Modern Hernia Repair: Techniques, Procedures & Current Evidence

Overview of Techniques

1. Mesh Technology - The Foundation of Modern Repair

• Bridge repair: mesh is fixed over the defect as a tension-free patch
• Plug repair: a plug of mesh is pushed into the defect (largely abandoned due to "meshoma" formation causing chronic pain and risk of erosion into adjacent organs)
• Augmented repair: defect closed with sutures + mesh added for reinforcement - currently the standard

• Polypropylene - inert, hydrophobic, monofilament; resists bacterial ingrowth; most widely used
• Polyester - hydrophilic; encourages microvascular ingrowth
• PTFE (polytetrafluoroethylene) - inert flat sheets; anti-adhesive; useful for intraperitoneal placement

2. Open Tissue Repair (No Mesh)

Shouldice Repair

1. Inguinal incision, 6-8 cm, parallel to inguinal ligament
2. Divide Scarpa's fascia; open external oblique aponeurosis through external ring
3. Identify and preserve ilioinguinal and iliohypogastric nerves
4. Isolate spermatic cord with Penrose drain; divide cremaster muscle longitudinally
5. Identify and dissect hernia sac; ligate or reduce indirect sac at internal ring
6. Open transversalis fascia from internal ring to pubic tubercle (the key step - this is unique to Shouldice)
7. Four-layer continuous suture repair of the posterior inguinal wall using the divided edges of transversalis fascia
8. Close external oblique aponeurosis over the cord
9. Skin closure

Desarda Repair (Newer Tissue Technique)

• A strip of external oblique aponeurosis is mobilized and used to reinforce the inguinal floor
• Early data show ~40% higher recurrence vs. Lichtenstein but no foreign body material

3. Open Mesh Repair: Lichtenstein "Tension-Free" Repair

• Divide Scarpa's fascia
• Identify and ligate/cauterize superficial epigastric veins
• Incise the external oblique aponeurosis in line with its fibers, extending through the external inguinal ring medially
• Identify and preserve the ilioinguinal nerve (runs along the inguinal canal)
• Elevate external oblique flap to locate the iliohypogastric nerve superiorly

• Encircle the spermatic cord with a Penrose drain
• Separate the indirect hernia sac (found on the anterolateral cord surface) from the cord using blunt dissection
• Identify and preserve the genital branch of the genitofemoral nerve within the cord

• Indirect sac: Dissect to the level of the internal ring; for small sacs, invert or ligate; for large/scrotal sacs, divide the sac mid-canal to avoid scrotal dissection
• Direct sac (Hesselbach's triangle): Imbricate (invert) the sac using absorbable suture - do not necessarily excise

• Cut a 7×15 cm polypropylene mesh to shape with a keyhole slit at the lateral end for the spermatic cord
• Fix the medial end of the mesh to the anterior surface of the pubic tubercle (1-2 cm overlap medially)
• Sew the inferior edge of the mesh to the shelving edge of the inguinal ligament with a running suture to just beyond the internal ring
• Fix the superior edge to the internal oblique aponeurosis with interrupted sutures
• Create the keyhole: the two tails wrap around the cord at the internal ring and are sutured together, reconstructing the ring snugly

• Close external oblique aponeurosis over the cord
• Approximate Scarpa's fascia with absorbable sutures
• Skin closure

4. Laparoscopic Repair: TEP and TAPP

4A. TEP - Totally Extraperitoneal Repair

• Infraumbilical incision; enter preperitoneal space (just deep to anterior rectus sheath, in front of posterior sheath)
• Insert a balloon dissector trocar and inflate under direct vision to develop the preperitoneal space (Retzius space)
• Place a 10-12 mm camera port here; insert two additional 5 mm working ports in the midline below the umbilicus

• Insufflate with CO₂ to 10-12 mmHg to maintain the preperitoneal space
• Sweep peritoneum posteriorly using blunt dissection
• Identify the pubic symphysis, Cooper's ligament, and the inferior epigastric vessels as anatomical landmarks

• Identify the hernia defect (direct = medial to inferior epigastric vessels; indirect = lateral)
• Reduce the hernia sac back into the preperitoneal space
• For indirect sacs: dissect from cord structures (parietalization); large sacs may be divided

• Roll a 10×15 cm mesh and introduce through the 10 mm port; unroll and flatten over the defect
• Position to cover the entire myopectineal orifice: medially past midline, laterally beyond the deep ring, inferiorly over Cooper's ligament
• No fixation is typically required in TEP (the preperitoneal pressure holds the mesh)

