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Page 2 of 8 Burton et al. Mini-invasive Surg 2021;5:26 https://dx.doi.org/10.20517/2574-1225.2021.26

hernias repaired in the United States annually [1,2,3] . Throughout the years there have been many
advancements in the operation including the genesis of laparoscopic techniques. With a multitude of
surgical methods, it can often become difficult in deciding the best method of repair. An array of factors
contributes to deciding which operative technique is best utilized for a patient presenting with an inguinal
hernia. We will explore these variables as well as the surgical techniques themselves.

SURGICAL TECHNIQUES
Open inguinal hernia repairs can be categorized into two main categories: tissue repair and mesh repair
[Table 1]. There are several named techniques that can be utilized for performing a tissue repair such as the
Bassini, McVay, Marcy, and Shouldice repairs [4,5,6] . The Desarda repair, a more recently described tissue
[7]
repair, utilizes a partially detached strip of external oblique aponeurosis . For open mesh repairs,
prosthetics are either placed anteriorly or preperitoneal. The gold standard mesh repair is the Lichtenstein
tension-free mesh repair which places the mesh anteriorly between the external and internal oblique
aponeuroses . Other open mesh techniques include the plug-and-patch, the Gilbert Prolene Hernia System
[8]
(PHS) Bilayer connected device repair, and the open preperitoneal mesh placed via an inguinal incision
after reduction of the hernia [9,10] . The Stoppa repair, is an open preperitoneal mesh repair utilized for large
inguinoscrotal and bilateral inguinal hernias, utilizing a lower midline incision . The anatomic exposure of
[11]
the Stoppa repair is the precursor for laparoscopic preperitoneal repairs. These aforementioned open
surgical techniques allow for repair both with and without mesh, as well as placing mesh in various
locations.

By utilizing the preperitoneal space and exposure of the myopectineal orifice described by Rene Stoppa,
laparoscopic approaches to inguinal hernia repairs are a minimally invasive option to inguinal hernia repair
by placing mesh in the preperitoneal space. There are two main methods of laparoscopic inguinal hernia
repair with the same exposure and coverage of the myopectineal orifice but differences in how access to the
preperitoneal space is gained. One approach avoids violation of the abdominal cavity (Totally
Extraperitoneal - TEP repair) and one enters the abdominal cavity (Transabdominal Preperitoneal - TAPP
repair). For both the TEP and TAPP repairs, dissection should ensure the critical view of the myopectineal
orifice which routinely exposes the inguinal anatomy allowing any direct, femoral, obturator, or indirect
hernias to be identified and reduced . Although these laparoscopic methods necessitate mesh use, recent
[12]
minimally invasive techniques utilizing robotic platforms may provide a means of mesh-free preperitoneal
repair in selected patients with direct and/or indirect defects .
[13]
In the TEP repair, surgery is contained within the extraperitoneal space. This can provide an advantage
when patients have had prior abdominal surgeries with the potential of adhesions and scar tissue
complicating the procedure, but still allowing for a minimally invasive approach. In the TAPP repair,
surgery takes place from the intraabdominal space and subsequent access to the preperitoneal space is
gained by incising the peritoneum and creating a peritoneal flap. The transabdominal view allows for a
deliberate evaluation of intraabdominal contents, such as when there is concern for ischemic bowel. Unlike
the TEP repair which is able to use insufflation between the abdominal wall and the peritoneum, the TAPP
repair requires the surgeon to actively retract the peritoneum during dissection. When considering
laparoscopic repair, surgeon experience and skill allow for replicability, decreased surgeon experienced
difficulty, and reduction of complications - large trocar sites should be properly closed to reduce the risk of
a subsequent trocar site hernia, the extraperitoneal space should carefully be created during a TEP repair to
avoid tears and large holes which can complicate and hinder exposure, access to the abdominal cavity and
pelvic exposure should be performed carefully to avoid enterotomies and/or injury to the peritoneum, and
dissection of the hernia sac away from cord structures should be methodical to avoid damage to nearby