Have a Hernia?

Please note: all of this information comes from reading, and not from experience. I am not an expert on this subject of hernia surgery, nor on the subject of animal and human anatomy and physiology. I am just trying to make learning about inguinal hernia surgery more convenient for you — by gathering what seems to be relevent information together, all in one spot.

It seems to be universally agreed upon that the choice of a surgeon is much more of a significant factor in whether you will have recurrences or complications, than the choice of a method. There are surgeons getting good results with all the methods I describe. I believe you are undoubtedly better off having a good surgeon using a method that may not seem to be the best method, than having a poor surgeon using what seems to be the best method. The difference in skills, from one surgeon to the next, seems to be much more than the difference in reliability of one method of surgery, in common use, as compared to another. I think it is generally best to let your surgeon use the method she wants to use, is familiar with, and knows how to get good results with. That said, some methods or hernia surgery have advantages over others. I think prospective patients should be aware of the differences, and the advantages and disadvantages of each.

Pushing or Pulling?

The peritoneum is a double layer of skin, with a layer of fluid between the 2 layers, that allow the 2 layers to slide along each other. The inner layer is attached, at various places, to the internal organs; the outer layer is similarly attached to the inner layer of the abdominal wall. The layer of fluid between the 2 layers of peritoneum allow the internal organs to move around, within the abdomen, without rubbing and abrading against the abdominal wall. Abdominal organs herniate - intra-abdominal pressure forces them out of the abdomen, pushing a section of the double-layered peritoneal sac ahead of them, and forming an extra-abdominal "hernia sac" made of peritoneum. Hernia surgery involves returning the herniated organs, and possibly the herniated section of sac (alternatively, part or all of the sac may be cut away), to their proper place in the abdomen, and then surgically altering the abdominal wall with the goal of preventing the organs from herniating again. There are two ways for a surgeon to approach the herniated abdominal organs (and the peritoneal sac) in order to return the organs to the abdomen: anteriorly and posteriorly. That is, hernia surgery can be performed using an anterior approach or a posterior approach. The organs can be, respectively, pushed or pulled back into the abdomen.

Anterior approaches; pushing

An anterior approach means making an incision over, or very near to, the area of the abdomen where the hernia is. The incision is, usually, a 5 to 10 centimter oblique (parallel to the inguinal ligament) incision, or a 5 centimeter left-right incision. After the skin, underlying fatty tissue, layers of fascia, and external oblique aponeurosis are cut through, then the peritoneal sac is dissected free from surrounding tissues that it likely has become adherent to — all from "above." The sac may need to be cut open, and tugged on, and stretched up and out, in order to be detached from surrounding tissue.

After the sac is detached, the herniated organs are "pushed" back into the abdomen. Then the sac itself is dealt with also. It is either (1) cut away, and its stump is then ligated in order close up the space created when part of it was cut away, or (2) the whole sac, or what is left of it, may be pushed back into the abdomen. The latter is usually preferred, in modern hernia surgery. It is usually possible to handle the sac this way, but sometimes it is not. For example if the sac reaches all the way into the scrotum, it may not always be possible to tug the far end of the sac out of the scrotum, without causing too much damage, so the sac may be cut so that a piece of it is left in the scrotum, and the other portion pushed back into the abdomen, perhaps after being ligated. The part left behind in the scrotum will atrophy.

Exactly where the sac protrudes from the abdomen in an inguinal hernia can vary. (1) The sac can protrude through the "internal inguinal ring" and follow the inguinal canal up toward the "external inguinal ring." Such an "indirect" hernia often finally extends through the external ring, continues along inside the spermatic cord, even reaching into the scrotum -- and is adherent to normal tissues along this path. (2) The sac can enter the inguinal canal somewhere between the internal ring and external ring. This is called a "direct" hernia; it pushes directly into the inguinal canal, instead of getting into the inguinal canal by squeezing through the internal ring. It may protrude through the external ring along with the spermatic cord, alongside the spermatic cord (outside the spermatic cord), and as it does so, becomes adherent to tissues in different ways. Since this "direct" hernia is outside the spermatic cord, it cannot reach into the scrotum. I am not sure about all the details of how a direct as opposed to an indirect inguinal hernia figures in females, where there is no 3-layered spermatic cord, and where what passes through the internal and external rings, instead of a spermatic cord, is a "round ligament" — extending from labium majora to uterus. But, basically, in both men and women, you have an inguinal canal, which is a tunnel through the muscle layers, the ends of which are defined by an internal ring and an external ring — and you can have an indirect inguinal hernia, which is defined as a hernia that enters the canal by passing thru the internal ring; or you can have a direct hernia, which is defined as a hernia that enters the inguinal canal between the internal ring and external ring. Finally, a hernia can be a combination of these "indirect" and "direct" hernia configurations, or it may be a somewhat novel presentation.

