Open surgical repair of inguinal and femoral hernia in adults

INTRODUCTION — 

The definitive treatment of all hernias, regardless of their origin or type, is surgical repair. Inguinal hernia repair is among the most common procedures performed by general surgeons. Many techniques have been used. (See "Overview of treatment for inguinal and femoral hernia in adults".)

When performed by experienced surgeons, both open and minimally invasive repairs are associated with low recurrence rates. The surgical approach should be individualized based on 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 [1,2].

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 hernias, and laparoscopic and robotic 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" and "Robotic groin hernia repair".)

INDICATIONS FOR OPEN REPAIR — 

In contemporary practice, minimally invasive groin hernia repair is preferred over the open approach because of faster recovery and reduced pain [3,4]. However, clinical circumstances may favor open repair due to the type of hernia, anatomic constraints, patient aversion to mesh, or the clinical need to avoid mesh (eg, contaminated wound due to bowel perforation). Specific indications for open groin hernia repair include (see "Overview of treatment for inguinal and femoral hernia in adults", section on 'Noncandidates for laparoscopic repair'):

●Inability to tolerate general anesthesia

●Prior pelvic surgery (eg, prostatectomy) or pelvic radiation

●Strangulated or incarcerated inguinal hernia

●Large scrotal hernia

●Ascites

●Active infection

ANATOMIC CONSIDERATIONS

Anatomy of inguinal canal — 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 locations — 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 the Hesselbach triangle medial to the inferior epigastric vessels. The Hesselbach 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.

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 female compared with male patients [5].

PREOPERATIVE EVALUATION AND PREPARATION — 

Preoperative evaluation and preparation prior to inguinal and femoral hernia repair, including thromboprophylaxis, prophylactic antibiotics, urinary retention prophylaxis, 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'.)

Anesthetic considerations — Whereas all minimally invasive groin hernia repairs require general anesthesia, open groin hernia repairs can be performed under local, regional, or general anesthesia.

●For elective open groin hernia repair, we suggest local anesthesia. Open inguinal hernia repair performed under local anesthesia has demonstrated several advantages compared with other anesthesia methods, including shorter operative times, reduced hospital length of stay [6], higher patient satisfaction, and lower costs [7]. Importantly, the risk of urinary retention is significantly lower with local anesthesia, occurring at 0.1 percent, compared with 8.6 percent with regional anesthesia and 1.4 percent with general anesthesia [8].

●For elective open groin hernia repair in patients >65 years old, we suggest against regional anesthesia. In one study of hernia repairs in this population, regional anesthesia has been associated with a higher incidence of medical complications (1.17 versus 0.59 percent), including myocardial infarction, pneumonia, and venous thromboembolism, compared with general anesthesia [9]. While either local or general anesthesia can be used, many favor local anesthesia due to concerns over the potential negative impact on cognitive function associated with general anesthesia [10].

●For emergency open groin hernia repair, general anesthesia may be required to facilitate hernia reduction or possible conversion to laparotomy if viscera resection is necessary.

SURGICAL TECHNIQUES — 

Many open techniques for groin hernia repair have been developed and are broadly categorized as tension-free mesh repairs and primary tissue repairs (table 1) [11-13].

Mesh repairs — When mesh placement is clinically appropriate and acceptable to the patient, we recommend tension-free mesh repair of groin hernias, rather than primary tissue repairs that are known to produce tension. Techniques that result in the placement of flat mesh in a single plane (Lichtenstein and preperitoneal repair) are recommended over other options (plug and patch and bilayer mesh repair).

●Lichtenstein repair – The most common open tension-free mesh repair is the Lichtenstein repair [14], which places the mesh anteriorly in onlay fashion [15,16]. The Lichtenstein repair is the most studied technique for open inguinal hernia repair [14,17]. It is suitable for most inguinal hernias, but not for femoral hernias, as the mesh does not cover the femoral ring. (See 'Uncomplicated inguinal hernias' below.)

