Embedded Files
Above is demonstrated the Marcy no-mesh repair, which can be a good option in certain young thin females (link to paper).
Here we present a selection of available operations for inguinal hernia repairs. We have grouped them based on the use of mesh. In general mesh is recommended by the surgical community. However we understand how some of our patients, after having done their own research, would prefer to avoid mesh implantation. We also offer several promising non-standard mesh repairs for select patients.
The Cober Method
The Cober Method
Developed by Dr. Cober, the Cober Method is not a novel surgical technique, but rather it is our adaptation of utilizing the currently available techniques developed by diverse surgeons and centers who all in their own right had exceptional experience and insight. The method rests upon the following tenets of hernia surgery:
The repair of hernias is a matter of quality of life and thus must aim for cure and minimizing risk of recurrence all while having low or zero tolerance for complications or chronic pain.
Less tension leads to less chance of recurrence and lower pain.
If there is tension, it should be patched to distribute and diffuse the tension.
The importance of permant sutures is less when there is good tissue overlap.
It is preferable to avoid the use of a foreign body if tissue-techniques can result in a similarly good outcome.
The least amount of anesthesia needed to achieve a comfortable experience is ideal.
For Inguinal Hernias
For Inguinal Hernias
Open repairs under MAC anesthesia are generally preferred (optimal health is desired -- good weight, fitness, health, and no smoking/toxic ingestions) due to simplicity, safety, and least invasiveness.
If there is an isolated femoral hernia:
Cober modification of Lockwood repair: medium-weight small mesh patch sutured to Cooper's, Inguinal, and Lacunar ligaments with permanent sutures with inner knots.
For direct and indirect hernias:
Goal 1: Restore normal anatomy
Indirect hernias are closed directly.
If there is only a small indirect hernia, a patch can be avoided with the use of a permanent suture.
Direct hernia options:
Close transversalis primarily with two layers, or
Shouldice first two layers.
Goal 2: Reinforce repair
If small indirect hernia with absorbable suture, patch with absorbable mesh or thin Desarda strip.
If large indirect hernia, patch with Desarda strip or mesh.
If small direct hernia with good tissue overlap, consider Desarda strip or light-weight mesh with Cober modification of Lichtenstein technique.
If large direct hernia, consider Desarda with permanent sutures or medium-weight mesh.
Cober modifications of popular techniques:
Shouldice: We often utilize the first two layers of a Shouldice repair as part of our restoration of normal anatomy and make the following modifications:
We do not divide the cremaster muscles.
We use prolene or PDS.
Desarda: We often utilize the technique as described most recently by Dr. Desarda but we make the following modifications:
If there was a large hernia or there is not excellent tissue overlap, we utilize permanent sutures to the inguinal ligament, and intermittently at the superior suture line.
If there was a large indirect hernia, we liberally apply lateral sutures to the inguinal ligament with permanent sutures.
Lichtenstein: We follow closely the Amid modification of the original description with the following modifications:
If there was a large hernia (especially a direct), we may utilize a medium-weight mesh.
We place permanent sutures to the inguinal ligament.
We place intermittent permanent sutures superiorly and especially medially.
We may trim the mesh tails based on nerve branch anatomy or with an inferior-based slit.
Our average mesh size is a bit smaller, about 6x12 cm.
Reference
Reference
Standard Mesh Repairs
Standard Mesh Repairs
Mesh repairs are considered the standard by most in the surgical community. Several hernia specialists however believe that mesh is overutilized in most hernias. In most studies, the use of mesh did not result in a statistically significant increase in chronic pain or complications. The use of mesh however was correlated with a lower recurrence rate (about 1-5%). There are rare cases of well-documented mesh-related illness due to uncommon immune reactions.
Open repair with mesh (Lichtenstein)
Benefits of this repair include not requiring general anesthesia and intubation. Furthermore, direct defects can be plicated safely (i.e. closed) prior to mesh patch placement. Meshes used can be light-weight or medium-weight (there is generally no need for heavy-weight meshes with this approach).
Laparoscopic repair with mesh (TEP)
Benefits of this repair include probably slightly less pain and routinely covering the femoral space. This approach does have a higher rate of complications such as hematomas. Furthermore, general endotracheal anesthesia is required, and the closure of direct defects is not performed due to inability to visualize the nerves from this approach. Meshes used are most commonly medium-weight with light-weigh options available.