So — there may be plenty of original thinking for the surgeon to do after she opens up the external oblique aponeurosis to see what is going on underneath it. From what I can figure out, the presentation, and places where the sac is adherent, may be unique, and dealing with the adherent sac may be a unique challenge. The presentation can be further complicated if the patient has had previous hernia surgery.

Among all the anterior methods in common use, there are of two basic ways of fixing up the patient's abdomnal wall so that the sac and internal organs will not pop out again, once the contents of the sac have been reduced and the sac has been pushed back into the abdominal space: (1) pure tissue repairs and (2) repairs using a prosthesis made out of a plastic-resin mesh.

While femoral hernias may sometimes be classified as a kind of inguinal hernia, simply because they occur in the inguinal region, the groin, they are a monkey business of a different kind, than the rest of the inguinal hernias. If you have a femoral hernia: your herniated organ follows the path that the femoral artery and femoral vein uses to get from the groin (the inguinal region) to the thigh. The other kinds of inguinal hernias (indirect, direct, and variations): your herniated organ follows either the path that your gonad blazed, during its descent from your abdomen to your scrotum; or your herniated organ follows the path that that your gonad might have taken, if only your gonad had decided to grow up to be a testicle instead of an ovary.

Some of the descriptions below may look sketchy. My plan now is to consider this page an outline, and to keep on adding more details, whenever I find a bit of time to do so.

Posterior approaches; pulling and pushing

For inguinal hernias, the two posterior approaches in common use have been: (1) Kugel Patch method, and (2) laparoscopic methods. In recent years (since 2005) the Kugel Patch has stopped being used, due to the frequency of severe problems that it has caused. But there are still plenty of people with Kugel Patches in place. Of the laparoscopic methods, the 2 methods in common use are totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP).

Once the "pre-peritoneal space" is accessed, from an incision that may be rather far away from the hernia, the adherent sac is separated, and the herniated organs are either "pulled" back into the abdomen, or coaxed back into the abdomen by a combination of pulling from inside, and, non-surgically pushing, with a hand, from outside the abdomen, over the area where the protrusion is, much the way the patient would reduce the hernia himself.

The "pre-peritoneal space," by the way, is the space between the inner surface of the 3-layered abdominal "wall" and the outer surface of the peritoneum. This is sometimes referred to as "the space of Bogros."


Pure Tissue Repairs — all are via an anterior approach

Some background. Inguinal Anatomy.

A primary landmark in the inguinal region is the inguinal ligament. A ligament is a strong tissue that connects bone to bone. It is flexible, but it does not contract and relax like muscle tissue. Check out the links at the bottom of this page, for info about where the inguinal ligament is. The traditional incision for an anterior inguinal hernia repair is an oblique incision — parallel to the inguinal ligament, and just a bit higher up toward the head and closer to the body's midline — maybe a centimeter.

There are three layers of muscular and aponeurotic tissue in the groin.

An aponeurosis is an elongated or wide area of tendon tissue that extends from a muscle, and serves not only as a tendon, but also works very much like a muscle fascial layer — allows another layer of muscle to slide over it as that other layer of muscle contracts and relaxes.

Every muscle is covered with layers of fascia, one layer on each side. And muscle is connected to bone by tendon tissue, tendons, at the ends of the muscle. As a muscle layer gets close to the bone, it seemingly becomes transformed into tendon tissue; and the area of tissue that is an extension of the muscle, and that is attached to the muscle on one side, and bone on the other, is called a tendon. As I indicated above, this tendonous extension of a muscle is also an aponeurotic extension, if it serves as fascia, as well as performs the functions of a tendon.

Muscle tissue is contractile. That is how it does what muscles do: by contracting. The typical configuration is, that when it contracts, it pulls on the tendon attached to it, and the tendon pulls on a bone that it is attached to, moving it — usually at a joint. The joint is connected together with ligaments (very strong flexible tissue). Tendon tissue in non-contractile, and very strong. It neither contracts nor relaxes, and stays about the same size. You can pull on it without stretching it much. Because a muscle is attached to a bone by a tendon, when a muscle contracts, the tendon takes up some of the shock of the contraction by stretching just a bit.

In the abdomen, muscles not only serve to move our skeletons, but they also form a strong, flexible, 3-layered retaining-wall that holds our internal organs inside against the intra-abdominal water pressure of these organs (made mostly of water). Their overall strength is obtained from a synergy of the 3 layers, with their fibers at angles to each other — very much like the overall strength of a tubeless tire, which holds pressurized air inside, comes from the synergy of several layers of nylon (or similar resin) cords, layered at angles to each other. The muscles, however, can also slide past each other to some degree. The nylon cords in a tire cannot.

