Laparoscopic inguinal and femoral hernia repair in adults

INTRODUCTION — The definitive treatment of most hernias, regardless of their origin or type, is surgical repair [1-4]. Laparoscopic groin hernia repair is increasingly popular because it offers the potential for less postoperative pain and a quick return to normal activities. (See "Overview of treatment for inguinal and femoral hernia in adults".)

However, the presence of certain relative contraindications to laparoscopic repair may mandate an open approach, including:

●Inability to tolerate general anesthesia

●Prior abdominal surgery

●Strangulated or incarcerated inguinal hernia

●Large scrotal hernia

●Ascites

●Active infection

As such, the surgical approach should be individualized on the basis of patient variables and surgeon skill set. 

Laparoscopic repair of inguinal and femoral hernias is discussed here. The classification and diagnosis of inguinal and femoral hernias, treatment approach, and other techniques are discussed elsewhere:

●(See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults".)

●(See "Overview of treatment for inguinal and femoral hernia in adults".)

●(See "Open surgical repair of inguinal and femoral hernia in adults".)

●(See "Robotic groin hernia repair".)

ANATOMIC CONSIDERATIONS — When performing laparoscopic inguinal or femoral hernia repair, the hernia defect is approached from its posterior aspect, and the repair involves placing mesh in the preperitoneal space (figure 1).

A clear understanding of the groin anatomy and its anatomic approaches is important for successful laparoscopic hernia repair (picture 1A-C). The general anatomy of the abdominal wall and groin region and the course of the nerves to the abdominal wall are discussed elsewhere. (See "Open surgical repair of inguinal and femoral hernia in adults", section on 'Anatomic considerations'.)

The concept of the "critical view of the myopectineal orifice" has been proposed as the appropriate exposure of the anatomical area that must be attained before placing mesh during laparoscopic inguinal hernia repair [5]. A series of steps are required before such a view can be achieved [6]. A scoring system based on this concept has been used for evaluation of laparoscopic inguinal hernia repairs [7].

In another publication, the concept of the "inverted Y" (picture 2), "five triangles" (picture 3), and dissection based in "three zones" (picture 4) establishes an effective and reproducible standardization of the laparoscopic inguinal hernia repair technique [8].

CHOICE OF LAPAROSCOPIC REPAIR — The anatomic approach to the preperitoneal space depends upon the laparoscopic technique preference for hernia repair. The two commonly used approaches to laparoscopic repair of inguinal and femoral hernias are the transabdominal preperitoneal (TAPP) hernia repair and the totally extraperitoneal (TEP) hernia repair approaches.

●TEP repair – TEP repair is performed in the preperitoneal space and was developed to avoid the risks associated with entering the peritoneal cavity [9,10]. The surgeon develops a working space between the peritoneum and the anterior abdominal wall so that the peritoneum is never violated. In experienced hands, this approach has the advantage of eliminating the risk of intra-abdominal adhesion formation [10,11].

●TAPP repair – TAPP repair involves the placement of mesh in a preperitoneal position, which is covered by peritoneum to keep the mesh away from the bowel. Because TAPP repair is performed transabdominally, it has a larger working space than TEP repair, with ready access to both groins, and can be attempted in patients with prior lower abdominal surgery. However, TAPP repair can result in injuries to adjacent intra-abdominal organs, adhesions resulting in intestinal obstruction, or bowel herniation [11,12].

Most patients — TAPP was the original laparoscopic approach, and TEP evolved to address some of the problems associated with TAPP repair, but TEP repair is technically more challenging because of the limited working space, which may explain higher conversion rates. Most surgical trainees in the United States learn TEP and TAPP repair. Outside of the United States, a TAPP approach may be more commonly used [13]. Although surgeons should learn both techniques, they should use the technique with which they are most familiar.