●Preperitoneal repair – By contrast, the preperitoneal repairs place mesh posteriorly in the underlay fashion like the minimally invasive repairs [18]. The open preperitoneal repairs can be used to repair both inguinal and femoral hernias [19-21]. Various open preperitoneal mesh techniques, such as the Nyhus, Rives, Stoppa, Read, Wants, and Kugel repairs, can achieve recurrence rates comparable to the Lichtenstein technique. However, there is insufficient evidence to directly compare outcomes among the different open preperitoneal methods [4]. (See 'Uncomplicated femoral hernias' below.)

●Plug and patch repair – 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 the placement of a flat piece of mesh overlying the inguinal floor. It should be noted that the plug can migrate and cause chronic pain. The most recent guideline on inguinal hernia repair recommends against the use of plugs or bilayer meshes [3].

●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 [22].

Nonmesh repairs — Nonmesh repair is felt to be the leading cause of failed hernia repair [23-28]. Although special maneuvers (eg, relaxing incisions) have been used to reduce tension associated with primary tissue approximation, a tension-free repair is arguably not achievable by most nonmesh repairs.

●Shouldice repair – The Shouldice technique is an anterior approach for open repair of inguinal hernias [29]. 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 [30]. Reports suggest that this multilayered closure avoids placing excessive tension on any single layer.

●Desarda repair – The Desarda repair uses a flap of the external oblique muscle aponeurosis to "patch" the defect in a manner like that of a Lichtenstein repair, but without prosthetic material. The Desarda technique has a shorter learning curve than the Shouldice technique, with favorable preliminary outcomes [31]. However, there are insufficient high-quality long-term data on recurrence and chronic pain to make recommendations on generalized adoption [4].

●Bassini repair – Originally introduced in 1887 but modified many times since [32], the Bassini repair is a primary tissue approximation approach to inguinal hernia repair that strengthens the weakened inguinal floor by suturing the conjoined tendon to the inguinal ligament from the pubic tubercle medially to the area of the internal ring laterally. The Bassini repair has been associated with a relatively high hernia recurrence rate [33].

●McVay repair – The McVay repair is the only open, nonmesh repair that can be used for the repair of either inguinal or femoral hernias [33].

The McVay repair is somewhat more technically challenging than the Bassini repair and involves incising the transversalis fascia in the region of the Hesselbach 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 nonmesh repairs.

CHOICE OF REPAIR — 

Once a decision has been made to perform an open groin hernia repair, the type of repair needs to be selected. Clinical circumstances may favor one approach over another due to the type of hernia, anatomic constraints, patient aversion to mesh, or the clinical need to avoid mesh (eg, contaminated wound due to bowel perforation).

Uncomplicated inguinal hernias — For open repair of uncomplicated inguinal hernias where mesh is appropriate and acceptable, we suggest the Lichtenstein technique rather than other open, tension-free mesh methods [34-36]. It has been extensively studied in large, randomized trials, offering results that are generalizable to the general population and typical surgeons [13]. The Lichtenstein technique is versatile, easier to master, and associated with a consistently low recurrence rate [11,37]. It is particularly suited for elective repair of large scrotal hernias [38], post-lower abdominal surgery hernias, and cases where general anesthesia is not feasible. However, randomized trials show no significant difference in recurrence rates when experienced surgeons use any tension-free mesh technique [19,20,23,25,39-41].

To obtain exposure for the Lichtenstein inguinal hernia repair:

●Incise the skin over the inguinal canal and angle slightly cephalad as the incision progresses laterally (figure 4).

●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 male patients, dissect the spermatic cord from the underlying transversalis fascia in the region of the Hesselbach 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 female patients, 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.

●An indirect hernia sac can be ligated and resected or invaginated (reduced) into the preperitoneal space. In a meta-analysis of six trials comparing the two techniques during Lichtenstein repair of inguinal hernias, sac ligation increased early postoperative pain without improving outcomes (eg, recurrence, chronic pain) [42]. 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 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. Direct hernia sacs should be reduced, and the overlying inguinal floor should be imbricated. Additionally, a weak inguinal floor should also be imbricated for mesh-based repairs to improve the apposition of the mesh.

●If a direct hernia is present and of sufficient size that it obscures the operative field, place a purse-string stitch at the base of the direct hernia in the transversalis fascia, invert the attenuated fascia, and tie the purse string (figure 5). Reinforce the purse string 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, the 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 purse-string suture may be needed. Smaller necks can be transfixed. Remove any cord lipomas or appendages of preperitoneal fat passing through the internal ring that extends along the cord structures.

