INTRODUCTION

Inguinal hernioplasty is among the most common procedures performed by general surgeons [1]. Indirect inguinal hernias develop at the internal ring, the site where the spermatic cord in males (the round ligament in females) enters the abdominal wall (figure 1 and figure 2). The origin is lateral to the inferior epigastric artery, in contrast to direct hernias which originate medial to the inferior epigastric vessels through Hesselbach's triangle. Hesselbach's triangle is an anatomic landmark, bounded by the rectus abdominis muscle medially, the inguinal ligament (Poupart's) inferiorly and the inferior epigastric vessels laterally. Femoral hernias protrude through the femoral ring, which is bounded anteriorly by to the inguinal ligament (ileopubic tract), posteriorly by Cooper’s ligament, medially by the lacunar ligament, and laterally by the femoral sheath (figure 3).

The main principles of hernia repair are to reinforce the floor of the inguinal canal and tighten the internal inguinal ring [2]. All hernia surgeons agree that repairs must be tension free to minimize recurrences [3]. In the past, relaxing incisions in the rectus sheath were used to reduce tension [4], but recurrences remained unacceptably high because autogenous tissues weaken over time. Mesh has been incorporated in hernia repairs to reduce tension, leading to a fall in recurrence rates. Although initial infection rates near 6 percent dampened enthusiasm for the use of mesh, use of appropriate antibiotic prophylaxis has significantly lowered the rate of infectious complications [5,6].

Many techniques have been proposed for hernia repair. These can be divided into tissue approximation repairs (such as the Bassini or McVay repair) and tension free repairs using mesh. The most commonly used open approaches include the Lichtenstein open tension-free hernioplasty, a plug and patch, or an open preperitoneal approach [7]. All of these options have their advocates and result in recurrence rates of 1 to 2 percent when performed by surgeons skilled in the technique [8-14].

We focus here on the Lichtenstein open tension-free hernioplasty, as it is considered the "gold standard" for open hernia repair [7]. Long-term results favor the Lichtenstein technique because of its low recurrence rate and ease of technical mastery, and because it can be performed in the outpatient setting with local anesthetic [15].

This topic will cover open repair of inguinal hernias. The diagnosis and general approach to the treatment of groin hernias is addressed in detail elsewhere. (See "Overview of abdominal hernias" and "Classification, clinical features and diagnosis of inguinal and femoral hernias in adults" and "Sports-related groin pain or 'sports hernia'" and "Overview of treatment for inguinal and femoral hernias".)