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Inguinal Hernia

Mastering the Anatomy

Heidi J. Miller, MD, MPH

KEYWORDS
 Inguinal herniorrhaphy  Lichtenstein  TAPP  Anatomy  Bassini  Inguinodynia

KEY POINTS
 Success of inguinal herniorrhaphy is defined by low recurrence and complication rates
and relies on the surgeon’s knowledge and understanding of groin anatomy and
physiology.
 Open tension-free mesh repair remains the most common and gold standard repair of
inguinal hernias, building on knowledge and understanding of groin anatomy developed
throughout history.
 A standardized dissection of the myopectineal orifice, following anatomic landmarks,
allows for identification of all possible groin hernias and adequate mesh coverage of
defects.

INTRODUCTION

Inguinal hernias are a common problem that affect a large number of people around
the globe. This leads to a surgical disease of significant scope, with 20 million inguinal
hernia repairs completed annually worldwide, and in the United States more than
800,000 are completed by 18,000 surgeons across the country.1 The success of an
inguinal hernia repair is defined by the permanence of the operation while creating
the fewest complications at minimal cost and allowing patients an early return to ac-
tivity. This success relies and depends on the surgeon’s knowledge and understand-
ing of groin anatomy and physiology. This article reviews relevant anatomy to inguinal
hernia repair as well as technical steps to common repair techniques as they relate to
this anatomy.

GENERAL ANATOMY AND IMPORTANT STRUCTURES AND LANDMARKS


 External landmarks of the abdominal wall are used for all approaches to gain ac-
cess to the correct area of the groin for hernia repair. For open approaches, the

The author has nothing to disclose.


Department of Surgery, MSC 10 5610, University of New Mexico, Albuquerque, NM
87131, USA
E-mail address: hjmillermd@gmail.com

Surg Clin N Am 98 (2018) 607–621


https://doi.org/10.1016/j.suc.2018.02.005 surgical.theclinics.com
0039-6109/18/ª 2018 Elsevier Inc. All rights reserved.
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initial incision is based on external landmarks, and for minimally invasive ap-
proaches, the use of external landmarks helps guide dissection and prevent
complications. Take note of the anterior superior iliac spine (ASIS), the pubic tu-
bercle, and the inguinal ligament (Fig. 1).
 Layers of the abdominal wall
 From superficial to deep, the layers of the abdominal wall in the inguinal region
are skin, subcutaneous tissue, Scarpa and Camper fascias, external oblique
(EO) fascia and muscle, internal oblique (IO) fascia and muscle, transversus
abdominis muscle (TAM), transversalis fascia (TAF), preperitoneal fat, and peri-
toneum. Medially the rectus abdominis muscle is encased by the anterior
rectus sheath (ARS) throughout and the posterior rectus sheath above the

Fig. 1. The inferior epigastric vessels are important landmarks on the anterior abdominal
wall, particularly because of their risk for injury during laparoscopic trocar entry. The artery
arises from the lower medial aspect of the external iliac artery. The vein flows into the
external iliac vein just cranial to the inguinal ligament. The femoral nerve emerges from
within the substance of the psoas major muscle to be exposed directly under the tough
inguinal ligament. This view shows the upper portion of the adductor longus, as well as
the pectineus muscle. The latter overlies the obturator foramen (canal) and the obturator
externus muscle, through which penetrate the obturator nerve plus the obturator vessels
(not shown). Note also that the saphenous and femoral veins cross above the pectineus mus-
cle. (From Baggish MS. Basic pelvic anatomy. In: Baggish MS, Karram MM, editors. Atlas of
pelvic anatomy and gynecologic surgery. 4th edition. Philadelphia: Elsevier; 2016. p. 5–58;
with permission.)
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arcuate line (Fig. 2 shows cross-section of the layers and Fig. 3 shows the
layers in relation to the inguinal region).
 The TAF is the innermost fascial layer of the abdominal wall muscles. It has 2
laminal layers, the more superficial of which is vascular; the deeper layer is an
avascular plane that makes a beneficial dissection plane into the preperitoneal
space (Fig. 4 shows the separation of these layers during a laparoscopic
dissection).
 Myopectineal orifice (MPO) (Fig. 5 shows anterior and posterior views of the
MPO and Fig. 6 is a laparoscopic view of the dissected MPO)
 The MPO was first described by Dr Henri Fruchaud in 1956 as a distinct area of
weakness in the pelvic region and is believed to have become weakened during
the evolutionary process as humans became bipedal, stood, and stretched this
area that already contained natural openings and areas of weakness.2
 The MPO is bordered by the conjoined tendon superiorly and Cooper ligament
inferiorly. The medial border is the rectus abdominus muscle and rectus
sheath, and the lateral border is the iliopsoas muscle. The MPO is divided
by the inguinal ligament, which runs diagonally from the ASIS to the pubic tu-
bercle. The suprainguinal space of the MPO contains the internal inguinal ring,
through which the spermatic cord penetrates the abdominal wall to course
through the inguinal canal and into the scrotum. This is the site of an indirect
inguinal hernia, which is a pathologic opening or weakness in the TAF, allowing
the peritoneum and its contents to bulge through the internal ring alongside the
spermatic cord or round ligament.