The 2018 international guidelines found comparable results of TEP and TAPP groin hernia repair in all aspects and hence recommended that surgeons choose a technique based on their skills, education, and experience [14]. A 2021 systematic review and network meta-analysis of 35 randomized trials comparing Lichtenstein, TEP, and TAPP repair of inguinal hernias reported no significant differences in hernia recurrence (relative risk [RR] 0.69, 95% CI 0.32-1.41), return to work/activities (weighed mean difference -0.31, 95% CI -1.73 to 1.31), or chronic pain (RR 0.99, 95% CI 0.42-2.33) between TEP and TAPP repairs [15].

Other studies comparing TAPP and TEP repairs show similar operative times (median 57 versus 62 minutes), similar degree of early postoperative pain [16], similar rates for overall complications (11 versus 13 percent) and recurrences, and similar incidences of specific complications such as seroma, scrotal edema, cord swelling, testicular atrophy, urinary bladder injury, and inguinal nerve lesions, as well as cost [14].

Access-related complications can differ: there is increased risk of visceral injuries during transabdominal entry with TAPP repair (0.6 versus 0.2 percent), while there is increased risk of vascular injuries (eg, inferior epigastric artery) during extraperitoneal entry and dissection during TEP repair (0.41 versus 0.28 percent) [17]. Port-site hernias were more common after TAPP repair (0.4 versus 0.026 percent), but the conversion rate in TEP repair was higher than in TAPP (0.47 versus. 0.26 percent) [13].

For laparoscopic groin hernia repair, the authors of this topic prefer the TEP techniques. However, individual surgeons should perform the laparoscopic technique that they are most experienced with, whether it is TEP or TAPP.

Special cases — Although both TEP and TAPP approaches are acceptable, one approach may be preferred to the other under specific clinical circumstances.

●Clinical scenarios favoring TEP approach:

•Intra-abdominal adhesions – TEP repair avoids the abdominal space; however, if the peritoneum is violated during the course of dissection, it is important to close the peritoneal defect to minimize adhesion formation.

●Clinical scenarios favoring TAPP approach:

•Prior lower abdominal surgery – In the face of prior preperitoneal pelvic dissection, it may not be possible to develop the proper exposure for TEP repair.

•Occult hernia – For patients in whom a groin hernia is suspected but has been difficult to confirm on imaging studies, a TAPP approach may offer a better view to determine the presence and location of the hernia. (See "Recurrent inguinal and femoral hernia", section on 'Occult hernias'.)

•Cost – The cost of using a balloon dissector to develop the working space is eliminated when the TAPP technique is used.

PREOPERATIVE EVALUATION AND PREPARATION — Preoperative evaluation and preparation prior to inguinal and femoral hernia repair, including thromboprophylaxis, antimicrobial prophylaxis, urinary retention prophylaxis, initial management of complicated hernia, and choice of anesthesia, are discussed separately. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Preoperative preparation'.)

Equipment — Appropriate instrumentation and supplies should be readily available and the proper functioning of laparoscopic imaging equipment verified prior to initiating anesthesia. An angled laparoscope, usually a 30° or a 45° scope, is used for these procedures, which allows for better visualization than a nonangled laparoscope. (See "Instruments and devices used in laparoscopic surgery".)

●10 or 5 mm 30° laparoscope

●Trocars – (2) 5 mm, (1) 10 to 12 mm

●Preperitoneal balloon dissector (eg, Spacemaker, Covidien), totally extraperitoneal (TEP) hernia repair only

●Polypropylene mesh, flat or preformed (eg, Bard 3D Max preformed mesh)

●Laparoscopic tack or strap applier (eg, Bard, Covidien, and Ethicon)

●Laparoscopic clip applier

Mesh for laparoscopic repair — Mesh is a necessary element of laparoscopic inguinal and femoral hernia repair to provide a tension-free hernia repair, which is the recommended method [18-20].

