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Background: Inguinal hernia repair is among the most frequently performed operations in general surgery worldwide. Over the past four decades, the field has evolved from tissue-based repairs to tension-free mesh techniques and, more recently, to minimally invasive and robotic-assisted approaches. This narrative review provides a comprehensive, clinically focused synthesis of the current evidence on all major adult inguinal hernia repair techniques.
Objective: A structured literature review was conducted across PubMed, Embase, and the Cochrane Library for publications from 2000 to 2024, with priority given to systematic reviews, meta-analyses, RCTs, and large registry studies. Evidence from our updated meta-analysis of four comparative studies (n = 1,021) is integrated.
Results: The Lichtenstein tension-free repair remains the gold-standard open approach, with recurrence rates consistently below 1% and robust long-term safety data. Laparoscopic repair — both TAPP and TEP — achieves equivalent recurrence and chronic pain outcomes, with TEP associated with shorter operative time but significantly greater carbon dioxide accumulation (respiratory acidosis: 90% in TEP vs 54% in TAPP, p < 0.01). Robotic-assisted techniques (eTEP, R-TAPP) represent an important emerging frontier, though cost remains a significant barrier.
Conclusion: No single technique is universally superior; patient-tailored selection based on hernia characteristics, patient comorbidities, and surgeon expertise is the cornerstone of contemporary practice.
Keywords: inguinal hernia; Lichtenstein repair; laparoscopic inguinal hernia repair; TAPP; TEP; robotic surgery; eTEP; systematic review
Inguinal hernia is a common surgical condition affecting millions of individuals worldwide, with an estimated annual volume exceeding 20 million repairs globally [1,2]. The condition arises when intra-abdominal contents — typically omentum or intestine — protrude through a defect in the abdominal wall at the inguinal region, classified anatomically as indirect (lateral to the inferior epigastric vessels) or direct (medial to these vessels) [1]. Left untreated, inguinal hernia can lead to serious complications, including incarceration, strangulation, and bowel obstruction, with mortality rates for emergency repair reported between 2% and 5% [1,3].
The surgical management of inguinal hernia has undergone remarkable transformation over the past 140 years. From Bassini's pioneering anatomical reconstruction in 1887, through the meticulous Shouldice four-layer technique of the mid-twentieth century, to the revolutionary introduction of tension-free mesh repair by Lichtenstein and colleagues in 1989, each evolution has substantially improved patient outcomes [4,5]. The adoption of laparoscopic approaches in the 1990s further refined the field, offering the benefits of minimally invasive surgery to hernia patients [6,7]. Most recently, robotic surgical systems have begun to influence the landscape, particularly in high-resource settings [8].
Despite this extensive body of evidence and well-established international guidelines — most notably the HerniaSurge Group International Guidelines published in 2018 — significant debate persists regarding the optimal surgical approach in various clinical scenarios [1]. The choice between open and laparoscopic techniques, between the two dominant laparoscopic approaches (TAPP and TEP), and the emerging role of robotic-assisted repair represents a nuanced decision that must be individualized to each patient and surgeon.
Several anatomical classification systems have been developed to standardize reporting. The Gilbert classification, as modified by Rutkow and Robbins, categorizes inguinal hernias into seven types based on the anatomy of the internal ring and posterior wall [9]. The European Hernia Society (EHS) classification provides an alternative framework incorporating both hernia location — lateral (L), medial (M), or femoral (F) — and defect size (small < 1.5 cm, medium 1.5–3 cm, large > 3 cm), validated for predicting recurrence and guiding technique selection [10].
Patient age and comorbidities represent the most critical variables influencing technique selection. Elderly patients with limited cardiopulmonary reserve may be disadvantaged by the carbon dioxide pneumoperitoneum required for laparoscopic repair, as evidenced by significantly higher rates of respiratory acidosis in the TEP group in randomized settings [11]. Chronic obstructive pulmonary disease, pulmonary hypertension, severe cardiovascular disease, and prior lower abdominal or pelvic surgery may preclude the safe establishment of a preperitoneal working space required for TEP [1,11]. Bilateral hernias — present in approximately 10–15% of patients — are generally best managed with a laparoscopic approach, which allows simultaneous bilateral repair through the same port configuration [1]. Recurrent hernias after previous open repair represent a classical indication for the posterior approach (TAPP or TEP), as this strategy avoids scarred anterior tissue planes [1].