Fig. 2. Cross-section representation of the layers and musculature and the abdominal wall.
A, focus on the anterior abdominal wall below the arcuate line. B, above the arcuate line.
m, muscle. (From Morton DA, Foreman KB, Albertine KH. The big picture: gross anatomy.
New York: The McGraw-Hill Companies, Inc; 2011. Available at: www.accessmedicine.com;
with permission.)
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Fig. 3. Layers of the abdominal wall, focused in the groin. (From Krpata DM, Rosen MJ.
Open inguinal repair. In: Delaney CP, editor. Netter’s surgical anatomy and approaches.
Philadelphia: Elsevier; 2014. p. 341–54; with permission.)

 The inferior epigastric vessels run medial to this and create the third border of
the medial triangle or Hesselbach triangle, which is the area of development of
direct hernias.3 The Hesselbach triangle is defined by the inferior epigastric
vessels laterally, the rectus abdominus muscle medially, and the inguinal liga-
ment inferiorly. The subinguinal space is inferior to the inguinal ligament and
contains the opening for the femoral canal, allowing the femoral vessels to

Fig. 4. Laparoscopic photo of dissection planes between the posterior rectus sheath, TAF,
and peritoneum.
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Fig. 5. Anterior and posterior views of myopectineal orifice. (From Elliott HL, Novitsky YW.
Laparascopic inguinal hernia repair. In: Delaney CP, editor. Netter’s surgical anatomy and ap-
proaches. Philadelphia: Elsevier; 2014. p. 357; with permission.)

Fig. 6. Laparoscopic photo of the dissection MPO.


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pass through the abdominal wall and allowing for weakness in the TAF, espe-
cially in women, due to a wider pelvic shape.
 The entire MPO is vulnerable to the development of hernias because of the
normal anatomic gaps in the tissue to allow structures to pass out of the
abdomen into the lower extremities or pelvis as well as the aponeurotic nature
of the area, whereas the rest of the abdominal wall is covered with layers of
thick muscle.
 Iliopubic tract (IPT)
 The IPT is a thickening of the TAF that fans out laterally in the transversalis and
iliac fasciae. Medially it attaches posterior to the Cooper ligament and it runs
parallel and deep to the inguinal ligament.
 The IPT is an important landmark for the preperitoneal approach to inguinal
hernia repair, because it is the posterior divider of the MPO. It also provides
the superior border of the triangle of pain, providing clues for the prevention
of postoperative inguinodynia.
 The IPT is used in tissue reconstruction of the floor of the inguinal canal, espe-
cially in the Shouldice procedure.
 Conjoint tendon: fusion of the medial fibers of the IO aponeurosis (IOA) and the
transversus abdominis fascia, which then turns inferiorly to insert into the crest
of the pubis and the Cooper ligament4
 Inguinal ligament: fibrous band made of thickened folds of the EOA that extends
from the ASIS to the pubic tubercle; fibers of the inguinal ligament that pass later-
ally and attach to the pectin pubis form the Cooper ligament (pectineal ligament)
 Inguinal canal: the passage that transmits structures from the pelvis to the peri-
neum, formed by fetal migration of the gonad; it is approximately 4 cm long and
connects the deep inguinal ring (opening in the TAF superior to the inguinal liga-
ment and lateral to the inferior epigastric arteries) to the superficial inguinal ring
(V-shaped opening in the EOA, superior-medial to the pubic tubercle).
 Nerves1,5
 Nerves of the inguinal region arise from the lumbar plexus; they innervate
abdominal muscles and supply sensation to the skin and peritoneum. Inguino-
dynia is a common complication in inguinal hernia repair, and it becomes of
greater concern as techniques continue to be refined, implant technology im-
proves, and recurrence rates become very low. Injury or entrapment can cause
pain, and transection can lead to pain or numbness. It is often difficult to differ-
entiate somatic and neuropathic pain.
 The risk of chronic inguinodynia increases with the presence of preoperative
pain, younger age, open surgery, neurolysis, postoperative complications,
and high 7-day postoperative pain score.
 The incidence of severe chronic pain affecting quality of life, daily activities,
and ability to work has been found to be 0.5% to 6%.
 Both acute and chronic postoperative pain should be treated early with multi-
modal pharmacologic management. Diagnostic nerve blocks, exclusion of
meshoma or recurrence, and further work-up should be completed prior to
consideration of surgical intervention, which should not be undertaken earlier
than 1 year after original surgery.
 See Fig. 7 for a representation of the sensory dermatomes.
- Lateral femoral cutaneous nerve (LFCN)