To perform a Lichtenstein hernia repair (figure 5):

●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. Many surgeons perform the medial and superior aspects of the repair using interrupted sutures to avoid injuring the iliohypogastric nerve.

●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 the recurrence of indirect hernias. In female patients, 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 [11]:

●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 onto 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 sutures are preferred across the internal oblique muscle reducing the risk of nerve entrapment compared with a continuous suture.

●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 the Hesselbach 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.

To close the wound:

●Once the hernia defect is repaired, the subcutaneous layer can be approximated with a running suture of 3-0 absorbable suture. Although this is not a part of the hernia repair, for the Lichtenstein technique, 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 [43]. The international hernia guidelines provide a strong recommendation for perioperative local anesthetic field blocks of the inguinal nerves, including ilioinguinal nerve blocks, in all open groin hernia repairs [3]. This can be performed at the end of the operation if not already performed. Combining these forms of local anesthetic may reduce opioid use, abuse, and addiction.

Patients who wish to avoid mesh — For patients with an uncomplicated inguinal hernia who prefer to avoid mesh, we recommend the Shouldice repair, which is also the preferred nonmesh method according to the 2023 HerniaSurge guidelines [4]. Among nonmesh techniques, Shouldice is associated with the lowest recurrence rates, though case selection may influence these results [44]. Shouldice repair can achieve one-year outcomes comparable to Lichtenstein and minimally invasive repairs in patients who are young (<40), thin (body mass index <24), and with smaller hernias (<3 cm) that are not femoral [45,46]. However, the Shouldice repair has a learning curve and is less commonly used in regions where mesh is readily available, limiting surgeon expertise in this technique.

Uncomplicated femoral hernias — Femoral hernias account for <10 percent of all groin hernias but represent 40 percent of hernia emergencies [47-49]. A femoral hernia should be repaired posteriorly rather than anteriorly, if possible. For this reason, femoral hernias are generally more easily approached with a minimally invasive technique. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Femoral hernia'.)

For open repair of uncomplicated femoral hernias where mesh is appropriate and acceptable, we suggest preperitoneal mesh placement to assure adequate coverage of the myopectineal orifice and femoral canal. The preperitoneal approach to open hernia repair is essentially an open version of the laparoscopic totally extraperitoneal repair [50,51]. The main points of the preperitoneal technique include (figure 6):

●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 a 10 x 15 cm sheet of polypropylene mesh to the pubic tubercle medially and Cooper's ligament inferiorly.

●A keyhole may be fashioned for the spermatic cord and sutured closed lateral to the cord (optional step).

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 (see 'Nonmesh repairs' above). Although the plug and mesh technique has also been used [52], plugs placed in the femoral space can migrate and cause chronic pain, and is therefore not recommended [3].

Complicated hernias — Complicated hernias refer to incarcerated or strangulated hernias with which mesh placement may be contraindicated depending on the level of contamination. Because all minimally invasive hernia repairs require mesh, a complicated hernia is one of the indications for open repairs, which can be accomplished with or without mesh.

Hernia reduction — The decision to reduce an incarcerated groin hernia at the bedside or in the operating room depends on the suspected risk of bowel ischemia or infarction as determined by clinical symptoms and biochemical parameters [4].

When operating on patients with an incarcerated groin hernia, 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 despite 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 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 inguinal or femoral hernia cannot be reduced despite traction from above and pressure from below. In such cases, a relaxing incision may be required to free the incarcerated contents while avoiding visceral injuries. Such a relaxing incision should be directed away from known locations of the epigastric vessels and groin nerves as follows (figure 9) [53]:

●Indirect inguinal hernia – Relaxing incisions should be made in the transversus abdominis muscle aiming cephalad and medially to avoid injury to the ilioinguinal nerve and inferior epigastric vessels. The iliohypogastric nerve typically courses cephalad and medial to the internal ring and can often be identified and avoided as well.

