Inguinal hernia repair is among the most common procedures performed by general surgeons. Many techniques have been used for hernia repair and these can be categorized as tension-free repairs, which typically use mesh, and primary tissue approximation repairs that do not use mesh. The most commonly used open approaches include the Lichtenstein repair, plug and patch repair, and the open, preperitoneal approach. When performed by surgeons with experience with the technique, each of these techniques is associated with low recurrence rates.
Open techniques for the repair of inguinal and femoral hernia are reviewed here. The classification and diagnosis of inguinal and femoral hernias, management of inguinal and femoral hernia, and laparoscopic techniques for inguinal and femoral hernia repair are discussed elsewhere. (See "Classification, clinical features and diagnosis of inguinal and femoral hernias in adults" and "Overview of treatment for inguinal and femoral hernia in adults" and "Laparoscopic inguinal and femoral hernia repair in adults".)
Inguinal anatomy is illustrated in the figure (figure 1A). The inguinal canal is formed by the aponeurosis of the external oblique muscle anteriorly, and the transversalis fascia and the transversus abdominus muscles posteriorly. The external inguinal ring is formed by the external oblique muscle. The internal inguinal ring is located in the transversalis fascia and composed of the transversus abdominus and internal oblique muscles. The iliac vessels exit the abdomen posterior to the inguinal canal. The anatomy of the abdominal wall is discussed in detail elsewhere. (See "Anatomy of the abdominal wall".)
Hernia location — Indirect inguinal hernias develop at the internal ring, the site at which the spermatic cord in males and the round ligament in females enter the inguinal canal. Indirect inguinal hernias originate lateral to the inferior epigastric artery (figure 1A-B), in contrast to direct hernias (figure 2), which protrude through Hesselbach's triangle medial to the inferior epigastric vessels. Hesselbach's triangle is bounded by the rectus abdominis muscle medially, the inguinal ligament inferiorly, and the inferior epigastric vessels laterally.
Femoral hernias (figure 3) protrude through the femoral ring, which is bounded by the inguinal ligament anteriorly, Cooper’s Ligament posteriorly, the lacunar ligament medially, and the sheath of the femoral vein laterally.