There are three layers of muscle and aponeurotic tissue that make up the "abdominal wall" right at the area where the incision is made to do an anterior inguinal hernia repair. Plus a fourth muscle, the rectus abdominus — it's outer edge is visible through the incision if the incision is spread apart. The three-layers right under the incision are the external oblique with its aponeurosis covering it and extending from it; the internal oblique; and the transversus abdominus.

Below these three layers of muscle and muscle fascia is the peritoneum, a double skin-like layer that covers and protects the internal organs. The inner layer of the peritoneum is somewhat attached to the internal organs; the outer layer is somewhat attached to the abdominal wall. The two layers slip back and forth under against each other, lubricated by serous fluid.This slipping motion allows the small and large intestine to shift position within the abdomen, as chyle and feces pass through them, without being damaged by abrasion. It allows the bladder to expand and contract without abrasion.

In the area of the incision, the external oblique presents its aponeurotic extension to the surgeon, rather than its muscular portion. The internal oblique and transversus abdominus — they each have an "arching edge," a few centimeters away from the incision and toward the body's midline, and can be seen after the aponeurosis of the external oblique is cut through, and the " flaps" created by cutting through it, are pulled apart. The transversus abdominus is underneath the internal oblique, that is, between the internal oblique and the peritoneum. The most posterior fascial layer of the transversus abdominus is called the transversalis fascia.

Each muscle has fascial layers on each side. And either the aponeurotic portion, the fascia, or the mucle tissue itself, of the external oblique, internal oblique and transversus abdominis muscle — have extensions that form the spermatic cord — inside of which are blood vessels and the vas deferens. The internal oblique is both muscle and fascia here, at the spermatic cord — and this portion of the internal oblique that contributes to the structure of the spermatic cord is called the cremasteric muscle. That is, the cremasteric muscle is an extension of the internal oblique muscle. Check out this simplified overview, and then check out this excellent inguinal anatomy info, particularly the cross-section of the spermatic cord at the bottom of the page. The external oblique and transversus abdominus muscle muscle contribute their fascia to the spermatic cord. The portion of fascia contributed by the tranversus abdominus muscle, to form the internal spermatic fascia, is called the transversalis fascia. The aponeurosis of the external oblique is what contributes to the external spermatic fascia.

The pure tissue repairs in common use today are Bassini, McVay (also called Cooper's Ligament repair), Marcy and Shouldice. There are other repairs, performed less frequently.


This repair was developed in 1886, by Dr. Eduardo Bassini. It's development is often said to mark the beginning of "modern hernia surgery."

A 10 centimeter incision, parallel to the inguinal ligament (oblique incision), is made. The external oblique aponeurosis is incised from internal ring to pubic tubercle, creating 2 flaps, a lateral flap and a medial flap, and revealing the spermatic cord, and the underlying layer of internal oblique, and transversalis fascia. The cremasteric muscle, which is one of the outer layers of the spermatic cord, is divided, creating a proximal stump and distal stump. The transversalis fascia is incised from internal ring to pubic tubercle, creating a lateral flap and medial flap. Then the natually existing lateral edge of the internal oblique muscle, and the transversus abdominus muscle, and the lateral edge of the surgically created medial flap, of the transversalis fascia, are all sutured to the inguinal ligament, with interrupted sutures. They have to be stretched a bit to reach. This is said to be the essence of the repair. Afterwards, the 2 flaps of external oblique are sutured back together, above the spermatic cord, that is, the spermatic cord is left in its normal anatomical position between the layer of internal oblique and the layer of external oblique.

What I think happens, I could be mistaken, is that in being stretched toward the inguinal ligament, the layers of tissue cover the dilated internal ring (indirect hernia), or the stretched and thinned transversalis fascia (direct hernia), that allowed the hernia to occur. This stretching, and suturing under "tension," is now often blamed for a rather large amount of post-operative pain, and long recuperation period, maybe 6 weeks. The stretching is also blamed for thinning the tissues and making them susceptible to allowing another hernia.


The McVay repair, which is a kind of "Cooper's Ligament Repair," involves similar stretching of tissues and attaching them to Cooper's ligament instead of to the inguinal ligament, as is done in Bassini and Shouldice repairs. Cooper's ligament, from what I can figure out, is something that provides an attachment for the pectineus muscle of the thigh, to the pelvic bone, and it extends from the surface of the pelvic bone. It extends from the periosteum of the pelvic bone, near the inguinal ligament — to I'm not sure where. This repair is said to have a lower rate of recurrences than the Bassini repair.


