Original Articles

By Dr. Antonio Manenti
Corresponding Author Dr. Antonio Manenti
Department Surgery, - Italy
Submitting Author Dr. Antonio Manenti

Inguinal hernia, Inguinal prosthetic repair

Manenti A. The Preperitoneal Inguinal Hernia Prosthetic Repair: Indications and Technical Notes. WebmedCentral SURGICAL TECHNIQUE 2011;2(12):WMC002622
doi: 10.9754/journal.wmc.2011.002622

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submitted on: 12 Dec 2011 09:53:34 AM GMT
Published on: 13 Dec 2011 03:35:12 PM GMT


The preperitoneal repair of an inguinal hernia (IH),performed by a classical anterior transinguinal approach is a simple and safe procedure, particularly indicated in case of evident weakness of the trasversalis fascia (TF).


In the recent years, the use of a prosthesis in the treatment of an IH has gained a widespread acceptance; different techniques are employed, placing the prosthetic mesh anteriorly, or behind the conjoined tendon in the preperitoneal space(1).
Generally the basic principles and indications of the preperitoneal procedure are not adequately considered in the training of young surgeons. The aim of this paper is to recall attention to this subject.


Our experience of preperitoneal inguinal prosthetic repair includes 50 cases, operated in the years 1995-2008 out of a total number of 150 operations for inguinal repair. There were 15 cases of indirect hernia, 21 direct, and 14 with these two types combined. All the operations have been performed monolaterally as a day-surgery and under local anaesthesia. The follow-up was continued up to 3-5 years.
Our operative technique has been directly derived from that of Horton and Florence (2), whose principal characteristics can be summarized as follows.
-Classical inguinal incision between the antero-superior iliac spine and the pubic tubercle, dividing  the external oblique fascia and the external ring and mobilizing the cord. The ilioinguinal nerve is gently isolated from the posterior inguinal wall. The external oblique fascia is largely cleaved from the conjoined tendon.
-In case of indirect hernia, the sac, carefully separated from the cord well beyond the internal ring, is reduced in the peritoneal cavity. In case of firm adhesion with the tunica vaginalis, it can be transacted in its middle part, leaving open the distal.
-When present a direct hernia, its sac is trimmed off the TF.
-At this moment, the decision for a preperitoneal repair is based on the conditions of the posterior inguinal wall: enlargement of the internal orifice, presence of a double IH, direct and indirect, global weakness of the TF (Illustration 1).
-In this case, the TF is opened from the internal orifice to the pubic tubercle, respecting the epigastric vessels.
- The subsequent dissection of the preperitoneum is extended laterally beyond the internal orifice, inferiorly to the Cooper’s ligament, and medially to the external border of the rectus sheath.
-A synthetic mesh, usually of polypropylene, rectangular in shape and of about 15 x 7cm in size, is prepared to cover all the dissected preperitoneal area, including the Bogros’space and the Fruchaud’s myopectineal orifice (3). An adequate slit is made in its superior border, to create a new internal ring and allow free passage of the cord (Illustration 2).
-The mesh, placed underneath the conjoined tendon, is anchored medially to the rectus abdominis sheath, inferiorly to the Cooper’s, and laterally to the inguinal ligament. In this way care is taken not to damage the iliohypogastric nerve in its possible intramuscular course. The two tails of the new created internal orifice in the prosthesis are crossed behind the cord and laterally sutured to the internal oblique muscle (Illustration 2).
-When possible, a new posterior musculo-aponeurotic inguinal wall is constructed approximating the edge of the conjoined tendon to the inguinal ligament. It helps to cover and isolate the mesh, and to prevent adhesions with the spermatic cord.
-The external oblique fascia is sutured to close the inguinal canal.
In our experience we have not observed any recurrence; in only 2 cases a transient inguinal pain was well controlled by a pharmacological treatment.