 Root leaves L2/3 and enters the abdomen medial and caudal to the ASIS
and runs in the lateral fringe of the psoas muscle, either below or along
the IPT, and can have multiple subbranches.
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Fig. 7. Lower extremity anatomy: proximal innervation (peripheral nerves labeled on right
side of the body, dermatomes on the left). n, nerve. (From Brown DL. Lower extremity block
anatomy. In: Farag E, Mounir-Soliman L, Brown DL, editors. Brown’s atlas of regional anes-
thesia. 5th edition. Philadelphia: Elsevier; 2017. p. 89–96; with permission.)

 The LFCN supplies sensation to the upper lateral thigh


- Genitofemoral nerve (GFM)
 Arises from first and second lumbar nerves. Located centrally on the
psoas medial to the iliohypogastric nerve (IHN) and ilioinguinal nerve
(IIN). The genital branch of the GFM perforates the abdominal wall at
the IPT near and lateral to the internal inguinal ring. It runs within the cre-
masteric fascia with the external genital vessels. The femoral branch of
the GFM passes under the inguinal ligament to follow the external iliac
artery. Each branch has been found to have as many as 3 subbranches.
 The genital branch of the GFM supplies sensation to labia majora or the
cremasteric reflex.
 The femoral branch of the GFM supplies the skin over the femoral trian-
gle, anterior medial thigh.
- Iliohypogastric nerve (IHN)
 Can share a root with the IIN, leaving from T12/L1 and emerging in the
lateral edge of the psoas muscle, crossing the quadratus lumborum
muscle (QLM). The IHN enters the TAM at the iliac crest and branches
and then enters the IO above and in front of the ASIS. It then runs
deep to the EO just above the inguinal canal and penetrates the EO
within 1 cm to 2 cm cranial to the external ring.
 The IHN provides the sensory innervation of the suprapubic region
- Ilioinguinal nerve (IIN)
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 Leaves L1 and courses of the QLM then anterior to the iliacus muscle.
The IIN enters the TAM near the anterior end of the iliac crest and then
passes through IOM and moves into the inguinal canal anterior to the
spermatic cord and leaves through the external ring.
 The IIN supplies sensation to the skin at the root of the penis, anterior
third of the scrotum, anterior medial thigh, and labia majora
- Femoral nerve

