Is polypropylene (Prolene) suture used continuously, and should it be placed medially rather than laterally when securing the mesh in inguinal hernia repair?

Prolene Suture Technique in Inguinal Hernia Repair

For inguinal hernia mesh fixation, polypropylene (Prolene) suture should be used in a continuous, non-locking running technique, and the mesh should be secured medially to the pubic tubercle and Cooper's ligament, with lateral fixation avoiding the "triangle of pain" to prevent nerve injury.

Continuous vs. Interrupted Technique

The evidence strongly supports continuous suturing with polypropylene:

• Continuous suturing distributes tension more evenly across the repair, reducing tissue ischemia and improving wound healing 1
• Historical data from 1,000 consecutive abdominal closures showed continuous monofilament polypropylene achieved only 0.4% dehiscence and 0.7% incisional hernia rates 1
• The continuous technique is simpler, faster, and more cost-effective than interrupted sutures 1
• Recent evidence confirms polypropylene is non-inferior to stainless steel wire for Shouldice repair, with 1.6% recurrence at 16 months follow-up 2

Medial vs. Lateral Placement

The mesh must be secured medially first, as this is the critical anatomical anchor point:

• Medial fixation to the pubic tubercle and Cooper's ligament provides the primary structural support for the repair
• The mesh should extend medially to overlap the pubic bone by at least 2 cm
• Lateral fixation must avoid the "triangle of pain" (bounded by the testicular vessels medially and the ilioinguinal nerve laterally) to prevent chronic neuralgia and vascular injury
• Lateral fixation, when needed, should be minimal and placed superior to the iliopubic tract

Technical Considerations

Use a non-locking continuous technique:

• Locking sutures create excessive tension points leading to tissue edema and necrosis 3
• Non-locking continuous sutures allow even tension distribution
• Start medially at the pubic tubercle and run laterally in a continuous fashion

Common pitfalls to avoid:

• Never place sutures lateral to the spermatic cord in the "triangle of pain" - this causes chronic groin pain
• Avoid excessive tension on continuous sutures - this compromises blood supply
• In contaminated fields (CDC Class III/IV), consider biological mesh instead of polypropylene due to 21% infection rates with synthetic mesh 4

The 2023 HerniaSurge guidelines update reinforces these principles for optimal groin hernia management 5.