What are the types of repair in direct inguinal hernia open approach?

Types of Repair in Direct Inguinal Hernia Open Approach

For direct inguinal hernias repaired via open approach, mesh-based repair using synthetic polypropylene mesh is the definitive standard technique, with the Lichtenstein repair being the most widely utilized method due to significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk. 1

Primary Repair Techniques

Mesh-Based Repairs (Standard of Care)

Lichtenstein Repair (Anterior Mesh Repair)

• This technique involves anterior reinforcement of the posterior inguinal wall (Fruchaud's floor) with polypropylene mesh placed in direct contact with the transversalis fascia and transversus abdominis muscle 2
• The mesh is stretched extensively over the weakened area and secured without tension, directly reinforcing the true barrier to abdominal pressure 2
• Mesh repair is strongly recommended as the standard approach for all non-complicated inguinal hernias, providing superior long-term outcomes even for small defects 1, 3
• Synthetic mesh use in clean surgical fields is associated with significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk 1

Plug and Patch Technique

• Involves placing a mesh plug into the hernia defect followed by an onlay mesh patch over the posterior wall 4
• This technique addresses both the defect itself and provides additional reinforcement of the entire inguinal floor 4

Preperitoneal Mesh Repairs (Open)

• The mesh is placed in the preperitoneal space, posterior to the transversalis fascia 1
• This approach is particularly useful when strangulation is suspected or bowel resection may be needed 1

Tissue-Based Repairs (Limited Indications)

Primary Suture Repair (Bassini, Shouldice, McVay)

• Reserved only for contaminated/dirty surgical fields with small defects (<3 cm) where bowel necrosis or gross enteric spillage has occurred 1, 3
• Associated with significantly higher recurrence rates (19%) compared to mesh repair (0%) 1
• Should not be used in clean surgical fields given the clear superiority of mesh repair 1

Surgical Field Classification Algorithm

Clean/Clean-Contaminated Fields (CDC Class I-II)

• Use synthetic polypropylene mesh for all direct inguinal hernias 1, 3
• Prosthetic repair with synthetic mesh is strongly recommended (Grade 1A) for patients with intestinal incarceration but no signs of strangulation or need for bowel resection 1
• Synthetic mesh can be safely used even with intestinal strangulation and/or bowel resection without gross enteric spillage, with no significant increase in 30-day wound-related morbidity 3

Contaminated/Dirty Fields (CDC Class III-IV)

• For defects <3 cm: Primary tissue repair without mesh 1, 3
• For defects ≥3 cm: Biological mesh is preferred when available 3
• If biological mesh unavailable: Polyglactin mesh or open wound management with delayed repair are viable alternatives 1, 3
• The choice between cross-linked and non-cross-linked biological mesh depends on defect size and degree of contamination 3

Mesh Selection Considerations

Standard Polypropylene Mesh

• Remains the gold standard for clean surgical fields with proven durability and low recurrence rates 1, 5
• Low-weight meshes with large pores decrease complications caused by synthetic material and reduce tissue tension 5
• Associated with excellent postoperative results, short hospitalization duration, and rapid socio-professional reintegration 5

Self-Gripping Mesh

• May result in less pain in the early postoperative phase (significantly larger pain reduction at 3 weeks: -10.6 vs -5.0) 6
• Significantly shorter operative time (mean 40 min vs 49 min for standard mesh) 6
• Critical caveat: Higher recurrence rates observed (5.5% vs 2.2%), though not statistically significant 6
• Does not affect chronic postherniorraphy pain at 1 year 6

Anesthesia Options for Open Repair

• Local anesthesia is recommended for emergency inguinal hernia repair in the absence of bowel gangrene, providing effective anesthesia with fewer postoperative complications 1, 7
• Open repair can be performed under local anesthesia in emergency settings, which is a significant advantage over laparoscopic approaches that require general anesthesia 1

Common Pitfalls to Avoid

• Never use tissue repair in clean fields: The significantly higher recurrence rate (19% vs 0%) makes this approach obsolete when mesh can be safely used 1
• Avoid high-weight, small-pore meshes: These increase complications and tissue tension compared to low-weight, large-pore alternatives 5
• Do not delay mesh placement in clean-contaminated fields: Synthetic mesh can be safely used even with intestinal strangulation and/or bowel resection without gross enteric spillage, with significantly lower recurrence risk regardless of defect size 1, 3
• Ensure proper mesh fixation: The mesh must be stretched extensively and secured without tension to prevent the "tent effect" in direct hernias 2