3.1 Bassini Repair. Introduced by Eduardo Bassini in 1887, this technique represents the classical tissue-based reconstruction of the posterior wall of the inguinal canal [4]. For much of the twentieth century, it constituted the standard of care, with recurrence rates ranging from 5% to 15% [4,13]. It has largely been superseded by tension-free mesh techniques in contemporary practice.
3.2 Shouldice Repair. Developed at the Shouldice Clinic in Toronto, this technique involves meticulous four-layer anatomical reconstruction using fine stainless steel wire sutures [14]. In the hands of surgeons at high-volume specialized centers, recurrence rates below 1% have been reported for primary unilateral hernias [14,15]. A systematic review found that these exceptional outcomes are not consistently replicated in community surgical practice — underscoring the significant learning curve and volume-outcome relationship [16]. The HerniaSurge 2018 guidelines conditionally recommend the Shouldice repair only in high-volume centers with specific expertise [1].
4.1 Lichtenstein Tension-Free Repair. The tension-free hernioplasty described by Lichtenstein and colleagues in 1989 represents one of the most significant advances in hernia surgery [5]. By placing a prosthetic polypropylene mesh over the posterior wall of the inguinal canal — rather than approximating tissues under tension — the Lichtenstein repair achieves mechanical reinforcement without structural strain. A flat polypropylene mesh (traditionally 8 × 16 cm or larger) is positioned over the posterior wall, secured with interrupted non-absorbable sutures to the pubic tubercle, inguinal ligament, and conjoint tendon [5]. Mesh types used in contemporary practice include heavyweight polypropylene, medium-weight polypropylene, partially absorbable meshes (Vypro II), self-gripping meshes (ProGrip), and three-dimensional preformed meshes, all achieving comparable recurrence rates when adequately sized (> 10 × 15 cm) [22].
The landmark RCT by Neumayer and colleagues, published in the New England Journal of Medicine in 2004, initially raised concerns about higher recurrence rates with laparoscopic versus open mesh repair [17]. This finding has not been replicated in subsequent meta-analyses and is now attributed to surgeon experience factors rather than a fundamental limitation of the laparoscopic approach [18,19]. Modern series performed by experienced surgeons report recurrence rates consistently below 1%, comparable to the Lichtenstein gold standard [18,19]. Registry data from Denmark and Sweden confirm cumulative recurrence rates of approximately 2% at ten years for primary Lichtenstein repair [20,21]. The HerniaSurge 2018 guidelines assign Grade 1A recommendation to the Lichtenstein repair as the preferred open repair technique for primary unilateral inguinal hernia in adult men [1].
4.2 Mesh Plug and Patch Techniques. The mesh plug technique, introduced by Rutkow and Robbins in 1993, uses a conical polypropylene plug to occlude the hernia defect combined with a flat onlay mesh patch [23]. Recurrence rates are comparable to the standard Lichtenstein repair (1–2%) [23,24]. Concerns regarding chronic pain from plug-related fibrosis — particularly in younger patients — have limited its widespread adoption [24].
Laparoscopic inguinal hernia repair emerged in the early 1990s, with two complementary approaches described simultaneously: TAPP by Dion and Morin in 1992, and TEP by McKernan and Laws in 1993 [6,7]. Both techniques place prosthetic mesh in the preperitoneal space to cover the myopectineal orifice, but differ in their approach to establishing this space.