●Direct inguinal hernia – Relaxing incisions should be made in the internal oblique or transversalis fascia directed inferomedially toward the conjoined tendon and rectus abdominus muscle. The iliohypogastric nerve runs medial to the direct space coursing from the cephalad direction.

●Femoral hernia – 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 with permanent sutures.

Hernia repair — The use of mesh to repair complicated inguinal hernias is controversial, as it may increase the risk of subsequent mesh infection. A 2023 Cochrane Review of 15 randomized trials involving 1,241 patients found "very uncertain" evidence regarding mesh versus nonmesh repair for outcomes such as 30-day surgical site infections, 30-day mortality, and one-year hernia recurrence [54].

In general, we feel that mesh repair techniques appear to be safe for the repair of complicated hernias provided the incarcerated tissues appear normal or only mildly edematous [55-57]. 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 [58-62]. Although others have used permanent or absorbable mesh after resection of gangrenous tissue, this is not our practice [63].

●If the use of mesh is deemed safe (eg, in a patient who presents early with incarcerated inguinal hernia manifesting only edema without gangrene or severe ischemia), we suggest a mesh repair with a flat, macroporous (eg, polypropylene) mesh similar to an uncomplicated groin hernia. (See 'Uncomplicated inguinal hernias' above and 'Uncomplicated femoral hernias' above.)

●When mesh is contraindicated (eg, wound contamination from bowel necrosis or perforation), a primary tissue repair such as a Shouldice repair or a Bassini repair with a McVay relaxing incision is required to avoid the risk of subsequent mesh infection. The surgeon should use the nonmesh technique they are most familiar with. (See 'Nonmesh repairs' above.)

●For complicated femoral hernia repair, if mesh is not deemed to be safe, we suggest a McVay repair, as it is the only nonmesh repair that addresses the femoral ring [23,64]. (See 'Nonmesh repairs' above.)

Surgical repair of complicated groin hernia is also discussed in another topic, including data for minimally invasive repair. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Complicated hernia'.)

Recurrent hernias — In general, an anterior, open hernia repair is chosen for the repair of recurrent hernia previously repaired using a minimally invasive technique. For most recurrent hernias following a prior open repair, a minimally invasive repair is often advised [65]. (See "Recurrent inguinal and femoral hernia", section on 'Anatomic approaches'.)

●After prior posterior repair – During open repair of a recurrent hernia after a prior posterior repair (open or laparoscopic), the previous mesh is unlikely to be encountered. In the absence of infection, there is no need to remove the prior mesh unless it interferes with completing an adequate, tension-free repair.

●After prior anterior repair – For open repair of a recurrence after a prior open, anterior repair, we recommend the Lichtenstein technique [66]. However, a preperitoneal repair may be used for recurrent direct hernias involving the entire canal floor [67]. Excision of the previous mesh may be necessary for a durable repair, but the risk of ischemic orchitis or injury to the vas deferens must be considered.

●After prior plug repair – If the prior repair was performed with a plug, a Lichtenstein repair can be performed without removing the previously placed plug; however, if the patient has chronic inguinal pain with a recurrent hernia after plug repair, the plug should be removed.

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 purse-string 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 [68-70].

●The sliding hernia sac should be opened with caution (figure 10). 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 cm circumferential cuff of adjacent peritoneal component of the sac attached, which will be used to peritonealize the extraperitoneal surface of the sliding component (figure 10).

●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 10).

●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.

MINIMIZING SURGICAL COMPLICATIONS — 

Serious complications after groin hernia repair are rare and include hernia recurrence (<4 percent) and post-herniorrhaphy neuralgia (5 to 10 percent). This section explores operative strategies aimed at reducing the risk of these complications and improving patient outcomes and is applicable to all mesh-based repair techniques.

Minimizing hernia recurrences — Because mesh reduces recurrence rates, it has become standard in most modern open groin hernia repairs. Consequently, optimizing the choice of mesh and fixation method is essential to minimizing persistent groin pain.

Mesh benefits — Mesh repair is endorsed by various hernia society guidelines [3,71-73] as numerous systematic reviews, large database studies, and meta-analyses of randomized trials have documented lower recurrence rates compared with nonmesh repair [23,24]. Here are a few examples:

●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) [23]. 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 nonmesh 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 [26]. Nonmesh repair, which was performed in 16 percent of the patients, was associated with an increased risk for recurrent hernia (hazard ratio 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 with mesh using either open or laparoscopic techniques [24,27].