Repair developed 1871. This is said to involve only simple suturing of any stretched or torn tissues that allowed the hernia to occur. It is used in babies and young children, where the hernia is more the result of abnormal development, than of injury to tissues, and where the regenerative ability of tissues is greater.


This is said to be a modification of the Bassini repair, that involves less stretching of tissues. A similar incision is made. The external oblique is incised in the same manner. The cremasteric is divided similarly. The transveralis fascia is incised from internal ring to pubic tubercle and separated from the layer of peritoneum underneath it. Then, there is a specific, complex protocol of overlapping one tissue with another, and making 4 sutured-together, overlapped seams, that eventually bring the tissues over to where they can be secured to the inguinal ligament. This is in contrast to the Bassini repair, where the 3 layers underneath the external oblique are merely pulled and stretched until they reach the inguinal ligament, rather than overlapped. The overlapped seams of the Shouldice repair are fastened with 2 long pieces of monofilament suture material, often fine stainless steel wire, rather than with numerous interrupted sutures. The external oblique aponeurosis is also involved in the Shouldice protocol, as well as the internal oblique, transversus abdominus, rectus abdominus, and transversalis fascia.

I've tried to come up with a brief simplification of what is sutured together, in 4 seams, with the 2 lengths of monofilament suture material; I cannot say I know this description is entirely correct. However, they way I have it figured, after the transversalis fascia is incised from internal ring to pubic tubercle, the patient is put back together sort of as follows, using one length of suture material for steps 1 and 2, and second length of suture material for steps 3 and 4::

  1. The lateral flap of transversalis fascia is folded back and the lateral edge of the medial flap of the transversalis fascia is sutured to the underside of the lateral flap.The proximal stump of the cremaster is included, at the internal ring, to strengthen the repair.
  2. The naturally occuring lateral edge of the internal oblique is sutured to the medial edge of the lateral flap of the transversalis fascia, whilst both are sutured to the inguinal ligament.
  3. The lateral flap of the external oblique aponeurosis is folded back and its undersurface is sutured to the outer surface of the internal oblique, along a line a few centimeters medial to its lateral edge.
  4. The lateral flap of the external oblique, along a line slightly medial to the last line, is again sutured to the outer surface of the internal oblique, along a line on the internal oblique slightly medial to the third line.

After the lower layers are overlapped and fastened, the distal stump of the cremaster is sutured to the medial end of the inguinal ligament. This prevents ptosis of the testicle and scrotum on the side of the body that has been repaired. Then, the spermatic cord is returned to its normal anatomic position, and the lateral edge of the medial flap of the external oblique, and the medial edge of the lateral flap of the external oblique, are "reapproximated" and sutured back together, same as with the Bassini and McVay repairs. Thus the cord will be sort of normally situated underneath a layer of external oblique, and above the now complexly overlapped layers of external oblique, internal oblique, transveralis fascia, and transversus abdominus.

The operation is said to result in fewer recurrences than either Bassini or McVay repairs, and four reasons are postulated. (1) The tissues are not stretched, and thinned, as much, during the operation; their strength is not reduced by the operation. (2) By being overlapped they form scar layers rather than scar lines. A scar layer, as compared to a scar line, is thought to be stronger and more resistant to the stretching effect of intra-abdominal pressure. Thus the tissue is less likely to be pulled apart at the seams by intra-abdominal pressure, and less likely to be stretched thinner, and made weaker, by intra-abdominal pressure. (3) None of the sutures goes all the way through all the layers, at any one spot, as they do in the Bassini repair, in spot after spot. That is, the suture holes don't align. Aligned holes are said to create a week spot, where they align. (4) The cremaster muscle is completely divided in both the Bassini and the Shouldice, to create a distal stump and a medial stump, but only in the Shouldice, is the medial stump of the cremaster muscle used to reinforce the internal ring. (In both operations, the distal stump of the cremaster muscle is anchored to the medial end of the inguinal ligament, to prevent ptosis of the testicle at the testicle end of the cremaster muscle.)

There is an good video of the surgery, with an good explanation of the procedure, here. It show Dr. Francis Christian teaching the procedure to surgical residents, at the University of Saskatchewan, Saskatoon, Canada.


This is pure tissue repair that resembles the Lichtenstein mesh repair in its simplicity. The creator claims here, and here, that results are about equal to Shouldice and Lichtenstein repairs in low frequency of complications and recurrences. Like the Lichtenstein repair, the Desarda repair is remarkable in its simplicity and my first thought upon understanding the basics of the operation was: why didn't someone think of this before?