 Root emerges from L2/3/4 lateral to the psoas muscle and travels below
the IPT laterally toward the femoral artery.
 The femoral nerve supplies motor function to the muscles of the leg and
sensory function to the skin of the inner thigh via the anterior cutaneous
femoral nerve
 Vasculature
 The external iliac artery is the arterial supply to the groin. The deep circumflex
iliac and inferior epigastric arteries branch off before becoming the common
femoral artery. The internal spermatic artery arises from the aorta. The obtu-
rator artery branches from the internal iliac artery and passes anteroinferiorly
on the lateral wall of the pelvis. In up to 80% of pubic rami, there is an aberrant
obturator artery that has an anastomosis with branches of the iliac or epigastric
arteries forming a ring that run directly on the Cooper ligament. This has been
named the corona mortis because significant hemorrhage can occur, with dif-
ficulty in obtaining control if the vessel is torn or cut. Although the presence of
this vessel is not uncommon, the incidence of injury from tacking and during
minimally invasive surgical (MIS) repair is rarely reported.6–8
 There are multiple venous plexi for drainage of the groin, including the panpini-
form plexus. These also can be clinically significant when injured and are inter-
twined with fatty tissues in the spermatic cord and preperitoneal space of
Retzius. It is injury or thrombosis of the panpiniform plexus that leads to testic-
ular atrophy after hernia repair.9

OPEN TISSUE REPAIR

Tissue repairs require in-depth understanding of the muscular and fascial anatomy of
the groin. At least 1 technique should be in a surgeon’s arsenal for patients who pre-
sent but are not candidates for mesh repair. The Bassini-Halsted repair was the gold
standard inguinal hernia repair for half a century. Bassini studied 262 repairs with no
mortality between 1885 and 1890, with a 1-year recurrence rate of less than 3%.10
McVay11 did a thorough study of groin anatomy and suggested additional steps in
the repair of inguinal hernias, recognizing Cooper ligament as a source of strength
for tissue closures. He also evaluated 580 of his repairs and showed a similar recur-
rence rate but with significant decrease in the rate after he started using Cooper liga-
ment for the posterior reconstruction.12
 Bassini repair10
 A 5 cm to 6 cm groin incision is made from the pubic tubercle laterally in the
Langer lines
 Expose the EO aponeurosis (EOA) and incise into the external ring.
 Identify and protect the IIN.
 Raise flaps of the EOA for approximately 3 cm to 4 cm above inguinal floor.
 Encircle the spermatic cord or round ligament, identify the hernia sac in the an-
teriomedial location, dissect the sac away from the other tissues, and reduce
the contents of the sac into the abdomen.
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 Suture ligate the hernia sac, if necessary the round ligament may be ligated
and transected.
 Assess and open the floor of the inguinal canal.
 Identify and assess the mobility of the conjoint tendon.
 Identify and clear the shelving edge of the inguinal ligament.
 Make a relaxing incision of the IOA or ARS for any tension.
 Suture the conjoined tendon to the shelving edge with interrupted permanent
sutures. It is possible to close the internal ring completely in women; it may be
closed tightly around the spermatic cord with enough space to pass a hemo-
stat or Kelly clamp. This may require an additional stitch lateral to internal ring if
the space is large.
 Close the EOA, scarpa’s fascia and skin in layers.
 McVay repair11 (Fig. 8)
 Follow steps 1-6 of the Bassini repair, as described above.
 Assess the floor of the canal, incise the TAF as well as any weak or attenuated
fascia, and identify the ipsilateral Cooper ligament.
 Make a relaxing incision in the ARS.
 Suture the conjoint tendon to the ipsilateral Cooper ligament with interrupted
permanent suture from the pubic tubercle to the femoral vein.
 The key transition suture includes a bite each of the Cooper ligament, conjoint
tendon, femoral sheath, and the shelving edge of the inguinal ligament.
 The internal ring is then reduced in size with lateral sutures as necessary.
 Close the EOA, scarpa’s fascia and skin in layers.
 Nerves most commonly injured during open repair are the IIN, IHN, and
g-GFN, most commonly during dissection. Neurectomy during open repair
does not reduce the incidence of chronic induinodynia. International guide-
lines recommend identification of all 3 nerves, thus reducing the risk to less
than 1%.5

Fig. 8. McVay repair. (From Krpata DM, Rosen MJ. Open inguinal repair. In: Delaney CP,
editor. Netter’s surgical anatomy and approaches. Philadelphia: Elsevier; 2014. p. 341–54;
with permission.)
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OPEN TENSION-FREE MESH REPAIR

The Lichtenstein hernioplasty has become the new gold standard inguinal hernia
repair. It can be done under local or general anesthesia, is easy to learn and repro-
duce, can be completed quickly, and has low recurrence and complication rates.
 Lichtenstein repair13 (Fig. 9)
 A 5-cm to 6-cm groin incision is made from the pubic tubercle laterally within
the Langer lines.
 Open the EOA and raise flaps approximately 3-4 cm above the inguinal floor,
taking care to avoid any underlying nerves.
- Visualize the iliohypogastric and ilioinguinal nerves.