●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, nonmesh) 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) [25].

Mesh material — For open mesh repair of uncomplicated groin hernias, we suggest using a flat, lightweight, macroporous polypropylene mesh rather than other prosthetic materials.

Flat meshes are preferred over mesh plugs and bilayer meshes, which carry higher risks of extensive fibrosis and intense inflammatory reactions [74,75]. Using large, flat mesh in a tension-free setting reduces mesh movement, and the lifetime risk of mesh erosion is lower compared with plugs. However, several meta-analyses of randomized trials show no significant difference in clinical outcomes between plug and patch repairs and Lichtenstein or the bilayered Prolene hernia system repairs for inguinal hernias [76-78]. It is possible that mesh-related complications were either not captured or occurred rarely in these trials.

Compared with heavyweight meshes (>70 g/m²), lightweight monofilament materials (<50 to 60 g/m²) are more pliable, easier to sterilize in cases of postoperative infection, and may reduce long-term discomfort and foreign body sensation [4,79]. Systematic reviews and meta-analyses have shown that lightweight meshes significantly reduce the risk of chronic pain (odds ratio 0.61, 95% CI 0.50-0.74) and foreign body sensation without affecting postoperative complications such as seroma, hematoma, wound infection, urine retention, testicular atrophy, or hernia recurrence [80-83]. However, lightweight partially absorbable meshes should be avoided in Lichtenstein repairs due to a higher recurrence rate [84].

Macroporous meshes with pores >75 micrometers allow permeation of the material with fibroblasts, collagen fibers, new blood vessels, and macrophages, all of which are essential for creating a strong repair [11]. Microporous materials, which have pores <10 micrometers, do not promote a sufficient inflammatory response and also do not provide sufficient tissue incorporation. For polypropylene mesh, a pore size >1 mm is required [4,85].

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 [86]. 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 USD $1, which is substantially less expensive than commercial mesh (approximately USD $125). However, a follow-up report cautioned that 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 [87].

Mesh fixation — Hernia meshes can be secured with sutures, tacks, or tissue glue, or they can be self-gripping [88-97]. For open mesh repair of groin hernias, surgeons may choose a mesh fixation method based on their experience, since all fixation methods have been associated with similar wound infectious complications and hernia recurrence rates.

●In 2014, a systematic review of 12 randomized trials compared the mesh fixation methods commonly used in open inguinal hernia repair (nonabsorbable suture, absorbable sutures, tacks, fibrin sealant, cyanoacrylate, and self-fixing mesh) [98]. There was no significant difference in recurrence or surgical site infection rates between fixation methods. There were insufficient data to declare the superiority of one method of fixation, but moderate-quality studies have suggested that both fibrin sealant and cyanoacrylate may have a beneficial effect on reducing immediate postoperative pain and chronic pain in at-risk populations, such as younger, active patients. In that review, the chronic pain rates for suture, fibrin sealant, cyanoacrylate, and self-fixing mesh were 15, 4, 8, and 18 percent, respectively. Although tissue glue (fibrin sealant or cyanoacrylate) has been associated with less early postoperative and chronic pain than sutures in some studies, the available data are far from conclusive. In 2018, the HerniaSurge group endorsed "atraumatic fixation" with their weakest recommendation [3].

●A 2021 systematic review and meta-analysis comparing sutured mesh with self-fixing mesh found that although a self-fixing mesh takes a shorter time to place (by a median difference of seven minutes), it confers no advantage when compared with a standard sutured mesh for open inguinal hernia repair in terms of chronic pain or recurrence [99]. A large cohort study of the Swedish Hernia Registry reached the same conclusion [100].

●A 2019 network meta-analysis comparing self-gripping mesh, glue fixation, and suture fixation showed an increase in acute postoperative pain (first 24 hours) with self-gripping mesh compared with glue fixation [101]. Ultimately, there was not enough evidence to suggest that either self-gripping mesh or glue fixation provided a superior repair to a suture fixation. Importantly, the authors identified that the routine use of self-gripping mesh or gluer fixation would likely be associated with considerable cost implications.