The external oblique is incised similarly to the way it is done in the other anterior approach repairs. The spermatic cord is dissected free the same way it is done in all the other anterior approach repairs. The sac are dissected free as usual and generally cut away. The herniated organs are returned to the abdomen as usual.

The lateral edge of the medial flap of the external oblique aponeurosis is sutured to the inguinal ligament, behind the spermatic cord. Then the medial flap of the external oblique is incised again, a few centimeters above the inguinal ligament, simultaneously creating (1) a new lateral edge to the medial flap, and (2) a "strip," or in my words a patch, made out of a strip of external oblique that is several centimeters wide. The medial edge of this "patch" is sutured to the internal oblique. The result is that a "patch" of external oblique aponeuroses is in place behind the spermatic cord, similarly to the way a Lichtenstein patch would be in place behind the spermatic cord. The difference is, that (1) this is a patch of living tissue and (2) this strip of external oblique aponeurosis is still attached normally to the external oblique muscle and contractions of the external oblique muscle have a dynamic affect on countering intra-abdominal pressure, rather than merely static effect that the non-living patch used in a Lichtenstein repair, would have.

The new lateral edge of the medial flap is sutured to the original medial edge of the lateral flap, above the spermatic cord -- that is, the external oblique is closed similarly to the way it is closed in Bassini, McVay, and Shouldice repairs. However it is the newly created lateral edge of the medial flap that is being used, instead of its original lateral edge; the original lateral edge of the medial flap has previously been sutured to the inguinal ligament. Thus, when the operation is completed, there are 2 layers of external oblique: one under the cord and one above it, instead of only one layer, above the cord, as in normal anatomy, and as in Bassini, McVay, and Shouldice repairs.

There is a really excellent video of the procedure, here.

Guarnieri Repair

More on this later. See this.


Mesh Repairs, Anterior Approach

Lichtenstein, Rutkow Plug&Patch, Prolene Hernia System, Moran repair


This went into high gear around 1986. Before its development most hernia repairs in adults were pure tissue repairs. Afterward a number of year of trying various combinations of mesh plugs and patches, surgeons began settling on the Lichtenstein method, and a rapid changeover from non-mesh methods, to the Lichtentein method, ensued. It may still be the most popular mesh method.

It uses a 7 or 8 centimeter incision. Dr. Amid, who worked with Dr Lichtenstein (now deceased) to develop the repair, and who may be considered the foremost living proponent of the Lichtenstein repair, reports that he is meticulous about identifying nerves and preserving them, and that it is important to do so. This is in contrast to plug-and-patch proponent Ira Rutkow, who stated that he ignores nerves. After the hernia sac is freed and the herniated organs reduced, a piece of flat polypropylene mesh, about 10 centimeters long by about 4.5 centimeters wide, is placed between the external oblique and internal oblique. A slit is made in the mesh to create two tails, which are wrapped around the spermatic cord where the cord emerges through the internal inguinal ring. The tails are overlapped. The mesh is held in place with about 8 sutures. This seems to be sufficient to hold the hernia back.

The mesh is monofilament polypropylene. It is a loose knit (not a weave). The body's natural reaction to polypropylene is to sequester it by forming a layer of non-vascular scar tissue around it. The result of implanting a layer of mesh is a layer of scar tissue with mesh embedded in it.

The hypothesis frequently presented, to account for how the mesh holds back the hernia, is a little puzzling. The mesh stimulates and promotes scar tissue development. The scar tissue is said to be a desirable post-operative response, a required post-operative response, if the operation is going to prevent re-herniation — because only with the development of this scar tissue is the area sufficiently strengthened to prevent re-herniation of organs. The kinds of knits that are used have a specific size of their spaces, or pores, between the filaments. These pores, are said to be "just the right size" to maximize the tissue ingrowth (of scar tissue) which is said to be necessary to hold back the hernia. Yet, at the same time, the mesh is said to be strong enough to hold back the hernia, even without the ingrowth of scar tissue, and that it is necessary that it be strong enough, because tissue ingrowth takes a while. They can't seem to make up their mind what holds back the hernia, the mesh, or the tissue ingrowth. The amount of tissue ingrowth varies from person to person, sometimes quite a lot, and can take months to develop.

Either way, this tissue ingrowth makes removing the mesh a much bigger operation than putting it in. I see this as a major disadvantage. Also, a 20-year old person may live 90 years after having such mesh implanted. What will happen to the mesh 90 years from now? There is no data from 90 years ago, to inform us. There is little or no data from 18 years ago or longer. No-one can tell us for sure what will happen 20 years down the road, much less 90 years. This, combined with the fact that removing mesh is difficult, and removing broken down, disintegrating mesh is would likely be even more difficult, makes me wary of having mesh placed in me. Imagine living to 100, and then finding out that you need major surgery to remove deteriorating mesh. The presence of a foreign body means that surgeons must increase their attention to infection control during and after surgery.