Polypropylene woven mesh (eg, Marlex, Prolene, SurgiPro) is the preferred prosthetic material used in essentially all studies describing laparoscopic hernia repair [21]. Expanded polytetrafluoroethylene (ePTFE, Gore-Tex) is another material that is used extensively for incisional hernias, but it has not been used for laparoscopic inguinal and femoral hernia repair except for the intraperitoneal onlay mesh (IPOM) technique. ePTFE provokes less of an inflammatory response, a process that is believed to be particularly important in inguinal and femoral hernia repair.

There are no direct trials comparing the two materials, and in the absence of data describing the use of ePTFE for TEP or transabdominal preperitoneal (TAPP) hernia repairs, we suggest using polypropylene mesh for laparoscopic inguinal and femoral hernia repair. (See "Reconstructive materials used in surgery: Classification and host response".)

Polypropylene mesh is commercially available in light, medium, or heavy weight. In a systematic review of patients who had laparoscopic inguinal hernia repair, the use of a lightweight mesh, as opposed to a heavyweight mesh, was associated with a lower incidence of chronic groin pain, groin stiffness, and foreign body sensation without any increased risk for hernia recurrence [22]. However, two other contemporaneous meta-analyses reported that lightweight and heavyweight mesh repair had similar outcomes in one [23] and that recurrence at 12 months was marginally increased in the lightweight mesh group in the other [24]. Two randomized trials published after the meta-analyses reported similar outcomes in terms of groin pain, foreign body sensation, and hernia recurrence with follow-up up to two years [25-27].

Preformed mesh that conforms to the preperitoneal space is available and is preferred by some surgeons over a flat piece of mesh that needs to be trimmed to accommodate the patient's anatomy. The particular product or the method used for placement is a matter of surgeon preference.

Patient positioning — The patient is usually placed in 15° to 20° Trendelenburg position to improve exposure of the working area, which is particularly important with TAPP hernia repair to move the small bowel away from the area of dissection.

TECHNIQUES FOR PRIMARY HERNIA REPAIR

Extraperitoneal exposure and dissection — The totally extraperitoneal (TEP) hernia repair avoids the peritoneal cavity by developing a plane of dissection in the preperitoneal space. The anatomy of the preperitoneal space and the location of the hernia defects are illustrated in the figure (figure 1). The TEP approach allows access to both groin regions and provides exposure of the inferior epigastric vessels, femoral vessels, pubic tubercle, Cooper's ligament, and spermatic cord.

Direct entry into the rectus sheath is via an incision just off the midline with blunt dissection to the linea semicircularis (figure 1). The anatomic landmarks for entry into the preperitoneal space are the median umbilical ligament and the hernia defect. The preperitoneal tissue is entered by establishing a plane between the posterior surface of the rectus muscle and the posterior rectus sheath and peritoneum (figure 2).

To dissect the preperitoneal space and obtain exposure:

●Make an infraumbilical incision contralateral to the hernia, which increases the distance between the incision and the hernia, and incise the anterior rectus sheath transversely. Retract the rectus muscle laterally to allow a 10 mm blunt trocar to be placed (figure 3) through which a dissector can be used to develop the preperitoneal space under direct vision using an angled laparoscope (figure 4). Alternatively, a balloon dissector can be used to expand this potential space (figure 5).

●Bluntly dissect the preperitoneal space in the avascular plane between the peritoneum and the transversalis fascia. Avoid the use of electrocautery during the dissection as this can lead to nerve injury [28].

●Identify the course of the epigastric artery and vein, and try to maintain their position anteriorly against the abdominal wall. Occasionally, the balloon dissector may develop the wrong plane and will dissect the epigastric vessels or rectus muscle fibers from the abdominal wall, which can make the remainder of the procedure more challenging.

●Once the preperitoneal space is dissected below the arcuate line, place two additional 5 mm trocars in the midline under direct vision (figure 3). Position one of these approximately 5 cm superior to the pubic symphysis. Place the other cannula midway between the umbilicus and the pubic symphysis. Some surgeons prefer to place these working cannulas lateral to the 10 mm umbilical trocar, contralateral to the hernia. Once the preperitoneal space is developed, insufflate the space through the 10 mm camera port.