5.1 Transabdominal Preperitoneal Repair (TAPP). The TAPP technique begins with the establishment of pneumoperitoneum (typically 12–15 mmHg carbon dioxide) and placement of three laparoscopic ports. The peritoneum is incised approximately 2 cm above the hernia defect, and the preperitoneal space is developed to expose the myopectineal orifice. A large prosthetic mesh (typically Bard 3D MAX, 15 × 10 cm) is placed with at least 2–3 cm of circumferential overlap, and the peritoneal edges are closed with a running suture [6]. The TAPP approach provides familiar intra-abdominal anatomical landmarks and allows simultaneous diagnostic laparoscopy, detecting occult contralateral hernias in 5–10% of patients [1]. Principal disadvantages relate to the requirement for intraperitoneal entry, including the rare but serious risks of adhesion formation and visceral injury.
5.2 Totally Extraperitoneal Repair (TEP). The TEP technique is distinguished by its deliberate avoidance of the peritoneal cavity. A subumbilical incision accesses the preperitoneal space directly, and carbon dioxide is insufflated (12–15 mmHg). The Retzius and Bogros spaces are developed by balloon dissection, and mesh is positioned without any requirement for peritoneal closure [7]. TEP eliminates the risks of peritoneal adhesion, visceral injury, and port-site hernia. The most significant disadvantage is a steeper learning curve: approximately 30–50 cases are required to achieve proficiency versus approximately 20–30 for TAPP [1,25].
5.3 A Critical Synthesis: TAPP Versus TEP. Our updated meta-analysis of four comparative studies comprising 1,021 patients (TAPP: n = 546; TEP: n = 475) provides the most current quantitative synthesis [26–29]. Regarding recurrence, three studies (956 patients) found only two total recurrence events — one in each group — yielding a pooled Peto odds ratio of 1.02 (95% CI: 0.07–14.0; p = 0.99) with no heterogeneity (I² = 0%) [26–28]. For chronic pain, two studies (854 patients) reported three total events, yielding a pooled Peto odds ratio of approximately 1.30 (95% CI: 0.13–12.5; p = 0.82) [26,27]. Both formally demonstrate equivalence, though sparseness of events limits interpretation (GRADE: very low to low). Operative time, analyzed using a random-effects model (I² = 85%; p = 0.001), showed a pooled mean difference of 14.6 minutes favoring TEP (95% CI: 5.0–24.2; p = 0.003), driven primarily by one large retrospective study [26] contributing 66.5% of total weight; two RCTs showed no significant difference [27,28].
6.1 Robotic TAPP (R-TAPP). The robotic TAPP approach replicates the conventional laparoscopic TAPP technique using the da Vinci robotic platform, with wristed articulating instruments providing seven degrees of freedom and three-dimensional stereoscopic visualization [8,30]. Early and medium-term series of R-TAPP demonstrate excellent outcomes: recurrence rates below 1%, low acute and chronic pain rates, and operative times of 50–80 minutes that decrease with experience [8,30]. A systematic review found that robotic approaches achieve outcomes equivalent to conventional laparoscopy with a potentially shallower learning curve [8].
6.2 Robotic Extracorporeal TEP (eTEP). The enhanced totally extraperitoneal approach (eTEP), first described in 2019, uses a lateral ports-in-placement strategy that creates the preperitoneal working space from a lateral-to-medial direction [31]. Reported outcomes from recent series (2022–2024) are encouraging: operative times of 50–70 minutes, conversion rates of 0–2%, recurrence at 6–12 months of 0–0.5%, seroma rates of 2–4%, and wound infection rates below 1% [31,32]. The wristed instrumentation of the robotic platform appears to offer particular advantages in the narrow extraperitoneal space.
Recurrence. Multiple systematic reviews confirm that both laparoscopic approaches and the open Lichtenstein repair achieve recurrence rates consistently below 1% in contemporary practice when performed by experienced surgeons with appropriately sized mesh [1,18,19]. Registry data from Denmark and Sweden confirm cumulative recurrence rates of approximately 2% at ten years [20,21].
Chronic pain. Moderate-to-severe chronic pain occurs in approximately 1–2% of patients after mesh-based repair, while any chronic groin pain is reported in 10–12% [1,33]. Laparoscopic approaches may achieve lower rates compared with anterior open repair because mesh is placed posteriorly, away from the inguinal nerves [1,18]. Risk factors include mesh fixation with tacks near the "danger triangle," extensive dissection, low surgical volume, and patient psychosocial factors [1,33].