Prolene Hernia System

This procedure may be performed using a 5 centimeter incision, smaller than that used for a Lichtenstein repair. Here is a description of the mesh that is used. The kind of polypropolene filaments, and the kind of knit, are similar, or identical, to the that used in the mesh used for a Lichtenstein repair, only they are knitted into a 3-dimensional form, rather than a flat sheet. The 3-dimensional form consists of: 2 flat sheets, an "underlay" sheet, and an overlay sheet; and a central connector which is cylindrical, 1.27 centimeters long, and 1.9 centimeters in diameter.

There underlay sheet is placed just below the transversalis fascia (which is the lowest or most posterior layer of the abdominal wall) and above the peritoneum. The area where it is placed is sometimes called the pre-peritoneal space. There may be lots of fatty tissue here. Tissue ingrowth occurs and the underlay sheet becomes adherant to the transversalis fascia, which may strengthen the transversalis fascia. The mesh may also adhere to the peritoneum, preventing normal "slipping" of the peritoneum past the abdominal wall. This is not thought to be a problem, because the organs can still slip back and forth along the peritoneum on the the other side of the peritoneum. But it can make removing the mesh exceedingly difficult, should it ever need to be removed. However the presence of an infection tends to make the mesh easier to remove, and infection is the most frequent reason for removing the mesh.

The central connector occupies the defect in the abdominal wall, which allowed the hernia to occur. It doesn't completely fill up the defect, but it does prevent the PHS from migrating.

The overlay sheet, identical to the sheet used in a Lichtenstein repair, is placed between the internal oblique and external oblique, exactly the same way the mesh used in a Lichtenstein repair would be placed. It may not need quite as many sutures since the central connector prevents migration. Sutures will be needed, however, to prevent rotation of the PHS, around the longitudinal axis of the cylindrical central connector. Although a "velcro" effect of the mesh also helps prevent such rotation.

Only the overlay mesh and perhaps the central connector, are sutured. Because the PHS is a one-piece unit, if the overlay is held in place, then the underlay mesh can't go anywhere either.

The manufacturer of the PHS believes that the pre-peritoneal mesh is better for holding back hernias than mesh placed between the internal oblique and external oblique.

Rutkow Plug and Patch (or sometimes just plug)

Dr. Ira Rutkow uses epidural anesthetic; he uses a 5 centimeter incision. In contrast to Dr. Amid, who says it is important to identify and preserve nerves, Dr Rutkow completely ignores nerves, saying it makes no difference if you find them or don't find then, and makes no difference if you cut them or don't cut them. Dr. Amid, however, has popularized an operation he calls a "triple neurectomy," which he uses to treat patients who have chronic pain from previous hernia surgery, of any kind.

After the sac is freed from its adhesions and its contents reduced, the sac is returned to the abdominal space and a polypropylene mesh plug consisting of many "petals" of mesh is inserted into the defect that allowed the hernia to occur, or that was created by the surgeon in the process of completely freeing the sac from all adhesions outside the abdominal space, and returning it to the abdominal space. This plug prevents the sac from re-herniating. For an indirect hernia it is placed well down into, and underneath, the internal ring. For direct hernia — also — well into the pre-peritoneal space. Petals are removed from the plug according to the size of the defect that the plug has to occlude, according to the surgeon's judgment. The plug is sewed in place with 6 to 8 sutures around its circumference. Then a patch, same as a Lichtenstein patch, except that it is not sutured in place, is added for first-time hernias. The patch causes scar formation and "prevents recurrence." It does not need to be sutured because it does not have to hold back any hernias right away. There is plenty of time for tissue ingrowth to fix it in place, before a recurrent hernia, near to the first hernia but not in the same exact spot, which is now occluded by the plug, is likely to show up, and try to squirm its way out. The patch is only there "as insurance" against a nearby hernia occurring at a later date.

Moran repair

This is similar to a Shouldice repair. Generally, suture lines 1 and 2, as described above in the Shouldice section, are used, but suture lines 3 and 4 are left out. A small piece of mesh is placed underneath the posterior wall, in addition. It is sutured in place when the 2 flaps of transversalis fascia that have been created by cutting it from internal ring to pubic tubercle, are overlapped according to the Shouldice protocol, and sutured together according to the Shouldice protocol. Polypropylene or Goretex is used.This piece of mesh is slightly smaller than that used for a Lichtenstein repair.


