Open and Shut Case: Indirect Inguinal Hernia Repair
by Brie Eteson, Medical Communications, Digital Surgery
Surgical approaches for hernia repair
Inguinal hernias are the most common abdominal wall hernia, accounting for around 70-75%.1 Repairing inguinal hernias is commonly done, to which there are multiple different acceptable approaches. Although the laparoscopic approach may boast shorter recovery times, open repair is still widely employed and depends on several factors, including the surgeon’s preference, institutional protocols, and patient presentation.2 Some indications for laparoscopic surgery are more specific and often include recurring or bilateral hernia repairs.
Another key difference that affects the choice of approach is that open repair can be performed under local anesthetic, whereas laparoscopic surgery must be performed under general anesthetic. This gives open surgery another gold star on its inclusivity list.2
When discussing hernias, people imagine large bulbous protrusions in the gut that appear if you skip your daily core exercises. We’re here to nip that in the bud. Whilst some hernias are a result of weak abdominal muscles (direct inguinal hernias), some are congenital (indirect inguinal hernias), or caused by having multiple pregnancies. Others are a result of previous injury or surgery, and some are caused by over-exercising.3
Due to an inherent weakness in the inguinal region established during testicular descent, indirect inguinal hernias are more common in men. Approximately 27% of men are affected by inguinal hernias in their lifetime, compared to 3% of women.1
The difference between an indirect and direct inguinal hernia is discussed in our previous blog post on laparoscopic TAPP hernia repair.
Mesh Over Suture
Several studies support mesh repair over suture repair in open hernia surgery, finding favorable recurrence rates.4,5,6 This simulation demonstrates the key steps of a mesh repair for an indirect inguinal hernia.
Retraction of the cord structures off the floor of the inguinal canal
Ensure preoperative procedures are completed. This includes patient positioning, application of anesthesia, patient draping, and identifying and marking the surgical site.
Incise the skin above the marked inguinal ligament, and divide the subcutaneous tissue to expose the external oblique aponeurosis. Palpate and identify the external inguinal ring. Develop a plane under the oblique aponeurosis in preparation for mesh placement.
Spermatic Cord Dissection
Retract the exposed cord structures from the inguinal canal. Using blunt dissection, carefully take down the adhesions between the cremasteric muscle fibers and the floor of the inguinal canal.
Correct orientation of the mesh for the appropriate anatomical side
Hernia Sac Mobilization
Dissect and separate the cremasteric muscle fibers of the cord structures to isolate the hernia sac. The hernia sac is now exposed and separated. The sac may then be opened to confirm the absence of viscera before it is twisted, transfixed at the base, and resected.
Lift the cord to expose the inguinal floor, and position the mesh around the spermatic cord. The mesh should be spread so that it lies flat over the myopectineal orifice.
Closure of the Abdominal Wall
Return the spermatic cord to its anatomical position. To conclude the procedure, close the external oblique aponeurosis, Scarpa’s fascia, and skin.
Positioning of the mesh around the spermatic cord
This simulation was produced with Medtronic to showcase devices used for this procedure. The products recommended in this simulation are linked below:
Learn the whole procedure with our step-by-step animations on the Touch Surgery™ app.
1. Jenkins JT, O’Dwyer PJ. Inguinal hernias. BMJ. 2008;336(7638):269-272.
2. Kapoor VK. What are the advantages and disadvantages of open and laparoscopic repair of inguinal hernias? Medscape. https://www.medscape.com/answers/1534281-69854/what-are-the-advantages-and-disadvantages-of-open-and-laparoscopic-repair-of-inguinal-hernias. Updated Apr. 16, 2020. Accessed Oct. 19, 2020.
3. Pietrangelo A. Inguinal Hernia Repair. Healthline. https://www.healthline.com/health/inguinal-hernia-repair. Published Dec 6, 2017. Updated Sep. 17, 2018. Accessed Oct. 16, 2020.
4. Hernia. National Health Service Website. https://www.nhs.uk/conditions/hernia/. Updated Jun. 19, 2019. Accessed Nov. 13, 2020.
5. Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann. Surg. 2004;240(4):578.
6. Luijendijk RW, Hop WC, Van Den Tol MP, et al. A comparison of suture repair with mesh repair for incisional hernia. N. Engl. J. Med. 2000;343(6):392–398.
7. Yang C, Deng S. Laparoscopic versus open mesh repair for the treatment of recurrent inguinal hernia: a systematic review and meta-analysis. Ann Palliat Med. 2020;9(3):1164–1173.
8. Eker HH, Hansson BM, Buunen M, Janssen IM, Pierik RE, Hop WC, Bonjer HJ, Jeekel J, Lange JF. Laparoscopic vs open incisional hernia repair: a randomized clinical trial. JAMA surgery. 2013;148(3):259–63.