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Burton et al. Mini-invasive Surg 2021;5:26 https://dx.doi.org/10.20517/2574-1225.2021.26 Page 3 of 8

Table 1. Classification of open and laparoscopic techniques for inguinal hernia repair
Open Laparoscopic
Mesh-free tissue repair Bassini
Marcy
McVay
Shouldice
Desarda
Mesh repair Anterior mesh Lichtenstein
Plug-and-patch
Bilayer device (PHS)
Preperitoneal mesh Open preperitoneal via inguinal incision TEP
Stoppa TAPP
TEP: Totally extraperitoneal; TAPP: transabdominal preperitoneal.

structures and creation of peritoneal holes.

LAPAROSCOPIC VS. OPEN
The argument of which method is superior - open or laparoscopic - is often had by surgeons. With the wide
array of techniques, patient factors, and surgeon factors, determining applicability of published results to
one’s own practice can be quite difficult. Evaluating the type of open or laparoscopic procedures being
assessed, the patients’ surgical histories, hernia size and patient comorbidities, and investigating surgeons’
expertise with each study all can be confounding variables that affect the results of a study and make meta-
analyses quite difficult with such heterogeneous study methods. We would argue that it is beneficial for
surgeons to have baseline familiarity of the multitude of surgical procedures, become proficient in both
mesh and mesh-free techniques as well as open and laparoscopic techniques to best tailor the surgery to the
patient and the clinical circumstances, and follow personal outcomes to evaluate individual results.

Surgeon familiarity with technique and anatomy is of utmost necessity to ensure good outcomes and avoid
complications. Gaining expertise with the Shouldice technique’s four layers is benefited by surgical
repetition, as shown by the results from the study by Malik et al. , which demonstrated repair at the high
[14]
volume Shouldice Hospital was far superior to those from lower volume hospitals (1.15% vs. 5.21%).
Although the 2012 Cochrane review found the Shouldice repair to be the best of all open mesh-free
techniques, it took longer, required a longer hospital stay, and still had higher recurrence rates compared
with mesh repair . Whereas only 36 Lichtenstein procedures were needed to gain proficiency with inguinal
[15]
hernia repair , it has been shown that as many as 250 laparoscopic hernia procedures are needed to attain
[16]
sufficient experience to ensure similar complication rates relative to open repairs [17,18] . Repetition of
procedures increases competency, and exposure to nuanced differences, and, in turn, improves surgical skill
and results.

Both the European Hernia Society (EHS) guidelines and the international guidelines for groin hernia
management published by the HerniaSurge group in 2018, recommend open Lichtenstein and laparoscopic
inguinal hernia repairs for nonrecurrent, unilateral inguinal hernias [19,20] . Based on surgeon experience, open
and laparoscopic repairs are acceptable methods. However, there are specific clinical scenarios in which
certain procedures may be more advantageous than others such as contaminated or infected wounds,
recurrent groin hernias, patients with contraindications to laparoscopy, and scenarios where multiple groin
hernias are suspected.