Mesh Repairs, Posterior Approach

Laparoscopic Repairs

Several small holes are made in the abdomen, usually at least three, away from the site of the hernia. The abdomen is blown up with air or carbon dioxide. A tiny television camera, and tools, are inserted through the holes. While watching a TV screen, the surgeon uses the tools to afix a piece of mesh where it is needed. Usually helical pieces of titanium wire are used to hold the mesh in place, instead of sutures, which I supposed would be impossible to tie using the kinds of grasping tools that are available for pushing through holes in the abdomen and using inside the abdomen.

Whether you have a single inguinal hernia repaired, laparoscopically, or have bilateral inguinal hernias repaired at the same time, laparoscopically, you will have at least 3 small incisions. One of them will be at least 10 millimeters long, the other two will each be at least 5 mm long. This totals about 20 mm or more of visible entry-wound scars, resulting from the incisions. If you have a single inguinal hernia repaired with a "mini-incision" anterior-approach repair (Plug & Patch or Prolene Hernia System) you will have a single incision about 50 mm long. If you have bilateral hernias repaired, with a mini-incision anterior approach repair, you will have a total of about 100 mm of scar. So the externally visible scarring for a lap repair is considerably less, if you have 2 (bilateral) ingunal hernias reparied at once, but the difference is not really a lot, if you are talking about repairing one hernia.

While the external "entry wounds" used for the laparascopic instruments may be slightly smaller for a lap repair, than for an anterior approach repair, from the reports I am hearing from patients who have had lap repairs, I have my doubts as to whether the overall trauma of a lap operation is less than that of an anterior-approach mesh operation or Shouldice operation. Since the instruments are inserted into the abdomen a distance away from where the hernia is, the surgeon has to "blaze a path" from the insertion point of her instruments, to where the hernia is. This page has a picture on top that will give you an idea of how much of a path has to be made. This appears to be somewhat traumatic. Your abdomen is insufflated with with gas, often with initial help from a "balloon dissector." More details are here; look at the fifth picture from the top, under the heading "Step 2, Creating the Pneumo-Pro-Peritoneum." This procedure stretches the muscle and skin of the abdomen — according to the picture, it appears to be quite a bit. It also compresses the intestines quite a bit. Many patients are reporting that they suffer considerable pain from this distension of their tissues, for days, or weeks, after their surgery. Presumably, the muscles and skin are often stretched enough to cause enough damage to the tissues — and to cause postoperative pain.

While a lap repair gives less external signs of invasion, I have my doubts as to whether a lap repair is really, overall, less invasive than an anterior approach repair. It seems that the internal or "hidden" trauma, if taken into account, may make a laparoscopic repair just as traumatic, if not more traumatic, than an anterior approach repair.

Trans-Abdominal Pre-Peritoneal (TAP)

The peritoneum is pierced where the tools go in, then pierced again by the same tools, in the other direction, where the hernia is.

Totally Extra-Peritoneal (TEP)

The tools never pierce the peritoneum. After the tools are pushed in, the tools are pushed along the outside of the peritoneum, between it and the inner abdominal wall, until they reach the site of the hernia.


Kugel Patch

A specially designed polypropylene mesh patch is used. If it is rolled up, and then let go, it will become flat again by itself. This is because it has a ring around its circumference that makes it flatten itself out. This enables it to be put in place via a posterior approach, without the aid of laparascopic instruments.

Only one small incision is needed. About 3 or 4 centimeters long. The incision is a few centimeters higher up on the abdomen than that used for an anterior approach. The hernia sac is freed and its contents reduced, through this incision that is near, but not right over, the hernia. Then the patch is inserted. It is held in place with only one suture.

The patch has about the same surface area as a Lichtenstein patch but has 2 layers of patch material and an outer "memory" ring. There is a lot more material implanted than with a Lichtenstein patch. The incision is rather smaller generally. Even smaller than the incision used for a plug and patch repair, or for the Prolene Hernia System.


Comparison of Methods

The proponents of putting mesh in the "pre-peritoneal" space, below the weakened tissue that allowed the hernia to occur, as in lap repairs, Kugel repairs, PHS repairs, and Moran repairs, believe that their repair method is stronger and more reliable than putting the mesh above the weakened tissue, as in a Lichtenstein repair, and stronger and more reliable than "pluging the hole in the barrel," as is done in a Plug&Patch repair. They compare the abdominal wall to the wall of a barrel, and say that if the patch is placed "inside the barrel," then intra-abdominal pressure tends to seal the "hole in the barrel." They say that if the patch is placed outside the hole, or in the hole, that intra-abdominal pressure tends to lift the patch off the hole in the barrel, or push it out of the hole, reducing the quality of the seal. Proponents of the Lichtenstein repair say that while a pre-peritoneal patch may be stronger, their method is more than strong enough, so strong that the number of recurrences is just as low as with pre-peritoneal repairs, and that extra trauma involved in getting the patch below the defect, does not reduce the incidence of recurrent hernias. Indeed, statistics have usually not shown a significant reduction in recurrences, for preperitoneal repairs, as compared to Lichtenstein repairs. Also, proponents of Lichtenstein repairs say that the sealing of a barrel is not the best analogy, since a barrel is a relatively static system, and an abdomen is a dynamic system, with several mobile layers of tissue, wherein increases in intra-abdominal pressure, are countered by changes in the muscle tone, and tissue position, of the tissues of the abdominal wall, that respond to the increase in pressure.

