesia.

Although there are some variations of the open preperitoneal inguinal hernia repair available (Kugel, ONSTEP, transinguinal etc.), the basic principles and advantages remain the same. As they become more popular, the open preperitoneal techniques are rapidly replacing the widespread conventional open and laparoscopic procedures.

Method description
A single small skin incision is made at the groin / lower abdomen. Using minimal tissue preparation, the inguinal (or femoral) hernia is inverted or removed. The surgeon then enters the preperitoneal space (the space between the membrane that forms the lining of the abdominal cavity and the muscles of the abdominal wall) and places a special designed mesh implant inside that space. As the total surface area / size of the mesh covering the hernia defect is much greater than the size of the incision, the mesh is first folded and then expanded inside the preperitoneal space. The special design of the mesh allows this expansion.

Comparison of widespread methods in inguinal hernia repair surgery

Mini-open preperitoneal mesh repair Laparoscopic mesh repair (TEP / TAPP) Open conventional mesh repair (Lichtenstein)
Anesthesia local, light sedation general local, regional or general
Duration of surgery 15 - 45 minutes 45 - 180 minutes 15 - 45 minutes
Suitable for femoral hernias yes yes no
Return to full activities 3 - 12 days 7 - 14 days 10 - 30 days
Discomfort after surgery minimal minimal - moderate moderate
Risk of seroma minimal moderate moderate
Risk of chronic pain minimal minimal moderate
Recurrence rate < 0.6% < 0.6% < 1%
Infection rate < 0.01% < 0.01% < 0.01%