Types of hernia repair
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Types of hernia repair
Hernia repairs are classified by approach and by whether mesh is used.
1. Tissue repair or primary suture repair
- The hernia defect is closed using the patient’s own fascia or muscle, without mesh.
- Best suited to selected small defects or when mesh is unsuitable.
- In groin hernia, common named techniques are:
- Bassini repair
- Shouldice repair
- McVay (Cooper ligament) repair
- Desarda repair
- Herniotomy means simply removing or tying off the hernia sac. It is commonly adequate for many pediatric inguinal hernias.
2. Open mesh repair, or hernioplasty
- An open incision is made over the hernia, its contents are reduced, and a prosthetic mesh reinforces the weak area.
- It is often called a tension-free repair.
- Common examples:
- Lichtenstein tension-free mesh repair: standard open anterior repair for many inguinal hernias.
- Open preperitoneal mesh repair, including Stoppa repair, often useful for bilateral or recurrent groin hernias.
- Onlay, sublay/retromuscular, preperitoneal, or intraperitoneal mesh placement for ventral and incisional hernias.
For ventral/incisional hernias, the three broad operative categories traditionally described are primary suture repair, open prosthetic mesh repair, and laparoscopic repair. Mesh generally lowers recurrence compared with suture-only repair, especially for larger defects. Maingot's Abdominal Operations, pp. 169-170.
3. Laparoscopic repair
Mesh is placed through small abdominal incisions. Main groin-hernia methods:
-
TAPP: TransAbdominal PrePeritoneal repair
- The surgeon enters the peritoneal cavity, reaches the preperitoneal plane, and places mesh.
-
TEP: Totally ExtraPeritoneal repair
- Mesh is placed in the preperitoneal space without entering the peritoneal cavity.
For ventral/incisional hernias, laparoscopic mesh repair may use intraperitoneal mesh placement, often termed IPOM (intraperitoneal onlay mesh), although newer extraperitoneal approaches are increasingly used.
4. Robotic-assisted repair
- A minimally invasive mesh repair performed using robotic instruments.
- It can facilitate suturing and complex abdominal-wall reconstruction, but it is still fundamentally an open-plane or laparoscopic-type repair rather than a separate biological repair category.
Quick classification by hernia site
| Site | Common repairs |
|---|---|
| Inguinal hernia | Herniotomy, Shouldice, Bassini, Lichtenstein mesh, TEP, TAPP |
| Femoral hernia | Open infrainguinal/high approach, preperitoneal mesh, TEP/TAPP |
| Umbilical/epigastric hernia | Primary suture for selected small defects, open mesh, laparoscopic/robotic mesh |
| Incisional/ventral hernia | Open mesh repair, retromuscular/sublay repair, component separation for complex cases, laparoscopic or robotic mesh repair |
| Parastomal hernia | Mesh repair by open, laparoscopic, or robotic approach; technique is individualized |
For adult inguinal hernia, contemporary teaching generally favors mesh-based repair when appropriate; standard options include open Lichtenstein repair and laparo-endoscopic TEP or TAPP. Bailey and Love's Short Practice of Surgery, section “Operations for inguinal hernia”; see also ACS patient guidance.
Herinorhapy
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herniorrhaphy definition surgical repair hernia suture
Herniorrhaphy is the surgical repair of a hernia by suturing the tissues, traditionally without using mesh.
Basic steps
- Expose the hernia sac.
- Return the herniated contents to the abdomen.
- Remove or ligate the sac if required.
- Close and reinforce the defect in the muscle/fascial wall with sutures.
Examples in inguinal hernia
- Bassini repair
- Shouldice repair
- McVay repair
- Desarda repair
Difference:
- Herniotomy: removal/ligation of the hernia sac only, commonly done in children.
- Herniorrhaphy: suture repair and strengthening of the posterior wall/defect.
- Hernioplasty: repair reinforced with a mesh.
In adult hernias, suture-only repair can have a higher recurrence risk than appropriately selected mesh repair. Bailey and Love's Short Practice of Surgery, “Herniotomy.” The American College of Surgeons definition uses herniorrhaphy more broadly for surgical hernia repair, while many surgical teaching contexts use it specifically for tissue or suture repair.
Best technique for each method
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inguinal hernia repair guidelines
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international guidelines groin hernia management Lichtenstein TEP TAPP recurrent bilateral female recommendation
There is no single best technique for every hernia. The choice depends on site, primary versus recurrent hernia, unilateral versus bilateral disease, patient factors, and surgeon expertise.