●The iliopubic tract (inguinal ligament) is not as well seen with a TEP approach but can be felt at the lower border of the internal inguinal ring. Direct hernia sacs often reduce spontaneously during the course of dissection. Indirect sacs are more difficult to manage and can be quite adherent to the cord structures. To identify an indirect sac, trace the epigastric vessels toward their origin to identify the spermatic cord as it enters the internal ring (figure 6). Minimize dissection in the area of Cooper's ligament to avoid disrupting the venous circle of Bendavid, a venous network fixed to the abdominal wall in the subinguinal space, which can produce troublesome bleeding [29]. Avoid excessive dissection in the region of the femoral canal, which can be identified by tracing Cooper's ligament laterally. Lymph nodes in the femoral canal can produce bleeding, and excessive dissection can lead to the development of a femoral hernia.

●Take care in dissecting an indirect hernia sac to ensure the vas deferens and the testicular blood vessels are not injured. Often, a cord lipoma will also be removed during this process. Once a small (<1.5 cm) sac is mobilized, it should be returned back to the peritoneal cavity (figure 7). Larger indirect (>3 cm) sacs that are difficult to dissect and reduce may need to be carefully divided just distal to the internal ring, leaving the distal sac in situ within the inguinal canal.

●Some surgeons prefer to lower the insufflation pressure during a TEP procedure to reduce the chance of peritoneal CO₂ leakage. It is our preference to set the insufflation pressure to 12 mmHg and to maintain a low-to-medium flow rate (3 to 20 L/minute) rather than a high flow rate (40 L/minute). We feel that this will allow the surgeon to create and maintain an appropriate preperitoneal space to dissect and place the mesh safely.

Transabdominal exposure and dissection — As with most laparoscopic procedures, the peritoneal cavity is entered during transabdominal preperitoneal (TAPP) hernia repair. The major advantage of the posterior approach to groin hernias is that all three hernia defects (direct, indirect, and femoral) are well visualized and in close proximity to each other, allowing easy repair of any type of groin hernia.

To obtain exposure and dissect the preperitoneal space:

●Access the peritoneal cavity using standard techniques (eg, Hasson, Veress needle) above the umbilicus using a 10 mm cannula. Once access to the peritoneal cavity has been established, insufflate the abdomen and place two additional cannulas (5 mm) bilaterally in a horizontal plane with the umbilicus (figure 8). Access techniques for laparoscopic surgery are discussed in detail elsewhere. (See "Abdominal access techniques used in laparoscopic surgery".)

●Identify the median and medial umbilical ligaments, bladder, inferior epigastric vessels, vas deferens, spermatic cord, iliac vessels, and hernia defects (figure 1). Incise the peritoneum beginning at the lateral edge of the median umbilical ligament at least 4 cm above the hernia defect and extending 8 to 10 cm laterally. For patients with bilateral hernias, a single transverse peritoneal incision extending from one anterior superior iliac spine to another on the opposite side can be used rather than two separate peritoneal incisions. It is important to make the incision sufficiently above the hernia defect to allow dissection of 2 to 3 cm of normal fascia to provide sufficient mesh overlap after mesh placement.

●Develop the peritoneal flap in the avascular plane between the peritoneum and the transversalis fascia. Mobilize the peritoneal flap to expose the pubic symphysis, Cooper's ligament, iliopubic tract, cord structures, inferior epigastric vessels, and hernia spaces. Be careful to identify and avoid injury to the femoral branch of the genitofemoral and lateral femoral cutaneous nerves.

●Gently reduce a direct inguinal hernia from the preperitoneal fat using gentle traction. Indirect sacs should be mobilized from the cord structures and reduced into the peritoneal cavity (figure 9). A larger hernia sac that is difficult to mobilize from the cord without undue trauma to the vas deferens or vasculature to the testicle can be divided just distal to the internal ring, leaving the distal sac in situ within the inguinal canal. Sac division does not negatively impact patient outcomes compared with complete sac reduction [30].

Mesh placement and fixation — Although some surgeons support nonfixation of mesh, we suggest mesh fixation rather than nonfixation for laparoscopic hernia repair to avoid the complications associated with mesh migration and mesh shrinkage.

Stapling/tacking injuries to the nerves are the most common source of postoperative neuralgia following laparoscopic hernia repair. This complication should be suspected if severe groin pain develops in the recovery room and should prompt the surgeon to return to the operating room to remove the offending tack. Inadvertently entrapping or otherwise injuring a nerve can also lead to chronic pain. Although the nerves are essentially never seen during laparoscopic hernia repair except in the thinnest of patients, nerve injuries can be prevented by avoiding the known course of the nerves relative to points of mesh fixation. (See 'Anatomic considerations' above.)

Some surgeons feel that not fixing the mesh is the best way to avoid nerve injury and also avoids the costs of the staple and reduces operative time [31,32]. A systematic review of six randomized trials involving 772 patients compared mesh fixation with nonfixation [33]. An advantage was found for nonfixation in terms of length of hospital stay (mean difference [MD] -0.37, 95% CI -0.57 to -0.17 days), operative time (MD -4.19, 95% CI -7.77 to -0.61 days), and cost. There was no significant difference in hernia recurrence, time to return to normal activities, seroma, and postoperative pain. A later trial found similar outcomes but worse pain scores for staple fixation, but no differences in analgesic requirements [34]. However, in most of these trials, hernia size is not well defined, and mesh size/overlap and its relation to recurrence is often not controlled. Thus, it is conceivable that mesh fixation is critical with a smaller mesh but does not matter as much with a larger mesh. Additionally, although nonfixation appears to be safe in the short term, serious long-term complications can occur related to migration of the nonfixed mesh, such as erosion of the mesh into adjacent organs.

Thus, most surgeons continue to fix the mesh into place using staples, tacks, sutures, or fibrin glue, each of which appears to have similar outcomes with regard to the risk of recurrent hernia [35-38]. Metallic fixation devices (eg, Protak) provide greater fixation strength but can cause serious complications such as adhesion formation or tack erosion into hollow viscera [39]. Other devices (eg, AbsorbaTack, Permasorb, or SorbaFix) are bioabsorbable but provide less fixation strength over time. Compared with tacks, fibrin glue has been associated with less chronic groin pain when used to secure mesh during hernia repairs [40]. A systematic review and meta-analysis of 15 trials found lower incidences of chronic groin pain (risk ratio [RR] 0.36, 95% CI 0.19-0.69) and hematoma (RR 0.29, 95% CI 0.10-0.82) when using glue-based, as opposed to mechanical, fixation [41]. The incidences of seroma and hernia recurrence were similar.

In a 2022 retrospective study of 25,190 TEP and TAPP repairs from the Swedish Hernia Registry, standard polypropylene mesh without fixation and lightweight mesh with fibrin glue fixation were associated with the lowest hernia recurrence rate among all mesh/fixation method combinations [21].

Self-fixating mesh was proposed as a solution to the problem of mesh fixation, but three-year results of a randomized trial comparing self-fixating mesh with sutured mesh in open hernia repair demonstrated a twofold increase in hernia recurrence rate without a difference in the rate of chronic pain [42]. A randomized trial comparing laparoscopic TAPP repair using self-fixating mesh or fibrin glue-fixed mesh reported no difference in hernia recurrence or pain at three months [43].

Mesh placement for unilateral inguinal hernia repair is performed in a similar fashion for TEP and TAPP repair. Bilateral repairs using a single piece of mesh can be performed much more easily with a TEP approach because a single, large space is created, whereas with the TAPP approach, each space is separately created. To place and fix the mesh:

●Introduce a rolled-up 15 x 10 cm piece of prosthetic mesh into the preperitoneal space through the 10 mm umbilical cannula once the dissection is completed and the hernia sac reduced.

●The landmarks for fixation of the mesh are the pubic tubercle, Cooper's ligament, posterior rectus sheath, and transversalis fascia at least 2 cm above to the hernia defect.

●Position the mesh so that it completely covers the direct, indirect, and femoral hernia spaces (figure 10). Some surgeons slit the mesh longitudinally or vertically to accommodate the cord structures; however, we prefer to simply place the mesh over the cord after completely reducing the hernia sac.

●Do not tack or staple the mesh below the iliopubic tract lateral to the spermatic cord and the epigastric vessels, to minimize the chance of damaging nerves and vascular structures [8]. This area contains the "triangle of pain," which contains the lateral cutaneous nerve of the thigh and the femoral branch of the genitofemoral nerve, and the adjacent "triangle of doom," which contains the external iliac artery and vein defined medially by the vas deferens and laterally by the spermatic vessels (picture 3). We typically use three to four tacks for mesh fixation, one in the pubic tubercle, sometimes a second tack in Cooper's ligament, one tack at the superior edge of the mesh at the medial edge, and one tack at the superior edge of the mesh just lateral to the inferior epigastric vessels.

Closure — Following the fixation of the mesh, the inferior peritoneal flap that is developed during TAPP repair should be positioned over the mesh to isolate it from the peritoneal cavity using running sutures, staples, tacks, or a biological sealant. Avoid gaps when closing the peritoneum to minimize the likelihood of future small bowel herniation and obstruction within this space.

Once the hernia repair is completed, a long-acting local anesthetic (eg, bupivacaine) can be sprayed onto the preperitoneal space and surfaces for preemptive analgesia.

The ports are removed, and the preperitoneal space (TEP) or abdominal cavity (TAPP) is decompressed. The fascia at the 10 mm umbilical cannula should be sutured to reduce the chance for future incisional hernia. We use absorbable subcuticular sutures to close the skin incisions.

TECHNIQUES FOR RECURRENT HERNIA REPAIR — Recurrent inguinal or femoral hernia repair is discussed in a dedicated topic. However, the points pertaining to laparoscopic repair are highlighted here. (See "Recurrent inguinal and femoral hernia".)

Prior open repair — When a laparoscopic repair is chosen for recurrent inguinal hernia repair, either totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) repair can be used. The authors of this topic prefer the TEP repair. The technical details of TEP and TAPP hernia repair have already been discussed in detail (see 'Techniques for primary hernia repair' above). Several technical points for laparoscopic repair of a recurrent inguinal hernia deserve mention and are discussed here.

●The hernia sac may be difficult to reduce into the preperitoneal space because it often adheres densely to the mesh from the prior anterior mesh repair, particularly prior mesh plug repairs. In this setting, divide the indirect sac and seal over its proximal end using an endo-loop or clips.

●Be prepared to manage pneumoperitoneum. Peritoneal tears are more common than during repairs of primary hernias because of the dense adherence of the mesh to the peritoneum. Conversion to a TAPP procedure may become necessary. Often, a small tear in the peritoneum will require no intervention since this does not change the preperitoneal working space. In the event that the tear causes a pneumoperitoneum that affects the preperitoneal working space, the surgeon may need to surgically clip or suture the tear and/or place an angiocatheter to decompress the pneumoperitoneum.

●Carefully examine the femoral space for the presence of a hernia during the dissection since femoral hernia is more common with recurrent hernia than with primary repairs [44].

Prior laparoscopic repair — Dissection of the preperitoneal plane is often difficult after a previous posterior mesh repair. For that reason, an attempt at a repeat TEP repair will often result in a peritoneal breach, forcing conversion to a TAPP repair. For patients with prior lower midline or preperitoneal operations, either a laparoscopic TAPP repair with mesh or open anterior repair with mesh will be easier to perform with the ultimate choice of procedure depending upon the expertise of the surgeon. Although this has not been formally studied, this may represent an indication for robotic TAPP repair, but more data are required. In a patient who has not previously undergone an anterior repair, a tension-free anterior mesh repair would be preferred over a laparoscopic repair for a hernia recurrence after a prior laparoscopic repair.

POSTOPERATIVE CARE AND FOLLOW-UP — Most laparoscopic hernia repairs are performed as outpatient procedures with the patient returning home once recovered from anesthesia. If the patient develops severe groin pain in the recovery room, it may be a sign that a staple or tack has been inadvertently placed through a nerve and should prompt the surgeon to return to the operating room to remove the staple or tack. Postoperative pain is usually well controlled using nonsteroidal anti-inflammatory agents (NSAIDs), if not contraindicated, with or without low-dose narcotic agents. (See "Approach to the management of acute pain in adults", section on 'Options for managing postoperative analgesia'.)

Patients should be counseled to expect bruising and swelling in the groin. Follow-up in the office should be scheduled for two weeks postoperatively, in the absence of other problems.

There are few high-quality data regarding the timing of return to work or strenuous activity following laparoscopic hernia repair. Recommendations are tempered by the patient's pain tolerance. Patients can generally return to work 48 hours after a laparoscopic hernia repair if they are not required to perform heavy lifting or straining. If the patient is doing well without complications, they may resume any heavy lifting, straining, or exercise two weeks after laparoscopic hernia repair.

COMPLICATIONS — Complications of laparoscopic inguinal and femoral hernia repair include wound or mesh infection, seroma or hematoma formation, urinary retention, chronic groin pain, and hernia recurrence. These are discussed in another topic. (See "Complications of inguinal and femoral hernia repair".)

LEARNING CURVE — Compared with the learning curve of an open anterior groin hernia repair (about 60 cases or three years of experiences [45]), the learning curve for laparoscopic hernia repair is more prolonged.

●Totally extraperitoneal (TEP) repairs – On average, more than 100 TEP repairs are required to achieve outcomes comparable with those of open anterior mesh repair [14]. There is limited evidence that the learning curve may flatten after about 450 procedures [46].

●Transabdominal preperitoneal (TAPP) repairs – One study reported significant improvements in conversions and admissions after 50 cases, although the complication rate was still higher than that of open repair [47]. A different study reported reduction in operative time and recurrence rate after 200 cases, although the trainee had not reached the end of the learning curve at that point [48,49].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Groin hernia in adults" and "Society guideline links: Laparoscopic and robotic surgery".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Groin hernias (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Definitions – The two commonly used approaches for the laparoscopic repair of groin hernia are the totally extraperitoneal (TEP) hernia repair and the transabdominal preperitoneal (TAPP) hernia repair, which approach the hernia defect posteriorly. The drawback of the TAPP procedure is entry into the peritoneal cavity. The TEP procedure, developed to avoid the risks of entering the peritoneal cavity, is technically more challenging. (See 'Choice of laparoscopic repair' above.)

●Techniques – For most patients undergoing laparoscopic groin hernia repair, TEP and TAPP repair produce comparable results in all aspects, and hence surgeons may choose a technique based on their skills, education, and experience. (See 'Choice of laparoscopic repair' above.)

●Mesh choice – For laparoscopic inguinal and femoral hernia repair, we suggest using a polypropylene mesh (Grade 2C). Other types of meshes (eg, expanded polytetrafluoroethylene [ePTFE]) are rarely used for this purpose. The particular product (eg, light versus heavy mesh, flat versus preformed mesh) is a matter of surgeon preference. (See 'Mesh for laparoscopic repair' above.)

●Mesh fixation – For all laparoscopic groin hernia repairs, we suggest mesh fixation rather than no fixation (Grade 2C). Mesh fixation avoids complications associated with mesh migration and mesh shrinkage, although it can be associated with inadvertent injury if a tack or suture is placed into a nerve. (See 'Mesh placement and fixation' above.)