 Separate the spermatic cord and cremaster muscle from the floor of the
inguinal canal and the pubic bone.
- The IIN, external spermatic vessels and the genital branch of the GFN

shoudl be included with the cord structures.


 Incise the cremasteric sheath in order to identify an indirect hernia sac, then
dissect the sac free of the cord structures and invert in the abdomen without
ligation of the cord.
- A large direct hernia sac can be inverted with absorpbable sutures.

- Large scrotal sacs can be transected if they are difficult to dissect out.

The proximal section should be suture ligated, and the distal section
kept open.

Fig. 9. Lichtenstein repair. (A, B) Mesh placement and recreation of the internal inguinal
ring. (C) Closure of the EOA to recreate the external inguinal ring. (From Krpata DM, Rosen
MJ. Open inguinal repair. In: Delaney CP, editor. Netter’s surgical anatomy and approaches.
Philadelphia: Elsevier; 2014. p. 341–54; with permission.)
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 Place a large 7 cm  15 cm mesh that overlaps the pubic tubercle by 1.5 cm -


2cm. Suture the mesh to the ARS superior to the pubic tubercle, avoiding the
periosteum.
 Continue to suture along the border of the mesh to the shelving edge.
- A femoral hernia can be repaired by opening the posterior wall to expose

the Cooper ligament, reduction of the hernia sac, and placing a suture
between the mesh and Cooper ligament.
 Slit the mesh laterally and position the cord structures between the two tails.
 Fixate the mesh to the conjoint tendon with 2 interrupted sutures, including the
ARS and IOA.
 Fixate the 2 mesh tails to the inguinal ligament and recreate the internal ring,
leaving 5 cm or more of mesh overlap lateral to the internal ring.
 Close the EOA, scarpa’s fascia and skin in layers.

MINIMALLY INVASIVE REPAIR

Laparoscopic inguinal hernioplasty was first described in the early 1990s and can be
completed from multiple approaches, including transabdominal preperiotoneal (TAPP),
totally extraperitoneal (TEP), or robotic TAPP. Laparoscopy in comparison with open
inguinal hernioplasty has been shown to have longer operative times, increased cost,
and longer learning curve but has the benefit of decreased immediate postoperative
pain and earlier return to work.14–17 Technical errors have been found, however, to be
the cause for recurrences and chronic pain, including insufficient mesh coverage and
inadequate dissection of the MPO.18 To reduce recurrence rates and chronic pain
complications, a recent description of a critical view of the MPO has been published.19
(see Fig. 6). Additional anatomic landmarks for MIS repair help identify potential downfalls
or danger zones of the dissection. The first is the triangle of doom (Fig. 10), which contains
the external iliac vessels and femoral nerve and is outlined by the vas deferens, gonadal
vessels, and peritoneal reflection. The triangle of pain (Fig. 11) contains at least the LFCN,
FN, and f-GFN and possibly other nerves, described previously, and is defined by the
gonadal vessels medially, the IPT superiorly, and the peritoneal reflection laterally.
 TAPP inguinal hernia repair
 Laparoscopic access is acquired by the surgeon’s approach of choice. Insuf-
flation is achieved and 3 ports are placed. Port placement is usually at the

Fig. 10. Triangle of Doom.


