People often ask what is the best repair for an inguinal hernia. These days, my answer is usually, ‘It depends.’ I liken the question to the question, “What is the best car?” Most of us have different ideas about what the best car is for us. We each have personal preferences relating to style, comfort, economy, gas vs. electric, cargo capacity, towing load, etc.
Just as we all want a vehicle to get us around safely and comfortably, all patients want a hernia repair that is long-lasting and causes minimal pain. But for some car shoppers the answer looks like a Ford F-150, for others it looks like a BMW, and for others still a Honda Accord fits the bill perfectly. Similarly, when it comes to inguinal hernias, there are several good operations available that cater to different needs. Below we compare robotic, laparoscopic, and open inguinal hernia repair (with and without mesh) and explain when we recommend each.
Which Is the Best Inguinal Hernia Repair? Outcomes Compared
| Outcome | Robotic | Laparoscopic | Open with mesh | Open without mesh |
|---|---|---|---|---|
| Estimated recurrence rate | 0.5–2% | 1–5% | 1–5% | 3–5% |
| Estimated chronic pain rate | 0.5–5% | 1–5% | 5–10% | 1–10% |
| Outcome | Robotic | Laparoscopic | Open with mesh | Open without mesh (absorbable sutures) | Open without mesh (permanent sutures) |
|---|---|---|---|---|---|
| Recurrence rate | <0.5% | 0.8% | 0.5% | 4% | 1% |
| Chronic pain rate | <0.5% | 0.5% | 0.8% | <0.5% | <0.5% |
Rates are approximate ranges, and individual results vary. For a review of the published evidence, see the HerniaSurge international guidelines for groin hernia management.
When a Laparoscopic Repair Is Best
We generally recommend the TEP (totally extraperitoneal) approach when doing a laparoscopic inguinal hernia repair. This keeps the working instruments out of the peritoneal cavity and minimizes disruption to the peritoneal lining. The TEP is generally best reserved for the following cases:
- When a posterior approach is desired (e.g., a recurrent hernia where the first operation was done open)
- Seeking to minimize post-op pain
- Small hernias (large indirect sacs can be technically difficult to reduce)
- Bilateral hernias (minimal increase in pain over a one-sided hernia)
There are many different ways to perform this operation, but here is generally what we recommend:
- Progrip mesh (light-medium weight)
- 3DMax MID for small-medium hernias (medium weight) with absorbable tacker/suture
- 3DMax for large hernias with absorbable tacker/suture
When a Robotic Repair Is Best
We recommend the robotic approach (most often TAPP, transabdominal preperitoneal) when a posterior repair is desired but the standard laparoscopic TEP is deemed too technically challenging to do a sound repair:
- When a posterior approach is desired (e.g., a recurrent hernia where the first operation was done open)
- Seeking to minimize post-op pain
- Large hernias (large indirect sacs can be technically difficult to reduce)
- The absolute lowest recurrence rate possible, due to the large overlap of an extra-large mesh
As with the laparoscopic approach, we often advocate the following:
- Progrip mesh (light-medium weight)
- 3DMax MID for small-medium hernias (medium weight) with absorbable tacker/suture
- 3DMax extra large for large hernias with absorbable tacker/suture
When an Open Inguinal Hernia Repair Is Best
We actually most often recommend the open repair because, in our experience, pain and recurrence are very low and similar to the robotic repair. With the open repair we have a few benefits:
- We can primarily close defects and restore normal anatomy
- We have good non-mesh options available, such as the Shouldice repair and the Desarda repair
- When mesh is used, it is often lighter in weight and smaller in size (e.g., Bard/Prolene Soft Mesh and Prolene Mesh)
- Less anesthesia requirement (“twilight” vs. general)
- Extreme safety
Anesthesia
While modern anesthesia is very safe, we generally prefer to use the least amount of anesthesia needed to achieve a good result and excellent pain control. Learn more about the benefits of local anesthesia.
Extreme Safety
With surgical procedures, there are very rare complications that often do not reach statistical significance in studies but nevertheless do occur. For inguinal hernias, these complications include testicular infarction, deep hematoma, small bowel obstruction, and major vascular injury. These complications are more common (albeit still rare) with laparoscopic and robotic approaches. In our experience with the open technique, these complications are essentially non-existent.
Though severe complications are exceedingly rare, for the patients who experience them, they can be life-altering. At the Palm Beach Hernia Institute, we have an extreme aversion to major complications and weigh this metric very highly when selecting a surgical approach, even though such events are very rare and do not reach statistical significance.
Choosing the Best Inguinal Hernia Repair: Surgeon Expertise and Patient Choice
In the end, it is imperative that the surgeon has good experience and results with their recommended approach. It is also helpful for curious patients to be informed of the options and be comfortable with their planned repair. If, for example, an educated patient prefers a non-mesh repair but their surgeon does not have good experience and results with non-mesh techniques, it would be advisable for the patient to consult with a surgeon who has experience and good results with non-mesh surgery. Similarly, if a patient would like the extremely low recurrence rate of a modern robotic TAPP hernia repair but their surgeon is more comfortable with open techniques, they would do well to find a surgeon with good experience and results in robotic repairs. That is why, when either a patient prefers, or I recommend, a technique that I do not regularly perform, we refer to one of our partnered specialists whose quality we have verified.
While an F-150 is the perfect vehicle for some, for others it is cumbersome and inefficient. Similarly, some surgical approaches are more closely aligned than others with a particular patient’s preferences and philosophy. Knowing what matters to you and the pros and cons of each approach can help you feel comfortable and confident in getting your hernia taken care of promptly and safely. For more detail, see our recommendations for inguinal hernia repair techniques and our inguinal hernia information page.
Disclosures: None. We are not sponsored by any mesh companies but simply offer for public education what we recommend. There are other mesh products that are similar to the products described here in terms of material, weight density, and pore size.