The main characteristics of this technique are: adequate exposure of the preperitoneal space; hermetic closure, from inside the muscolo-aponeurotic wall, of all the possible sites of recurrence, inguinal,femoral and obturator; anchorage of the mesh to musculo-aponeurotic structures, preventing in this way its dislodgement or folding (4,5,6,7). We think that the construction of a new internal orifice avoids the long dissection of the cord, necessary in case of its parietalisation with subsequent risk of damage and entrapment of its nervous structures.
The preperitoneal dissection is usually easy to accomplish, except in case of local scarring, as after iliac lymphadenectomy, or vascular approach to the external iliac artery. These two conditions are a contraindication to this technique.
Clearly, the above described procedure combines the advantages of the preperitoneal placement of the prothesis with the easy open anterior inguinal approach.
Comparing this technique with others more commonly used and based on the anterior placement of the prosthesis, characteristically that of  Lichtenstein (8,9), some differences are evident:
-minor possibility of recurrence, inguinal and especially femoral;
-the deep preperitoneal lodgement of the mesh protects against infections from the superficial planes of the wound;
-the abdominal pressure helps the mesh to adhere to the muscolo-aponeurotic structures of the whole inguinal region, that constitute a strong barrier against its anterior bulging or displacement;
-the preperitoneal location of the prosthesis resumes the position and the function of  the TF (10), also before its colonization by the new–produced connective tissue;
-the TF, clearly weak, is completely replaced, rather than only reinforced, as in the anterior disposition of the prosthesis.
The anterior placement of the mesh, typically the Lichtenstein’s operation, is applied more largely than the preperitoneal repair: in our experience with a ratio of 2:1. It requires a more limited dissection, also permitting a good reinforcement of the posterior inguinal wall through a simpler  anterior approach, and finds its principal indication when the TF can be still recognized as a preserved anatomical plane.


The surgical correction of an IH requests a good anatomical dissection and an accurate evaluation of the conditions of  the whole inguino-femoral region, in order to choose the best technique of reconstruction. The use of a prosthetic mesh, which certainly facilitates the surgeon, has not to be considered an universal “panacea”. On the contrary, a careful choice between the two different procedures, today more diffused, the anterior “tension free” hernioplasty and the posterior preperitoneal repair, is always advisable.
At this regard, the young surgeons must be skilled in both these techniques, while their senior colleagues must not remain crystallized on a single procedure.
Considering these aspects, the above mentioned technique of Horton and Florence, must be taken into good consideration.


1. Awad S.S., Fagan S.P. Current approach to inguinal hernia repair. Am J  Surg2004;188(Suppl.6A):9S-16S.
2. Horton M.D., Florence M.G. Simplified preperitoneal Marlex hernia repair. Am J Surg 1993; 165: 595-599.
3. Fagan S.P., Awad S.S. Abdominal wall anatomy: the key to a successful inguinal hernia repair. Am J Surg 2004;188(Suppl.6A):3S-8S.
4. Pelissier E.P. Inguinal hernia preperitoneal placement of a memory-ring patch by anterior approach. Preliminary experience. Hernia 2006; 10:248-252.
5. Pelissier E.P., Monek O., Blum D., Ngo P. The Polysoft patch:prospective evaluation of feasibility, postoperative pain and recovery. Hernia 2007;11:229-234.
6. Berrevoet F., Maes L., Reyntjens K. et al. Transinguinal preperitoneal memory ring patch versus Lichtenstein repair for unilateral inguinal hernias. Langenbeck’s Arch Surg 2010;395:557-562.
7. Berrevoet F.,Sommeling C., Gendt S. et al. The preperitoneal memory-ring patch for inguinal hernia: a prospective multicentric feasibility study. Hernia 2009;13:243-249.
8. Amid P.K. Lichtenstein tension-free hernioplasty: its conception, evolution and principles. Hernia 2004;8:1-7.
9. Muldoon R.L., Marchant K., Johnson D.D. et al. Lichtenstein anterior preperitoneal prosthetic mesh placement in open inguinal hernia repair: a prospective, randomized trial. Hernia 2004;8:98-103.
10. Condon R.E. Surgical anatomy of the transversus abdominis and trasversalis fascia. Ann Surg 1971;173:1-5.

Source(s) of Funding


Competing Interests



This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website.

0 reviews posted so far

0 comments posted so far

Please use this functionality to flag objectionable, inappropriate, inaccurate, and offensive content to WebmedCentral Team and the authors.


Author Comments
0 comments posted so far


What is article Popularity?

Article popularity is calculated by considering the scores: age of the article
Popularity = (P - 1) / (T + 2)^1.5
P : points is the sum of individual scores, which includes article Views, Downloads, Reviews, Comments and their weightage

Scores   Weightage
Views Points X 1
Download Points X 2
Comment Points X 5
Review Points X 10
Points= sum(Views Points + Download Points + Comment Points + Review Points)
T : time since submission in hours.
P is subtracted by 1 to negate submitter's vote.
Age factor is (time since submission in hours plus two) to the power of 1.5.factor.

How Article Quality Works?

For each article Authors/Readers, Reviewers and WMC Editors can review/rate the articles. These ratings are used to determine Feedback Scores.

In most cases, article receive ratings in the range of 0 to 10. We calculate average of all the ratings and consider it as article quality.

Quality=Average(Authors/Readers Ratings + Reviewers Ratings + WMC Editor Ratings)