Open Right Inguinal Hernia Repair

David R. Farley, MD
Content Author:
Matthew Zeller DO, Pierce Campbell, Max Mirande DO
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Background Information:

Inguinal hernias occur when abdominal contents herniate through the inguinal canal (indirect) or Hesselbach's triangle (direct) or both (pantaloon hernia). Direct inguinal hernias occur secondary to increased intraabdominal pressure and indirect hernias resulting from patent processus vaginalis in males or canal of Nuck in females (an extension of the peritoneum that closes during normal development). Inguinal hernias may contain various contents but commonly contain intraperitoneal fat, small bowel, or cord lipoma. An inguinal hernia containing the appendix is termed an Amyand’s hernia. A sliding hernia occurs when a retroperitoneal organ makes up part of the hernia sac. Inguinal hernias are repaired using open or minimally invasive (laparoscopic or robotic) techniques. Asymptomatic inguinal hernias often become symptomatic over time. 


Symptomatic direct or indirect inguinal hernias should be electively repaired. Incarcerated hernias should be repaired emergently.

Procedure Description:

An open inguinal hernia is a procedure performed through an incision in the groin overlying the inguinal canal. There are many techniques of open inguinal hernia repair, the most common being the Lichtenstein repair. This technique uses a mesh to reinforce inguinal structures after reducing the hernia sack and isolating the spermatic cord contents. The Lichtenstein repair is a tension-free mesh repair.

Key Anatomy:

Subcutaneous tissue 

  • Camper's fascia
  • Scarpa's fascia

Abdominal wall:

  • External oblique aponeurosis
  • Internal oblique muscle
  • Hesselbach's triangle (direct hernia space)
  • ~Lateral border: inferior epigastric vessels
  • ~Inferior border: inguinal ligament
  • ~Medial border: lateral border of rectus abdominis muscle

Inguinal anatomy

  • Deep (internal) inguinal ring
  • Superficial (external) inguinal ring
  • Spermatic cord
  • ~Cremaster muscle (fibers from internal oblique muscle)
  • ~Pampiniform venous plexus
  • ~Testicular artery
  • ~Vas deferens
  • ~~Artery of the vas deferens
  • Inguinal ligament (Poupart's ligament)
  • ~Shelving edge of the inguinal ligament
  • Cooper's ligament
  • Lacunar ligament


  • Ilioinguinal nerve
  • Genital branch of the genitofemoral nerve
  • Iliohypogastric nerve


  • Anterior superior iliac spine (ASIS)
  • Pubic tubercle 
  • Iliac vessels


General surgical risks:

  • Bleeding
  • Infection

Risks with open hernia repair with mesh (incidence following an open hernia repair with mesh)

  • Post herniorrhaphy neuralgia/inguinodynia (13% at three months follow upⁱ) 
  • Seroma (1.6%²) or hematoma formation (6.1%²)
  • Deep surgical site infection (0.45%³)
  • ~Often requiring mesh removal
  • Orchitis (0.7%4⁴)
  • Sexual dysfunction and pain with sexual activity (13% and 3.7% respectively⁵)
  • Injury to hernia contents

American College of Surgeons/Association for Surgical Education Medical Student Core Curriculum

Groin Mass

Online MedEd

Mayo Clinic


  • Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice by Courtney M. Townsend Jr. JR. MD
  • Zollinger's Atlas of Surgical Operations, Tenth Edition 10th Edition by Robert Zollinger, E. Ellison 
  • Atlas of General Surgical Techniques: Townsend, Evers
  • Essentials of General Surgery 5th Edition, by Peter F. Lawrence MD, Richard M. Bell MD, Merril T. Dayton MD, James C. Hebert MD FACS

Key Literature:

  • Open vs Laparoscopic approach

  1. Nienhuijs S, Staal E, Strobbe L, Rosman C, Groenewoud H, Bleichrodt R. Chronic pain after mesh repair of inguinal hernia: a systematic review. Am J Surg. 2007;194(3):394-400. doi:10.1016/j.amjsurg.2007.02.012
  2. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial [published correction appears in JAMA. 2006 Jun 21;295(23):2726]. JAMA. 2006;295(3):285-292. doi:10.1001/jama.295.3.285
  3. Orelio CC, van Hessen C, Sanchez-Manuel FJ, Aufenacker TJ, Scholten RJ. Antibiotic prophylaxis for prevention of postoperative wound infection in adults undergoing open elective inguinal or femoral hernia repair. Cochrane Database Syst Rev. 2020;4(4):CD003769. