Inguinal hernia surgery

From Wikipedia, the free encyclopedia
Jump to: navigation, search
Open surgical repair of a right inguinal hernia

Inguinal hernia surgery is an operation to repair a weakness in the abdominal wall that abnormally allows abdominal contents to slip into a narrow tube called the inguinal canal in the groin region.

Surgery remains the ultimate treatment for all types of hernias as they will not get better on their own, however not all require immediate repair.[1][2] Elective surgery is offered to most patients taking into account their level of pain, discomfort, degree of disruption in normal activity, as well as their overall level of health.[1] Emergency surgery is typically reserved for patients with life-threatening complications of inguinal hernias such as incarceration and strangulation. Incarceration occurs when intra-abdominal fat or small intestine becomes stuck within the canal and cannot slide back into the abdominal cavity either on its own or with manual maneuvers. Left untreated, incarceration may progress to bowel strangulation as a result of restricted blood supply to the trapped segment of small intestine causing that portion to die.[3] Successful outcomes of repair are usually measured via rates of hernia recurrence, pain and subsequent quality of life.[4]

Surgical repair of inguinal hernias is one of the most commonly performed operations worldwide and the most commonly performed surgery within the United States. A combined 20 million cases of both inguinal and femoral hernia repair are performed every year around the world with 800,000 cases in the US as of 2003. The UK reports around 70,000 cases performed every year.[5] Groin hernias account for almost 75% of all abdominal wall hernias with the lifetime risk of an inguinal hernia in men and women being 27% and 3% respectively. Men account for nearly 90% of all repairs performed and have a bimodal incidence of inguinal hernias peaking at 1 year of age and again in those over the age of 40. Although women account for roughly 70% of femoral hernia repairs, indirect inguinal hernias are still the most common subtype of groin hernia in both males and females.[6]

Indications for surgery[edit]

Society guidelines recommend that indications for surgery take into account the severity of symptoms, the type of hernia, previous surgeries, hernia size, bowel incarceration and the overall general health of the patient.[4][1][7][8]

Non-urgent repair[edit]

Elective surgery is planned in order to help relieve symptoms, respect patient preference and prevent future complications that may require emergency surgery.[9][10]

Surgery is offered to the majority of patients in whom:[7][2]

  • symptoms interfere with their normal level of activity
  • hernias that become increasingly difficult to reduce
  • in females as it is often difficult to classify the subtype on exam alone.

Symptomatic hernias tend to cause pain or discomfort within the groin region that may increase with exertion and improve with rest. A swollen scrotum within males may coincide with persistent feelings of heaviness or generalized lower abdominal discomfort. The sensation of groin pressure tends to be most prominent at the end of the day as well as after strenuous activities. Changes in sensation may be experienced along the scrotum and inner thigh.[11]

Urgent repair[edit]

A hernia in which the small intestine has become incarcerated or strangulated constitutes a surgical emergency. Symptoms include:[9][3][11]

  • fever
  • nausea and vomiting
  • extreme pain in the area of the hernia
  • warm hernia bulge with surrounding skin redness
  • can no longer pass gas or stool

Surgical repair within 6 hours of the above symptoms may be able to save the strangulated portion of intestine.[2]

Contraindications to surgery[edit]

As with all medical interventions, patients should engage in shared decision-making with their physicians as almost all procedures carry significant risks. The benefits of inguinal hernia repair can become overshadowed by risks such that elective repair is no longer in a patient's best interest. Such cases include:[11][2][4]

  • Patients with unstable medical conditions
  • Repair using mesh is withheld in patients who have active infections within the groin or within the blood stream
  • Elective repair is delayed in pregnant women until 4 weeks after delivery

Additionally, certain medical conditions can prevent patients from being candidates for laparoscopic approaches to repair. Examples of such include:[9][2][4]

  • Patients unable to undergo general anesthesia
  • Prior major open abdominal surgery
  • Patients with ascites
  • Previous radiation therapy to the pelvis
  • Patients with a complex hernia

Surgical approaches[edit]

Techniques to repair inguinal hernias fall into two broad categories termed "open" (Tension repairs & tension free repairs) and "laparoscopic". Surgeons tailor their approach to each patient by taking into account factors such as their own experience with either techniques, the features of the hernia itself, and the patient's anesthetic needs.[9][11]

The cost associated with either approach varies widely across regions. As an example the UK's NHS spends £56 million a year in repairing inguinal hernias 96% of which were repaired via the open mesh approach while only 4% were done laparoscopically.[5] The cost associated with either technique has been studied by many countries and their respective hernia societies. Most have been able to show that open hernia repair provides the most value-to-cost as compared to laparoscopic repairs.[12][13][14][15][16] Factors such as the use of disposable surgical products, cost of addressing complications, as well as overall time spent in the operating room were examined in such studies. In contrast, updated guidelines published by the International Endohernia Society cast doubt on the comprehensiveness of such studies due in part to the complexity inherent in calculating costs across institutions. The IES asserts that hospital and societal costs are in fact lower for laparoscopic repairs as compared to open approaches. They recommend the routine use of reusable instruments as well as improving the proficiency of surgeons to help further decrease costs as well as time spent in the OR.[17]

Open hernia repair[edit]

All techniques involve an approximate 10-cm incision in the groin. Once exposed, the hernia sac is returned to the abdominal cavity or excised and the abdominal wall is very often reinforced with mesh[3] or tissues.There are many techniques that do not utilize mesh and have their own situations where they are preferable.[18][7]

Open repairs are classified via wether prosthetic mesh is utilized or whether the patient's own tissue is used to repair the weakness. Prosthetic repairs enable surgeons to repair a hernia without causing undue tension in the surrounding tissues while reinforcing the abdominal wall. Repairs with undue tension have been shown to increase the likelihood that the hernia will recur. Repairs not using prosthetic mesh are preferable options in patients with an above-average risk of infection such as cases where the bowel has become strangulated.[11]

One large benefit of this approach lies in its ability to tailor anesthesia to the patients needs. Patients can be administered local anesthesia, a spinal block, as well as general anesthesia.[9] Local anesthesia has been shown to cause less pain after surgery, shorter operating times, shorter recovery times as well as decrease the need for patients to go back to the hospital. However, patients who undergo general anesthesia tend to be able to go home faster and experience fewer complications.[19][20][2] The European Hernia Society recommends local anesthesia particularly for patients with ongoing medical conditions.[4]

Open mesh repairs[edit]

Polypropylene mesh used for inguinal hernia surgery
Inguinal Hernia Patch. Animation in the reference.

Repairs that utilize mesh are usually the first recommendation for the vast majority of patients including those that undergo laparoscopic repair.[4] Procedures that employ mesh are the most commonly performed as they have been able to demonstrate greater results as compared to non-mesh repairs.[11] Approaches utilizing mesh have been able to demonstrate faster return to usual activity, lower rates of persistent pain, shorter hospital stays, and a lower likelihood that the hernia will recur.[21][4][22][23][24][25]

Options for mesh include either synthetic or biologic. Synthetic mesh provides the option of using "heavyweight" as well as "lightweight" variations according to the diameter and number of mesh fibers.[26] Lightweight mesh has been shown to have fewer complications related to the mesh itself than it's heavyweight counterparts.[27] It was additionally correlated with lower rates of chronic pain while sharing the same rates of hernia recurrence as compared to heavyweight options.[28][29][30] This has led to the adoption of lightweight mesh for minimizing the chance of chronic pain after surgery.[11] Biologic mesh is indicated in cases where the risk of infection is a major concern such as cases in which the bowel has become strangulated. They tend to have lower tensile strength than their synthetic counterparts lending them to higher rates of mesh rupture.[31]

Biomeshes are increasingly popular since their first use in 1999[32] and their subsequent introduction on the market in 2003. Some meshes have a price comparable to the high end of synthetic meshes, the cheapest ($500) being Surgisis-Biodesign, manufactured by Cook Group, made from the extra cellular matrix of pig small intestinal submucosa.[33] Currently, there exists one synthetic totally absorbable mesh, Tigr Matrix, manufactured by Novus Scientific, on the US market (510(k) Food and Drug Administration clearance)[34] since 2010 and on the EU market since 2011. It only has one 3-year pre-clinical evidence on sheep.[35]

Meshes made of mosquito net cloth, in copolymer of polyethylene and polypropylene have been used for low-income patients in rural India and Ghana.[36] Each piece costs $0.01, 3700 times cheaper than an equivalent commercial mesh.[37][38] They give results identical to commercial meshes in terms of infection and recurrence rate at 5 years.[37]

Lichtenstein technique[edit]

The Lichtenstein tension-free repair has persisted as one of the most commonly performed procedures in the world. The European Hernia Society recommends that in cases where an open approach is indicated, the Lichtenstein technique be utilized as the preferred method.[4] Recent studies have indicated that mesh attachment with the use of adhesive glue is faster and less likely to cause post-op pain as compared to attachment via suture material.[39][40][41]

Plug and patch technique[edit]

The plug and patch tension-free technique has fallen out of favor due to higher rates of mesh shift along with its tendency to irritate surrounding tissue. This has led to the European Hernia Society recommending that the technique not be used in most cases.[4]

Other open mesh repair techniques[edit]

A variety of other tension-free techniques have been developed and include:[9][11]

  • Prolene mesh system (PHS)
  • Kugel (preperitoneal repair)
  • Stoppa
  • Trabucco (Hertra mesh)
  • Wantz
  • Rutkow/Robbins

Open non-mesh repairs[edit]

Techniques in which mesh is not used are referred to as tissue repair technique, suture technique, and then subdivided in tension technique and tension free technique. All involve bringing together the tissue with sutures.[9] [2][11]

Shouldice technique[edit]

The Shouldice technique is the most effective non-mesh repair thus making it one of the most commonly utilized methods.[21] Numerous studies have been able to validate the conclusion that patients have lower rates of hernia recurrence with the Shouldice technique as compared to other non-mesh repair techniques.[42] However this method frequently experiences longer procedure times and length of hospital stay. Despite being the superior non-mesh technique, the Shouldice method results much higher rates of hernia recurrence in patients when compared to repairs that utilize mesh.[4][42]

Bassini technique, first suture. 1. Aponeurosis musculi obliq. ext.; 2. Musculus obliquus internus; 3. Musculus transversalis; 4. Fascia transversalis; 5. Peritoneum; 6. Ligamentum inguinale.
Bassini technique[edit]

The first efficient inguinal hernia repair was described by Edoardo Bassini in the 1880s.[43][44] In the Bassini technique, the conjoint tendon (formed by the distal ends of the transversus abdominis and internal oblique muscles) is approximated to the inguinal ligament and closed.[45]

Other open non-mesh techniques[edit]

The Shouldice technique was itself an evolution of prior techniques that had greatly advanced the field of inguinal hernia surgery. Such classic open non-mesh repairs include:[11][9]

Laparoscopic repair[edit]

Port sites for inguinal hernia repair
Intraoperative view by TEP Operation. 1. Genital ramus of genitofemoral nerve. 2. Preperitoneal lipom and spermatic cord.

There are two main methods of laparoscopic repair: transabdominal preperitoneal (TAPP) and totally extra-peritoneal (TEP) repair. When performed by a surgeon experienced in hernia repair, laparoscopic repair causes fewer complications than Lichtenstein, particularly less chronic pain. However, if the surgeon is experienced in general laparoscopic surgery but not in the specific subject of laparoscopic hernia surgery, laparoscopic repair is not advised as it causes more recurrence risk than Lichtenstein while also presenting risks of serious complications, as organ injury. Indeed, the TAPP approach needs to go through the abdomen. All that said, many surgeons are moving to laparoscopic methodologies as they cause smaller incisions, resulting in less bleeding, less infection, faster recovery, reduced hospitalization, and reduced chronic pain.[47][48]

Laparoscopic mesh surgery, as compared to open mesh surgery
Advantages Disadvantages
  • Quicker recovery[48][49]
  • Less pain during first days[48]
  • Fewer postoperative complications[49]
such as infections, bleeding and seromas[48]
  • Less risk of chronic pain[48]
  • Needs surgeon highly experienced

(>200 operations/year) in inguinal hernia repairs[citation needed]

  • Longer operating time[49]
  • Increased recurrence of primary hernias if

surgeon not experienced enough[49]

There is no difference in cost between laparoscopic and open repair as the increased costs of operation are offset by the decreased recovery period. Recurrence rates are identical when laparoscopy is performed by an experienced surgeon.[48] When performed by a surgeon less experienced in inguinal hernia lap repair, recurrence is larger than after Lichtenstein.[50]

Non-surgical management[edit]

Studies have demonstrated that men whose hernias cause little to no symptoms can safely continue to delay surgery until a time that is most convenient for patients and their healthcare team. Research shows that the risk of inguinal hernia complications remains under 1% within the population.[51][10][1][11] Watchful waiting requires that patients maintain a close follow-up schedule with providers to monitor the course of their hernia for any changes in symptoms and can be safely offered for up to 2 years.[52][3]

Patients who do elect watchful waiting eventually undergo repair within five years as 25% will experience a progression of symptoms such as worsening of pain. Elective repair discussions should be revisited if patient's begin to avoid aspects of their normal routine due to their hernia.[53][54][2] After 1 year it is estimated that 16% of patients who initially opted for watchful waiting will eventually undergo surgery. Furthermore, 54% and 72% will undergo repair at 5-year and 7.5-year marks respectively.[55][7]

The use of a truss is an additional non-surgical option for men. It resembles a jock-strap that utilizes a pad to exert pressure at the site of the hernia in order prevent excursion of the hernia sack. It has little evidence to support its routine use and has not been shown to prevent complications such as incarceration or strangulation of bowel. However some patients do report a soothing of symptoms when utilized.

 Complications and prognosis[edit]

Inguinal hernia repair complications are unusual and the procedure as a whole proves to be relatively safe for the majority of patients. Risks inherent in almost all surgical procedures include:[1]

  • bleeding
  • fluid collections
  • infection
  • damage to surrounding structures such as vessels, nerves and organs
  • urinary retention requiring a catheter

Risks that are specific to inguinal hernia repairs include such things as:[7][1][11]

  • injury to the bladder
  • injury to nearby nerves
  • in males, injury to the tube that conveys sperm from the testicle to the penis
  • Genital or ejaculatory pain or impairment of sexual activity[56]
  • in males, bruising and swelling of the scrotum
  • recurrence of the hernia
  • chronic regional pain
    • also known as Post-herniorrhaphy inguinodynia or Chronic postoperative inguinal pain

Post-herniorrhaphy inguinodynia is a condition where 10-12% of patients experience severe pain after inguinal hernia repair. The mechanism of which remains a complex combination of different forms of pain signals.[57][58][59] It can occur with any inguinal hernia repair technique and if unresponsive to pain medications, further surgical intervention is often required.[60] Removal of mesh in combination with bisection of regional nerves is commonly performed to address such cases.[61][62][63] There remains ongoing discussion amongst surgeons regarding the utility of planned resections of regional nerves as an attempt to prevent its occurrence.[63][64]

Mortality rates for non-urgent, elective procedures was demonstrated as 0.1% and around 3% for procedures performed urgently.[65][2] Other than urgent repair, risk factors that were also associated with increased mortality included being female, requiring a femoral hernia repair, and older age.[66][67][68]


Upon awakening from anesthesia, patients are monitored for their ability to drink fluids, produce urine, as well as their ability to walk after surgery. Most patients are then able to return home once those conditions are met.[7] It is not uncommon for patients to experience residual soreness for a couple of days after surgery.[69][18] Patients are encouraged to make strong efforts in getting up and walking around the day after surgery.[59] Most patients can resume their normal routine of daily living within the week such as driving, showering, light lifting, as well as sexual activity.[1] Long work absences are rarely necessary and length of sick days tend to be dictated by respective employment policies.[59][2]

Post-op development of any of the following should warrant timely reporting via phone:[18][7]

  • fever greater than 39C/101F
  • progressive swelling of the surgical site
  • severe pain
  • recurring nausea or vomiting
  • worsening redness around incisions
  • drainage of pus from incisions
  • difficulty or lack of producing urine
  • new-onset shortness of breath

Prevention and screening[edit]

Most indirect inguinal hernias in the abdominal wall are not preventable. Direct inguinal hernias may be able to be prevented by maintaining a healthy weight, refraining from smoking, preventing straining during bowel movements, and maintaining proper lifting techniques when heavy lifting.[7][1] There is no evidence that indicates physicians should routinely screen for asymptomatic inguinal hernias during patient visits.[70]


  1. ^ a b c d e f g h Hewitt, D. Brock (2017-06-27). "Groin Hernia". JAMA. 317 (24). doi:10.1001/jama.2017.1556. ISSN 0098-7484. 
  2. ^ a b c d e f g h i j  Missing or empty |title= (help);
  3. ^ a b c d "Inguinal Hernia | NIDDK". National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 2017-12-01. 
  4. ^ a b c d e f g h i j "World Guidelines for Hernia Management" (PDF). European Hernia Society. Retrieved December 1, 2017. 
  5. ^ a b "Laparoscopic surgery for inguinal hernia repair | Guidance and guidelines | NICE". Retrieved 2017-12-05. 
  6. ^ P. Wagner, Justin; Brunicardi, F. Charles; Amid, Parviz K.; Chen, David C. (2014). Brunicardi, F. Charles; Andersen, Dana K.; Billiar, Timothy R.; Dunn, David L.; Hunter, John G.; Matthews, Jeffrey B.; Pollock, Raphael E., eds. Schwartz's Principles of Surgery (10 ed.). New York, NY: McGraw-Hill Education. 
  7. ^ a b c d e f g h "Inguinal Hernia Repair Surgery Information from SAGES". SAGES. Retrieved 2017-12-05. 
  8. ^ "Laparoscopic surgery for inguinal hernia repair | Guidance and guidelines | NICE". Retrieved 2017-12-05. 
  9. ^ a b c d e f g h DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. 113880, Groin hernia in adults and adolescents; [updated 2017 Nov 27, cited Nov 27, 2017]; [about 28 screens]. Available from Registration and login required.
  10. ^ a b "Inguinal hernia - Diagnosis and treatment - Mayo Clinic". Retrieved 2017-12-05. 
  11. ^ a b c d e f g h i j k l Wagner, Justin; Brunicardi; Amid; Chen (2015). "Inguinal Hernias". Schwartz's Principles of Surgery, 10e. New York, NY: McGraw-Hill. ISBN 978-0-07179674-3. 
  12. ^ Medical Research Council Laparoscopic Groin Hernia Trial Group. (May 2001). "Cost-utility analysis of open versus laparoscopic groin hernia repair: results from a multicentre randomized clinical trial". The British Journal of Surgery. 88 (5): 653–661. doi:10.1046/j.1365-2168.2001.01768.x. ISSN 0007-1323. PMID 11350435. 
  13. ^ Payne, J. H.; Grininger, L. M.; Izawa, M. T.; Podoll, E. F.; Lindahl, P. J.; Balfour, J. (September 1994). "Laparoscopic or open inguinal herniorrhaphy? A randomized prospective trial". Archives of Surgery (Chicago, Ill.: 1960). 129 (9): 973–979; discussion 979–981. ISSN 0004-0010. PMID 8080380. 
  14. ^ Hynes, Denise M.; Stroupe, Kevin T.; Luo, Ping; Giobbie-Hurder, Anita; Reda, Domenic; Kraft, Margaret; Itani, Kamal; Fitzgibbons, Robert; Jonasson, Olga (October 2006). "Cost effectiveness of laparoscopic versus open mesh hernia operation: results of a Department of Veterans Affairs randomized clinical trial". Journal of the American College of Surgeons. 203 (4): 447–457. doi:10.1016/j.jamcollsurg.2006.05.019. ISSN 1072-7515. PMID 17000387. 
  15. ^ Anadol, Ziya A.; Ersoy, Emin; Taneri, Ferit; Tekin, Ercüment (June 2004). "Outcome and cost comparison of laparoscopic transabdominal preperitoneal hernia repair versus Open Lichtenstein technique". Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A. 14 (3): 159–163. doi:10.1089/1092642041255414. ISSN 1092-6429. PMID 15245668. 
  16. ^ Stylopoulos, N.; Gazelle, G. S.; Rattner, D. W. (February 2003). "A cost--utility analysis of treatment options for inguinal hernia in 1,513,008 adult patients". Surgical Endoscopy. 17 (2): 180–189. doi:10.1007/s00464-002-8849-z. ISSN 1432-2218. PMID 12415334. 
  17. ^ Bittner, R.; Montgomery, M. A.; Arregui, E.; Bansal, V.; Bingener, J.; Bisgaard, T.; Buhck, H.; Dudai, M.; Ferzli, G. S. (2015). "Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society)". Surgical Endoscopy. 29 (2): 289–321. doi:10.1007/s00464-014-3917-8. ISSN 0930-2794. PMC 4293469Freely accessible. PMID 25398194. 
  18. ^ a b c Hewitt, D. Brock; Chojnacki, Karen (2017-08-22). "Groin Hernia Repair by Open Surgery". JAMA. 318 (8). doi:10.1001/jama.2017.9868. ISSN 0098-7484. 
  19. ^ Nordin, Pär; Zetterström, Henrik; Gunnarsson, Ulf; Nilsson, Erik (2003-09-13). "Local, regional, or general anaesthesia in groin hernia repair: multicentre randomised trial". Lancet. 362 (9387): 853–858. doi:10.1016/S0140-6736(03)14339-5. ISSN 1474-547X. PMID 13678971. 
  20. ^ van Veen, Ruben N.; Mahabier, Chander; Dawson, Imro; Hop, Wim C.; Kok, Niels F. M.; Lange, Johan F.; Jeekel, Johannus (March 2008). "Spinal or local anesthesia in lichtenstein hernia repair: a randomized controlled trial". Annals of Surgery. 247 (3): 428–433. doi:10.1097/SLA.0b013e318165b0ff. ISSN 0003-4932. PMID 18376185. 
  21. ^ a b Scott, N. W.; McCormack, K.; Graham, P.; Go, P. M.; Ross, S. J.; Grant, A. M. (2002). "Open mesh versus non-mesh for repair of femoral and inguinal hernia". The Cochrane Database of Systematic Reviews (4): CD002197. doi:10.1002/14651858.CD002197. ISSN 1469-493X. PMID 12519568. 
  22. ^ Rosenberg, Jacob; Bisgaard, Thue; Kehlet, Henrik; Wara, Pål; Asmussen, Torsten; Juul, Poul; Strand, Lasse; Andersen, Finn Heidmann; Bay-Nielsen, Morten (February 2011). "Danish Hernia Database recommendations for the management of inguinal and femoral hernia in adults". Danish Medical Bulletin. 58 (2): C4243. ISSN 1603-9629. PMID 21299930. 
  23. ^ Bay-Nielsen, M.; Kehlet, H.; Strand, L.; Malmstrøm, J.; Andersen, F. H.; Wara, P.; Juul, P.; Callesen, T.; Danish Hernia Database Collaboration (2001-10-06). "Quality assessment of 26,304 herniorrhaphies in Denmark: a prospective nationwide study". Lancet. 358 (9288): 1124–1128. doi:10.1016/S0140-6736(01)06251-1. ISSN 0140-6736. PMID 11597665. 
  24. ^ Matthews, Richard D.; Anthony, Thomas; Kim, Lawrence T.; Wang, Jia; Fitzgibbons, Robert J.; Giobbie-Hurder, Anita; Reda, Domenic J.; Itani, Kamal M. F.; Neumayer, Leigh A. (November 2007). "Factors associated with postoperative complications and hernia recurrence for patients undergoing inguinal hernia repair: a report from the VA Cooperative Hernia Study Group". American Journal of Surgery. 194 (5): 611–617. doi:10.1016/j.amjsurg.2007.07.018. ISSN 1879-1883. PMID 17936422. 
  25. ^ EU Hernia Trialists Collaboration (March 2002). "Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials". Annals of Surgery. 235 (3): 322–332. ISSN 0003-4932. PMC 1422456Freely accessible. PMID 11882753. 
  26. ^ Earle, David B.; Mark, Lisa A. (February 2008). "Prosthetic material in inguinal hernia repair: how do I choose?". The Surgical Clinics of North America. 88 (1): 179–201, x. doi:10.1016/j.suc.2007.11.002. ISSN 0039-6109. PMID 18267169. 
  27. ^ Bittner, R.; Arregui, M. E.; Bisgaard, T.; Dudai, M.; Ferzli, G. S.; Fitzgibbons, R. J.; Fortelny, R. H.; Klinge, U.; Kockerling, F. (September 2011). "Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]". Surgical Endoscopy. 25 (9): 2773–2843. doi:10.1007/s00464-011-1799-6. ISSN 1432-2218. PMC 3160575Freely accessible. PMID 21751060. 
  28. ^ Sajid, Muhammad S.; Kalra, Lorain; Parampalli, Umesh; Sains, Parv S.; Baig, Mirza K. (June 2013). "A systematic review and meta-analysis evaluating the effectiveness of lightweight mesh against heavyweight mesh in influencing the incidence of chronic groin pain following laparoscopic inguinal hernia repair". American Journal of Surgery. 205 (6): 726–736. doi:10.1016/j.amjsurg.2012.07.046. ISSN 1879-1883. PMID 23561639. 
  29. ^ Sajid, M. S.; Leaver, C.; Baig, M. K.; Sains, P. (January 2012). "Systematic review and meta-analysis of the use of lightweight versus heavyweight mesh in open inguinal hernia repair". The British Journal of Surgery. 99 (1): 29–37. doi:10.1002/bjs.7718. ISSN 1365-2168. PMID 22038579. 
  30. ^ Bittner, R.; Montgomery, M. A.; Arregui, E.; Bansal, V.; Bingener, J.; Bisgaard, T.; Buhck, H.; Dudai, M.; Ferzli, G. S. (2015-02-01). "Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society)". Surgical Endoscopy. 29 (2): 289–321. doi:10.1007/s00464-014-3917-8. ISSN 0930-2794. 
  31. ^ Smart, Neil J.; Bloor, Stephen (September 2012). "Durability of biologic implants for use in hernia repair: a review". Surgical Innovation. 19 (3): 221–229. doi:10.1177/1553350611429027. ISSN 1553-3514. PMID 22143748. 
  32. ^ Edelman, DS; Hodde, JP (2006). "Bioactive prosthetic material for treatment of hernias". Surgical technology international. 15: 104–8. PMID 17029169. 
  33. ^ Inguinal Hernia Repair with Biodesign® (Surgisis®) -- David Edelman, MD [1][unreliable medical source?]
  34. ^[full citation needed]
  35. ^ Hjort, H.; Mathisen, T.; Alves, A.; Clermont, G.; Boutrand, J. P. (2011). "Three-year results from a preclinical implantation study of a long-term resorbable surgical mesh with time-dependent mechanical characteristics". Hernia. 16 (2): 191–7. doi:10.1007/s10029-011-0885-y. PMC 3895198Freely accessible. PMID 21972049. 
  36. ^ Clarke, M. G.; Oppong, C.; Simmermacher, R.; Park, K.; Kurzer, M.; Vanotoo, L.; Kingsnorth, A. N. (2008). "The use of sterilised polyester mosquito net mesh for inguinal hernia repair in Ghana". Hernia. 13 (2): 155–9. doi:10.1007/s10029-008-0460-3. PMID 19089526. 
  37. ^ a b Tongaonkar, Ravindranath R.; Reddy, Brahma V.; Mehta, Virendra K.; Singh, Ningthoujam Somorjit; Shivade, Sanjay (2003). "Preliminary Multicentric Trial of Cheap Indigenous Mosquito-Net Cloth for Tension-free Hernia Repair". Indian Journal of Surgery. 65 (1): 89–95. 
  38. ^ Wilhelm, T.J.; Freudenberg, S.; Jonas, E.; Grobholz, R.; Post, S.; Kyamanywa, P. (2007). "Sterilized Mosquito Net versus Commercial Mesh for Hernia Repair". European Surgical Research. 39 (5): 312–7. doi:10.1159/000104402. PMID 17595545. 
  39. ^ Sun, Ping; Cheng, Xiang; Deng, Shichang; Hu, Qinggang; Sun, Yi; Zheng, Qichang (7 Feb 2017). "Mesh fixation with glue versus suture for chronic pain and recurrence in Lichtenstein inguinal hernioplasty". The Cochrane Database of Systematic Reviews. 2: CD010814. doi:10.1002/14651858.CD010814.pub2. ISSN 1469-493X. PMID 28170080. 
  40. ^ de Goede, B.; Klitsie, P. J.; van Kempen, B. J. H.; Timmermans, L.; Jeekel, J.; Kazemier, G.; Lange, J. F. (May 2013). "Meta-analysis of glue versus sutured mesh fixation for Lichtenstein inguinal hernia repair". The British Journal of Surgery. 100 (6): 735–742. doi:10.1002/bjs.9072. ISSN 1365-2168. PMID 23436683. 
  41. ^ Shen, Ying-mo; Sun, Wen-bing; Chen, Jie; Liu, Su-jun; Wang, Ming-gang (April 2012). "NBCA medical adhesive (n-butyl-2-cyanoacrylate) versus suture for patch fixation in Lichtenstein inguinal herniorrhaphy: a randomized controlled trial". Surgery. 151 (4): 550–555. doi:10.1016/j.surg.2011.09.031. ISSN 1532-7361. PMID 22088820. 
  42. ^ a b Amato, Bruno; Moja, Lorenzo; Panico, Salvatore; Persico, Giovanni; Rispoli, Corrado; Rocco, Nicola; Moschetti, Ivan (2012-04-18). "Shouldice technique versus other open techniques for inguinal hernia repair". The Cochrane Database of Systematic Reviews (4): CD001543. doi:10.1002/14651858.CD001543.pub4. ISSN 1469-493X. PMID 22513902. 
  43. ^ doctor/3213 at Who Named It?
  44. ^ Bassini E, Nuovo metodo operativo per la cura dell'ernia inguinale. Padua, 1889.[page needed]
  45. ^ Gordon, T. L. (1945). "Bassini's Operation for Inguinal Hernia". BMJ. 2 (4414): 181–2. doi:10.1136/bmj.2.4414.181. PMC 2059571Freely accessible. PMID 20786215. 
  47. ^[full citation needed]
  48. ^ a b c d e f "Hernia - laparoscopic surgery (review)". National Institute for Health and Clinical Excellence. 2004. Retrieved 2007-03-26. 
  49. ^ a b c d Trudie A Goers; Washington University School of Medicine Department of Surgery; Klingensmith, Mary E; Li Ern Chen; Sean C Glasgow (2008). The Washington manual of surgery. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. ISBN 0-7817-7447-0.  [page needed]
  50. ^ Neumayer, Leigh; Giobbie-Hurder, Anita; Jonasson, Olga; Fitzgibbons, Robert; Dunlop, Dorothy; Gibbs, James; Reda, Domenic; Henderson, William; Veterans Affairs Cooperative Studies Program 456 Investigators (2004). "Open Mesh versus Laparoscopic Mesh Repair of Inguinal Hernia". New England Journal of Medicine. 350 (18): 1819–27. doi:10.1056/NEJMoa040093. PMID 15107485. 
  51. ^ Mizrahi, Hagar; Parker, Michael C. (March 2012). "Management of asymptomatic inguinal hernia: a systematic review of the evidence". Archives of Surgery (Chicago, Ill.: 1960). 147 (3): 277–281. doi:10.1001/archsurg.2011.914. ISSN 1538-3644. PMID 22430913. 
  52. ^ "The Canadian Association of General Surgeons (CAGS) has developed a list of 6 things physicians and patients should question in general surgery". Choosing Wisely Canada. Retrieved 2017-12-07. 
  53. ^ "World Guidelines for Hernia Management" (PDF). European Hernia Society. Retrieved December 1, 2017. 
  54. ^ Miserez, M.; Peeters, E.; Aufenacker, T.; Bouillot, J. L.; Campanelli, G.; Conze, J.; Fortelny, R.; Heikkinen, T.; Jorgensen, L. N. (April 2014). "Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients". Hernia: The Journal of Hernias and Abdominal Wall Surgery. 18 (2): 151–163. doi:10.1007/s10029-014-1236-6. ISSN 1248-9204. PMID 24647885. 
  55. ^ Chung, L.; Norrie, J.; O'Dwyer, P. J. (April 2011). "Long-term follow-up of patients with a painless inguinal hernia from a randomized clinical trial". The British Journal of Surgery. 98 (4): 596–599. doi:10.1002/bjs.7355. ISSN 1365-2168. PMID 21656724. 
  56. ^ Aasvang, Eske Kvanner; Møhl, Bo; Bay-Nielsen, Morten; Kehlet, Henrik (June 2006). "Pain related sexual dysfunction after inguinal herniorrhaphy". Pain. 122 (3): 258–263. doi:10.1016/j.pain.2006.01.035. ISSN 1872-6623. PMID 16545910. 
  57. ^ Kehlet, H. (February 2008). "Chronic pain after groin hernia repair". The British Journal of Surgery. 95 (2): 135–136. doi:10.1002/bjs.6111. ISSN 1365-2168. PMID 18196556. 
  58. ^ Callesen, T.; Bech, K.; Kehlet, H. (December 1999). "Prospective study of chronic pain after groin hernia repair". The British Journal of Surgery. 86 (12): 1528–1531. doi:10.1046/j.1365-2168.1999.01320.x. ISSN 0007-1323. PMID 10594500. 
  59. ^ a b c "World Guidelines for Hernia Management" (PDF). European Hernia Society. Retrieved December 1, 2017. 
  60. ^ Starling, J. R.; Harms, B. A.; Schroeder, M. E.; Eichman, P. L. (October 1987). "Diagnosis and treatment of genitofemoral and ilioinguinal entrapment neuralgia". Surgery. 102 (4): 581–586. ISSN 0039-6060. PMID 3660235. 
  61. ^ Aasvang, Eske K.; Kehlet, Henrik (February 2009). "The effect of mesh removal and selective neurectomy on persistent postherniotomy pain". Annals of Surgery. 249 (2): 327–334. doi:10.1097/SLA.0b013e31818eec49. ISSN 1528-1140. PMID 19212190. 
  62. ^ Zacest, Andrew C.; Magill, Stephen T.; Anderson, Valerie C.; Burchiel, Kim J. (April 2010). "Long-term outcome following ilioinguinal neurectomy for chronic pain". Journal of Neurosurgery. 112 (4): 784–789. doi:10.3171/2009.8.JNS09533. ISSN 1933-0693. PMID 19780646. 
  63. ^ a b Amid, Parviz K.; Chen, David C. (October 2011). "Surgical treatment of chronic groin and testicular pain after laparoscopic and open preperitoneal inguinal hernia repair". Journal of the American College of Surgeons. 213 (4): 531–536. doi:10.1016/j.jamcollsurg.2011.06.424. ISSN 1879-1190. PMID 21784668. 
  64. ^ Alfieri, S.; Amid, P. K.; Campanelli, G.; Izard, G.; Kehlet, H.; Wijsmuller, A. R.; Di Miceli, D.; Doglietto, G. B. (June 2011). "International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery". Hernia: The Journal of Hernias and Abdominal Wall Surgery. 15 (3): 239–249. doi:10.1007/s10029-011-0798-9. ISSN 1248-9204. PMID 21365287. 
  65. ^ Abi-Haidar, Youmna; Sanchez, Vivian; Itani, Kamal M. F. (September 2011). "Risk factors and outcomes of acute versus elective groin hernia surgery". Journal of the American College of Surgeons. 213 (3): 363–369. doi:10.1016/j.jamcollsurg.2011.05.008. ISSN 1879-1190. PMID 21680204. 
  66. ^ Arenal, Juan J.; Rodríguez-Vielba, Paloma; Gallo, Emiliano; Tinoco, Claudia (2002). "Hernias of the abdominal wall in patients over the age of 70 years". The European Journal of Surgery = Acta Chirurgica. 168 (8-9): 460–463. doi:10.1080/110241502321116451. ISSN 1102-4151. PMID 12549685. 
  67. ^ Koch, A.; Edwards, A.; Haapaniemi, S.; Nordin, P.; Kald, A. (December 2005). "Prospective evaluation of 6895 groin hernia repairs in women". The British Journal of Surgery. 92 (12): 1553–1558. doi:10.1002/bjs.5156. ISSN 0007-1323. PMID 16187268. 
  68. ^ Dahlstrand, Ursula; Wollert, Staffan; Nordin, Pär; Sandblom, Gabriel; Gunnarsson, Ulf (April 2009). "Emergency femoral hernia repair: a study based on a national register". Annals of Surgery. 249 (4): 672–676. doi:10.1097/SLA.0b013e31819ed943. ISSN 1528-1140. PMID 19300219. 
  69. ^ Hewitt, D. Brock; Chojnacki, Karen (2017-10-03). "Laparoscopic Groin Hernia Repair". JAMA. 318 (13). doi:10.1001/jama.2017.11620. ISSN 0098-7484. 
  70. ^ DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. 113880, Groin hernia in adults and adolescents; [updated 2017 Nov 27, cited Nov 27, 2017]; [about 28 screens]. Available from Registration and login required.