Minimizing chronic pain — Chronic pain following inguinal hernia repair is often caused by injury or entrapment of sensory nerves that innervate the groin, including the ilioinguinal, iliohypogastric, genital branch of the genitofemoral, and lateral femoral cutaneous nerves (table 2). Post-herniorrhaphy neuralgia can be minimized by avoiding manipulation of the nerves during dissection and hernia repair or by neurectomy. Diagnosis and treatment of post-herniorrhaphy groin pain are discussed elsewhere. (See "Post-herniorrhaphy groin pain".)

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 be required to protect it. In these instances, a pragmatic neurectomy should be performed, although some surgeons routinely divide it. (See 'Minimizing chronic pain' above.)

●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, or subfascial.

●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.

Minimize nerve manipulation — Chronic pain following inguinal hernia repair is often due to neuralgia [102,103]. Neuralgia can be due to injury or entrapment of any of the above-mentioned sensory nerves that innervate the groin (table 2) [102]. Understanding the inguinal neuroanatomy provides the surgeon with "nerve awareness." Having nerve awareness allows the surgeon to limit the manipulation of these nerves. Keeping the nerves within their investing fascia is recommended to reduce chronic postoperative inguinal pain [104].

The type of mesh used and the method of fixation are potential causes of persistent groin pain and post-herniorrhaphy neuralgia [105]. The salient points to selecting the best mesh and fixation method to minimize post-herniorrhaphy neuralgia are discussed above. (See 'Mesh material' above and 'Mesh fixation' above.)

Neurectomy — Besides avoiding manipulation of the nerves during dissection and hernia repair, post-herniorrhaphy neuralgia can also be minimized by routine or selective neurectomy during open groin hernia repair [106-109]. We perform 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 – Some surgeons routinely sacrifice one or more nerves prophylactically at the time of hernia repair in patients [110-118]. A 2012 meta-analysis of six randomized trials found that, compared with no division, routine division of the ilioinguinal nerve during open inguinal hernia repair did not reduce the rate of chronic pain or numbness at 6 and 12 months, but increased the rate of sensory loss or change [119]. Only a few studies compared routine division with nondivision of the iliohypogastric nerve and found no difference in chronic pain after one year [120,121]. There is no study on routine division of the genital branch of the genitofemoral nerve, although it is virtually always sacrificed in female patients along with the round ligament without the need for selective identification, and thus, is thought to cause chronic pain in females undergoing inguinal hernia repair. (See "Post-herniorrhaphy groin pain".)

●Pragmatic neurectomy – We perform 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. In an observational study of 525 patients undergoing Lichtenstein hernia repair, selective neurectomy of "at-risk" nerves was associated with a lower rate of pain at three months than groin nerve preservation [122]. 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.

Preperitoneal repair — Some data suggest that open preperitoneal mesh repair may result in fewer cases of chronic post-herniorrhaphy neuralgia compared with traditional onlay open repair. Open preperitoneal repair is essentially an open version of the laparoscopic totally extraperitoneal 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) [123]. At five years, however, groin pain had spontaneously resolved in all but one patient in both groups [124]. The recurrence rates were similarly low (1.7 percent preperitoneal versus 3.8 percent Lichtenstein).

●In another trial comparing two open preperitoneal techniques (TransREctus Sheath PrePeritoneal [TREPP] and TransInguinal PrePeritoneal Technique [TIPP]), both resulted in very low rates of chronic groin pain at one year (TREPP 1.9 percent, TIPP 1.4 percent) [125]. More patients developed recurrences after TREPP than TIPP (8.9 versus 4.6 percent), but the difference was due to a learning curve associated with the former.

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 urgent nature of the hernia repair. Elective cases are usually discharged the same day. Nausea and urinary retention are the most common problems that require an overnight stay. (See "Complications of inguinal and femoral hernia repair".)

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 [126]. Patients who undergo nonmesh 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 [127,128].

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 [128]. One small study that examined reaction times in an emergency stop simulation suggested that driving can resume 10 days following surgery [129].