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Fig. 11. Triangle of Pain.

umbilicus, with bilateral ports placed approximately 10 cm lateral to the midline


and slightly cranial to the middle port (Fig. 12).
 The working space of Retzius is accessed via creation of a peritoneal flap. By
incising the peritoneum above the imaginary line between bilateral ASIS, nerve
injury during closure can be avoided.
 The dissection of the flap follows the preperitoneal space, separating the TAF
in the deep, avascular plane. This leaves the inferior epigastric vessels pro-
tected by the TAF and leads the dissection directly into preperiotoneal space
of Retzius.
 The medial dissection in the preperitoneal space at the midline leads into the
space of Retzius and to the pubic symphysis. This space is dissected across
the midline to expose the bilateral pubic tubercles and Cooper ligaments.
 The dissection is continued laterally from the midline to expose the Hesselbach
triangle in order to visualize a direct defect, if present. If a direct defect is iden-
tified the dissection should definitely be taken across the midline to expose the
contralateral Cooper ligament and allow adequate space for medial mesh
overlap.
 Further posterior dissection drops the bladder away from the Cooper ligament,
and allows for adequate mesh placement inferiorly and allows for inspection of
the obturator foramen.

Fig. 12. Internal pelvic landmarks.


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 Dissection between Cooper ligament and the iliac vein allows for visualization
of the femoral orifice to evaluate for a femoral hernia.
 Lateral dissection of the peritoneal flap is undertaken, following the preperito-
neal space, and sweeping the peritoneum inferiorly and laterally beyond the
ASIS. Care should be taken in the triangle of pain to avoid contact with nerves
or the body of the psoas muscle.
 The indirect sac is then dissected off of the cord structures, until they are pa-
rietalized. This dissection is not complete until the cord structures lie flat and
are free of movement with the flap is pulled upward. The psoas muscle and
iliac vessels should also be visualized during this step.
 The cord structures should be inspected as they leave the abdomen in order to
identify cord lipomas, usually found lateral to the cord elements. These should
be dissected out and can be used to cover the inferior border of the mesh
within the flap.
 Place mesh to completely overlap the MPO, securing as deemed necessary to
avoid mesh slippage or folding (Fig. 13). Most 10-cm  15-cm meshes are
adequate for coverage, although a larger mesh may at times be needed.19 Fix-
ation with tacks or sutures should be avoided below the IPT, along the psoas,
or caudal to the ASIS line to avoid injury to nerves. LFCN and IIN are the most
commonly injured nerves during MIS repair, either injured during lateral dissec-
tion or impinged with tacks if exposed medially to the ASIS. Fibrin glue has
been found to provide adequate mesh fixation with possible decrease in post-
operative chronic pain.20
 Closure of the peritoneal flap is undertaken, with suture, glue, or tacking,
ensuring that no penetrating fixation is placed inferior to the ASIS line.
 TEP inguinal hernia repair
 A skin incision is made near the umbilicus, allowing access to either side of the
linea alba and dissection down to the ARS. The ARS is incised and the rectus
muscle dissected bluntly, and a port is placed anterior to the posterior rectus
sheath.
 Access to the preperitoneal space is gained through blunt dissection, which
can be achieved with the aid of a balloon dissector. Following the posterior
rectus sheath inferiorly, the arcuate line is traversed. The TAF must be pene-
trated to enter the true preperitoneal space and access the space of
Retzius.

Fig. 13. Laparoscopic mesh overlapping the entire MPO.


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 Working ports are placed, frequently along the midline as the dissection takes
place. Insufflation of the preperitoneal space is achieved.
 The dissection proceeds in a similar fashion as a TAPP repair, and is described
in steps 4 to 11 above under TAPP inguinal hernia repair.
TAPP and TEP have been studied closely, and both have been found safe and suc-
cessful approaches to inguinal hernia repair. Some studies have shown increased risk
of bowel injury with TAPP and increased vascular injury with TEP. Any noted difference
in outcomes or complications, however, is likely more related to the type of hernia
repaired than the technique used.21 The rate of chronic postoperative pain is doubled,
however, with the use of more than 10 tacks during a TAPP repair.22

SUMMARY

Inguinal hernia repair is one of the most commonly performed surgeries in the United
States and around the world. Because of this, the complexity of both the anatomy
and the repair technique is often overlooked. An understanding of inguinal anatomy,
however, allows the surgeon to develop a full arsenal of approaches to this problem,
providing options for patient and surgeon depending on the situation.

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