Recovery. Laparoscopic repair is consistently associated with faster return to normal activities and work — approximately four to seven days earlier in pooled analyses — with the greatest advantages seen for bilateral hernia repair and patients with physically demanding occupations [34].
Complications. Major complications — including bowel injury, vascular injury, and spermatic cord injury — are rare (<0.5%) across all techniques. Seroma is the most common minor complication (2–15%), typically self-resolving without intervention [1].
Recurrent inguinal hernia after open repair represents a classical indication for the posterior (laparoscopic or robotic) approach. Large registry data from Denmark and Sweden demonstrate that laparoscopic repair for recurrent hernia after open repair achieves recurrence rates of 2–4% at five years, and this is strongly endorsed by international guidelines [1,35]. Bilateral inguinal hernia is best managed with a laparoscopic approach, allowing simultaneous bilateral repair. TEP may be particularly advantageous for bilateral cases because it avoids peritoneal entry and allows seamless bilateral preperitoneal dissection [1]. Elderly patients and those with cardiopulmonary comorbidities warrant careful consideration of the carbon dioxide physiological implications discussed in Section 5.3 — TEP carries a demonstrably higher risk of respiratory acidosis [29], and TAPP or open Lichtenstein repair under regional or local anesthesia may represent safer options. Femoral hernia carries a higher risk of incarceration, and laparoscopic repair — both TAPP and TEP — is preferred in both sexes [1]. Emergency and incarcerated hernia: TAPP offers the advantage of direct visualization of hernia contents and the option for conversion if bowel resection is required. TEP is generally contraindicated in the emergency setting [1].
The evidence synthesized in this review does not support a single universal technique as optimal for all patients. The choice of surgical technique should be the product of a systematic, individualized assessment of three interconnected domains: patient factors (age, comorbidities, anesthesia risk, prior surgical history, patient preference), hernia characteristics (laterality, primary versus recurrent status, hernia type and size, suspected concurrent pathology), and surgeon expertise (specific technique repertoire, annual case volume, institutional resources, available equipment).
The HerniaSurge guidelines recommend that surgeons perform at least 30–50 cases of any specific laparoscopic technique before assuming proficiency, and that focusing initially on one approach — rather than alternating between TAPP and TEP — leads to faster competency acquisition and better patient outcomes [1]. A surgeon early in their learning curve is better served by TAPP or open Lichtenstein repair.
First, the Lichtenstein tension-free mesh repair remains the gold-standard open approach, with recurrence rates consistently below 1% and robust safety data. It is the preferred approach when local or regional anesthesia is desired and when minimally invasive equipment is unavailable.
Second, laparoscopic repair — both TAPP and TEP — achieves recurrence rates and chronic pain outcomes equivalent to the Lichtenstein repair, with faster recovery and return to work. Both are Grade 1A recommended by international guidelines [1]. TEP is associated with shorter operative time in most series, but this advantage is inconsistent and highly context-dependent (I² = 85%).
Third, TAPP may represent the safer laparoscopic option for elderly patients or those with cardiopulmonary comorbidities, given the significantly greater carbon dioxide accumulation demonstrated with TEP in randomized trial data [29].
Fourth, robotic-assisted techniques (eTEP and R-TAPP) represent important advances that expand the therapeutic armamentarium, particularly for their potential to make minimally invasive preperitoneal repair accessible to surgeons who found the conventional laparoscopic learning curve prohibitive. Cost remains the principal barrier to universal adoption.
Fifth, individualized decision-making integrating patient factors, hernia characteristics, and surgeon expertise is the cornerstone of contemporary best practice. No single technique is universally superior.
Future research priorities include large, adequately powered multicenter RCTs with standardized outcome definitions and five-year or longer follow-up; integration of patient-reported outcome measures including quality of life instruments and return to work timelines; specific investigation of carbon dioxide physiological effects in elderly and cardiopulmonary-compromised populations; expansion of robotic hernia surgery registries; and continued innovation in mesh design.
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