Best repair by situation
| Situation | Preferred technique | Why |
|---|---|---|
| Child with inguinal hernia | Herniotomy | The sac is ligated and removed. Posterior-wall strengthening or mesh is usually unnecessary. |
| Adult primary unilateral inguinal hernia, open approach | Lichtenstein tension-free flat mesh repair | Standard, reproducible open mesh repair with low recurrence. |
| Adult primary bilateral inguinal hernia | Laparo-endoscopic repair: TEP or TAPP | Both sides can be repaired through the same small incisions. |
| Recurrent inguinal hernia after an open anterior repair, e.g. Lichtenstein | TEP or TAPP | Uses the posterior plane, avoiding scar tissue from the previous anterior operation. |
| Recurrent inguinal hernia after TEP/TAPP | Open anterior mesh repair, usually Lichtenstein | Avoids re-entering the previously dissected posterior plane. |
| When mesh is refused or contraindicated | Shouldice repair | Best-established pure tissue, non-mesh repair, but technically demanding. |
| Femoral hernia, particularly in women | TEP/TAPP preperitoneal mesh repair, when expertise is available | Gives good access to the entire myopectineal orifice and helps identify/cover occult femoral defects. |
| Small primary umbilical/epigastric defect | Primary suture repair in selected cases | Suitable only for small defects with good surrounding fascia. |
| Larger or recurrent umbilical, ventral, or incisional hernia | Mesh repair, preferably retromuscular/sublay when feasible | Mesh reduces recurrence; the exact plane and approach are individualized. |
| Large complex ventral/incisional hernia | Open or robotic retromuscular mesh repair with component separation if required | Restores fascial continuity and allows wide mesh overlap. |
In short
- Best open mesh repair for routine inguinal hernia: Lichtenstein repair
- Best non-mesh tissue repair: Shouldice repair
- Best minimally invasive groin repair: TEP or TAPP, with neither universally superior
- Best repair after previous open groin repair: TEP/TAPP
- Best repair after failed TEP/TAPP: Lichtenstein/open anterior repair
- Best pediatric operation: Herniotomy
For adult inguinal hernia, mesh-based repair is generally preferred. If a non-mesh operation is needed, Shouldice is regarded as the best tissue-based repair, though it requires specific surgical skill. Current Surgical Therapy, “Tissue Repair”; Sabiston Textbook of Surgery, “Tissue Repairs.” International guidance considers TEP and TAPP to have comparable outcomes, so the choice should be based on the surgeon’s training and experience, as summarized in the HerniaSurge guidance.
Compare Lichtenstein, Shouldice, TEP, and TAPP in a table
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HerniaSurge guidelines Lichtenstein Shouldice TEP TAPP comparison recovery chronic pain recurrent bilateral
| Feature | Lichtenstein | Shouldice | TEP | TAPP |
|---|---|---|---|---|
| Full name | Lichtenstein tension-free repair | Shouldice tissue repair | Totally Extraperitoneal repair | TransAbdominal PrePeritoneal repair |
| Surgical approach | Open anterior | Open anterior | Laparoscopic posterior | Laparoscopic posterior |
| Mesh | Yes, flat mesh | No | Yes, preperitoneal mesh | Yes, preperitoneal mesh |
| Basic principle | Mesh is placed over the posterior wall of the inguinal canal without tension | Multilayer reconstruction of posterior wall using sutures | Mesh placed in preperitoneal space without entering abdominal cavity | Surgeon enters abdominal cavity, opens peritoneum, places preperitoneal mesh, then closes peritoneum |
| Anaesthesia | Local, regional, or general | Usually regional or general | General | General |
| Best use | Standard open repair for primary unilateral adult inguinal hernia | Patient declines mesh or mesh is unsuitable, with an experienced Shouldice surgeon | Bilateral primary hernia; recurrent hernia after previous open anterior repair | Bilateral/recurrent hernia; useful when intra-abdominal visualization or contralateral inspection is beneficial |
| Major advantage | Reproducible, relatively short learning curve, can be done under local anaesthesia | Avoids foreign material/mesh | Avoids entering peritoneal cavity; less postoperative pain and faster recovery than many open repairs | Excellent internal view, easier anatomic orientation for some surgeons, permits inspection of opposite groin |
| Main limitation | Chronic groin pain or numbness can occur; mesh-related issues are possible | Technically demanding; higher recurrence than mesh repair if not performed expertly | Technically demanding preperitoneal dissection; limited working space | Enters peritoneal cavity, with potential visceral injury, adhesions, port-site hernia, and need for peritoneal closure |
| Recurrence | Low with correct technique | Best non-mesh option, but generally higher than mesh repairs | Low, comparable with TAPP in experienced hands | Low, comparable with TEP in experienced hands |
| Chronic pain tendency | Generally higher than laparo-endoscopic approaches | Variable; depends heavily on technique and tissue tension | Generally lower than open anterior mesh repair | Generally lower than open anterior mesh repair |
| Suitability after failed open repair | Usually not preferred because it re-enters the scarred anterior plane | Not usually preferred for the same reason | Preferred posterior approach | Preferred posterior approach |
| Suitability after failed TEP/TAPP | Preferred anterior approach | Possible if mesh avoidance is necessary and expertise exists | Usually avoid re-entering same posterior plane | Usually avoid re-entering same posterior plane |
| Key learning issue | Easiest of the four to standardize | Most technically demanding open tissue repair | Requires advanced laparoscopic expertise | Requires laparoscopic expertise and safe intraperitoneal access |
Practical take-home
- Best standard open mesh repair: Lichtenstein
- Best non-mesh repair: Shouldice
- Best for bilateral inguinal hernia or recurrence after open repair: TEP or TAPP
- TEP vs TAPP: outcomes are broadly comparable. Choose based on surgeon expertise and patient anatomy. TEP avoids entering the abdominal cavity, whereas TAPP provides more intra-abdominal visualization.
Guidelines recommend flat-mesh Lichtenstein repair as an open option, Shouldice when a non-mesh repair is chosen, and TEP/TAPP as laparo-endoscopic options. Mulholland and Greenfield's Surgery: Scientific Principles and Practice, Grade 3/4, p. 343. TEP and TAPP have comparable outcomes in experienced hands, according to the HerniaSurge guideline summary.
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