• Desufflate CO₂ slowly while watching the mesh to ensure it stays flat
• Fascial closure at 10 mm port site; skin closure

4B. TAPP - Transabdominal Preperitoneal Repair

• Enter the peritoneal cavity via Hasson technique or Veress needle at umbilicus
• Establish pneumoperitoneum; three-trocar technique (10 mm umbilical camera + two 5 mm lateral working ports)

• View the inguinal region from inside; identify the medial umbilical ligament, inferior epigastric vessels, and hernia defect
• Make a curved peritoneal incision about 2 cm above the hernia defect, from the medial umbilical ligament to the anterior superior iliac spine
• Develop the preperitoneal flap inferiorly, exposing Cooper's ligament, the vas deferens, and gonadal vessels (the "triangle of doom" and "triangle of pain" must be avoided laterally)

• Reduce any direct or indirect hernia contents
• Parietalize the cord structures (separate peritoneum from vas and vessels) to allow flat mesh placement

• Insert and position a 10×15 cm mesh to cover the entire myopectineal orifice
• Optionally fix with tacks to Cooper's ligament medially (lateral fixation near the triangle of pain is avoided to prevent nerve injury)

• Close the peritoneal flap over the mesh with a running suture or tacker to prevent bowel contact with the mesh
• Desufflate and close port sites

5. eTEP - Extended Totally Extraperitoneal (The Newest Standard)

• Small infraumbilical incision on the side opposite the hernia
• Enter the retrorectus (Retzius) space behind the rectus muscle but in front of the posterior rectus sheath
• Place a 12 mm camera port

• CO₂ insufflation; develop the space working medially, then cross the midline
• Dissect into the Retzius space on the side of the hernia - this creates the "extended" space much larger than standard TEP

• Two 5 mm working ports placed on the ipsilateral side, typically in the mid-abdomen and iliac fossa

• Identify Cooper's ligament, inferior epigastric vessels, vas deferens, and gonadal vessels
• Reduce hernia sac; parietalize the cord structures
• For bilateral hernias: work can proceed to the contralateral side in the same large space

• A larger mesh (12×17 cm or greater) is placed, covering the entire myopectineal orifice bilaterally if needed
• Mesh fixation generally not required; lies flat under preperitoneal pressure

• Release CO₂; confirm mesh position
• Port site fascial closure; skin closure

6. Robotic Hernia Repair

Robotic TAPP (r-TAPP)

1. Robotic trocar placement: 8 mm camera at umbilicus + two 8 mm arm ports laterally
2. Enter peritoneum; identify hernia anatomy
3. Peritoneal flap raised; hernia reduced; cord structures parietalized
4. Mesh inserted, positioned, and sutured in place (robotic instruments make suturing far easier than laparoscopic)
5. Peritoneal closure with running barbed suture (major advantage of robotic - this step is far more reliable)

Robotic eTEP (r-eTEP) - Latest Technique

1. Contralateral infraumbilical 8 mm camera port
2. Two ipsilateral 8 mm robotic working ports
3. Retrorectus space development, midline crossing, full space creation
4. Robot docked; hernia reduction, cord parietalization
5. Large mesh deployed and smoothed using robotic arms
6. Optional peritoneal closure possible with robotic suturing

Robotic Ventral Hernia Repair (RVHR)

• Robotic approach has longer operative time vs. laparoscopic (146 vs. 94 min)
• No difference in 90-day outcomes or pain
• At 2 years: lower recurrence rate with robotic approach (P=0.019)
• Defect closure is much easier robotically due to articulating instruments - the key advantage

7. Comparison Summary

8. Current Evidence (2025)

• Robotic TAPP vs. laparoscopic TEP: comparable clinical outcomes; robotic approach associated with longer operative time but trending toward lower recurrence
• Single-port vs. multi-port laparoscopic/robotic repair (PMID: 39419843): no significant difference in major outcomes; single-port offers cosmetic advantage
• For ventral hernias (PMID: 39966282 - ROVER review, 2025): robotic-assisted ventral hernia repair shows reduced surgical site occurrences and recurrence compared to laparoscopic IPOM

Important clinical note: The choice of technique depends on surgeon training/expertise, patient anatomy, hernia type/size, bilaterality, prior repairs, and institutional resources. No single technique suits all hernias. - Bailey & Love's Surgery, 28th Ed., p. 1091