Proponents of mesh repairs say that the foreign body reaction caused by mesh is rarely a problem, and that as far as we know, mesh repairs will last indefinitely. Proponents of pure tissue repairs such as Shouldice repairs say that long-term outcome of mesh repairs are unproven, as there simply has been little or no data collected on the long-term outcome, since only a small number were done before 1986. While mesh seems to last at least 18 years, young people may last 30 years, or 70 years, or 100 years. Further, mesh is hard to remove. Removing mesh causes much more trauma than putting it in. If there is a problem with mesh, it is hard to deal with. Re-doing a pure-tissue repair, if it is ever needed, is not an awfully lot more traumatic than the original repair.

James R Starling: " Despite the fact that it [polypropylene mesh] is essentially an inert material, occasionally a patient has a clinical immune response to the mesh.

Dr. Phillips: "It would be very helpful to identify those patients preoperatively because the consequences of this type of response can be tragic. The patients sometimes feel as though they are being tortured by their pain."

Current reports of post-op discomfort for non-mesh repairs have not increased, but persistant pain or discomfort has become more frequent since the increased use of mesh (since 1986). Perhaps 30% of all hernia patients report significant post-op pain, with 15% having pain that significantly interferes with their lives.

Nevertheless, there are studies that show no significant difference in chronic pain between patients with Shouldice repairs and patients with Lichtenstein repairs. Another study shows just slightly more chronic pain in the Lichtenstein group — 6 percent as compared to 4 percent.

One of the disadvantages of laparoscopic hernia surgery is that the incisions through which the trocars are placed, are far away from the area where the hernia was, and from where the mesh is placed to repair the hernia, and thus you can develop a new hernia, a trocar hernia at the incisions for the laparoscopic trocars. This is a kind of incisional hernia. In all anterior-approach mesh repairs, both the area of the original hernia, and the remainder of the area under the incision incision, are protected from re-herniation, by the mesh that is implanted.


Other Abdominal Hernia Surgery

Inguinal herniae are the most common kinds of abdominal herniae (and they are more common in men than women) but they are far from the only types of abdominal herniae that plague beings with bellies. Surgery for incisional hernias and umbilical hernias may use different methods than those used for inguinal herniae.

Incisional herniae can occur just about anywhere, and their location can be near to or far from senstive structures.

The proximity of inguinal herniae to physiologically important structures, in men particularly — the vas deferens in men, the 3 nerves running in the area, and the pampiform plexus (a concentration of blood vessels) — makes inguinal hernia surgery, and especially inguinal hernia surgery in men, an an art unto itself. Yet it is common practice in may countries, for hernia surgery to be relegated to the youngest and least experienced surgeons, and for such surgeons to rely on this kind of surgery, for their livelyhood. The result is, that historically, a very high rate of recurrent hernias has occurred, among people who have had inguinal hernia surgery. Historically, something like 1 in 3 hernia repairs has resulted in a recurrence with 5 years. This has driven the medical community to push for changeover to surgery that is easy for novice surgeons to repair, and that results in much fewer recurrences, hence the rise of the Lichtenstein repair, and other mesh repairs. However the result of this, has been a definite rise of chronic pain syndromes, subsequent to inguinal hernia repair. As the problem of recurrent hernias have become something that is receding into the past, the problem of post-hernia-surgery chronic pain has become the problem of the present.

Incisional herniae and umbilical herniae, like inguinal herniae, can be reduced and repaired from either a posterior or anterior approach.

Pediatric hernias are another ball of wax.

End note links. Note that you may need to register to view some of these web pages.

Simplified overall anatomy
Excellent inguinal anatomy info
Good overview of history and development of inguinal hernia surgery
More descriptive info regarding hernia surgery options; detailed drawings
Drawings showing comparison of Bassini, Shouldice and Lichtenstein repairs

copyright 2004-2005 by Theodore Zuckerman
last update 2012 Feb 14


Methods of Inguinal Hernia Surgery in Adults

by Theodore Zuckerman written 2003, last updated 2013 Apr 04


Al Yankovic offers medical advise (clip is 8 seconds long)