Robotic repair with mesh (rTAPP)
Benefits of this repair include probably slightly less pain and routinely covering the femoral space. This approach does have a higher rate of complications such as hematomas and bowel obstruction. Furthermore, general endotracheal anesthesia is required, and the closure of direct defects is not performed due to inability to visualize the nerves from this approach. Meshes used can range from light-weight to medium-weight to heavy-weight depending on the anatomy encountered.
Standard Non-Mesh Repairs
Standard Non-Mesh Repairs
Many studies demonstrate that non-mesh repairs are comparable to mesh repairs. Therefore several hernia specialists believe that non-mesh repairs are equivalent when performed by experts (recurrence rates of 3-6%). Most agree that these repairs should either not be used or used with caution in patients with risk factors for recurrence (e.g. recurrent hernias, obesity, and smoking).
Shouldice
Benefits of this repair include a long track record from the Shouldice Clinic. This repair uses four layers to distribute the tension of a Bassini Repair resulting in superior outcomes. It does require opening the floor even in patients with intact floors.
Desarda
Benefits of this repair include less tension as a strip of external oblique is used to keep the conjoint tendon and inguinal ligament in connection. This more closely mirrors the tension-free Lichtenstein mesh repair whilst using a strip of physiologically active tissue in place of a mesh.
Non-Standard Non-Mesh Repairs
Non-Standard Non-Mesh Repairs
These repairs are not as well studied but show promise in preliminary research. Selection of one of these procedures requires a pre-operative ultrasound and more in-depth analysis prior to operation to assess for suitability. We expect recurrence rates to be consistent with non-mesh repairs, e.g. 3-6%. For these repairs we suggest local or light MAC anesthesia so the patient can cough after the repair to ensure stability.
Open high ligation
This is an application of the high ligation procedure to patients with small indirect inguinal hernias. This procedure does not require general endotracheal anesthesia. This approach may be coupled with Marcy or Lytle sutures to tighten the internal ring. Furthermore a light-weight absorbable mesh such as DuraSorb can be utilized to buttress the repair.
Kang repair
This appears to be a physiologically and anatomically sound repair which we expect to have comparably high success rates to the Shouldice repair but is more uniquely tailored to the actual hernia defect. This repair is currently as of 2026 only offered at the Gibbeum Hospital in Seoul. We expect this to become a standard option once it is replicated in studies by other surgeons and institutions.
Laparoscopic/robotic high ligation
For appropriately selected patients, this may be the least invasive procedure available in terms of pain and tissue dissection. This procedure, though requiring general endotracheal anesthesia, is the quickest procedure resulting in the least amount of time under anesthesia. This repair is adapted from pediatric hernia repairs for adults with similar hernia pathophysiology. Cord lipomas and direct hernias are unable to be addressed with this procedure, therefore we currently do not offer this.
Laparoscopic absorbable mesh (aTEP)
This procedure is equivalent to the standard TEP but utilizes an absorbable mesh. This requires general endotracheal anesthesia. We do not offer this to patients with direct hernias as we do not offer posterior defect closure due to inability to visualize the nerves from this approach.
General Decision Factors
General Decision Factors
Small, asymptomatic hernia → No surgery may be needed at this time ("watchful waiting")
Female → Consider Laparoscopic TEP or no-mesh repair under MAC anesthesia and rule-out femoral hernia
Bilateral hernia (left and right) → Laparoscopic TEP or robotic TAPP if large
Obesity / BMI > 40 (see calculator on page) → Robotic TAPP but ideally lose weight
Recurrent hernia → Approach the hernia from a different approach as to what was done initially
Previous lower abdominal surgery (e.g. prostatectomy) or pelvic radiation → Desarda / Lichtenstein
Age less than 40 → Consider Desarda / Shouldice / Laparoscopic High Ligation
Age greater than 70 → Lichtenstein
Small internal ring hernia with preperitoneal fat in a young thin female with intact floor anatomy; a Marcy repair with absorbable suture and DuraSorb (absorbable mesh) buttress was utilized here.
Here we discuss the success rate of inguinal hernia surgery. Generally these days, recurrence rates are quite low, and so our goal is to, while maintaining low recurrence rates, to refine our surgical outcomes and decrease post-op pain, minimize recovery, and lower the rate of chronic pain.
Google Sites
Report abuse