OUTCOMES — 

Hernia recurrence after open inguinal hernia repair is generally low, and rates are similar to those occurring after laparoscopic inguinal hernia repair [130]. Population-based studies indicate that open-mesh procedures are associated with lower recurrence rates than non-open-mesh procedures [23]. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Unilateral hernia'.)

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 'Patient outcomes'.)

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: Groin hernias (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Open repair techniques – Many open techniques for groin hernia repair have been developed and are broadly categorized as tension-free mesh repairs and primary tissue repairs (table 1). Mesh repairs are preferred to primary tissue repairs because of a lower hernia recurrence rate. When mesh placement is clinically appropriate and acceptable to the patient, we use techniques that result in the placement of flat mesh in a single plane (eg, Lichtenstein and preperitoneal repair). (See 'Surgical techniques' above and 'Minimizing hernia recurrences' above.).

●Choice of repair – Once a decision has been made to perform an open groin hernia repair, the type of repair needs to be selected. Our recommendations are as follows (see 'Choice of repair' above):

•For open repair of uncomplicated inguinal hernias where mesh is clinically appropriate and acceptable to the patient, we suggest the Lichtenstein technique rather than other open, tension-free mesh methods (Grade 2C). The Lichtenstein repair is well-studied, has a low recurrence rate, can be easily mastered, and can be performed in the outpatient setting using local anesthetic (figure 5). (See 'Uncomplicated inguinal hernias' above.)

•For patients with an uncomplicated inguinal hernia who wish to avoid mesh, we suggest the Shouldice repair (Grade 2C). Among the available nonmesh repairs, Shouldice has the lowest hernia recurrence rate. (See 'Patients who wish to avoid mesh' above.)

•For uncomplicated femoral hernias where mesh is clinically appropriate and acceptable to the patient, we perform an open preperitoneal mesh repair when a minimally invasive repair is contraindicated (figure 6). Femoral hernias are better repaired posteriorly than anteriorly. (See 'Uncomplicated femoral hernias' above.)

•For repair of complicated groin hernias, a relaxing incision may be required to free incarcerated contents (figure 9). The optimal repair depends upon whether there are contraindications to the placement of mesh. (See 'Complicated hernias' above.)

-Practices may vary according to clinical scenarios (eg, the degree of contamination) and individual surgeon preference. We consider it safe to use mesh in a patient who presents early with incarcerated inguinal hernia manifesting only edema without gangrene or severe ischemia. (See 'Mesh repairs' above.)

-If mesh is contraindicated (eg, wound contamination), a nonmesh primary tissue repair is required. For inguinal hernias, we perform a Shouldice repair, although a Bassini repair with a McVay relaxing incision is a reasonable alternative. For femoral hernias, the McVay repair is the only option that does not require mesh. (See 'Nonmesh repairs' above.)

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

●Mesh choice and fixation – Mesh is a standard component of most contemporary open techniques for groin hernia repair, effectively reducing the recurrence rate. However, the choice of mesh and the method of fixation can contribute to persistent groin pain and post-herniorrhaphy neuralgia. (See 'Minimizing hernia recurrences' above.)

•For open mesh repair of groin hernias, we suggest using a flat lightweight, macroporous polypropylene mesh rather than other prosthetic materials (Grade 2B). Lightweight mesh has been associated with less chronic pain than heavier-weight mesh. (See 'Mesh material' above.)

•For open mesh repair of groin hernias, surgeons should choose a mesh fixation method based on their experience. No fixation method has been conclusively found to be superior to others. (See 'Mesh fixation' above.)

●Pragmatic neurectomy – Chronic pain following inguinal hernia repair is often caused by injury or entrapment of sensory nerves that innervate the groin, including the ilioinguinal, iliohypogastric, genital branch of the genitofemoral, and lateral femoral cutaneous nerves (table 2). Post-herniorrhaphy neuralgia can be minimized by avoiding manipulation of the nerves during dissection and hernia repair or by neurectomy. (See 'Minimizing chronic pain' above.)

Rather than routine prophylactic neurectomy or no neurectomy, we perform 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. (See 'Minimizing chronic pain' above.)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Forrest D Griffen, MD, who contributed to earlier versions of this topic review.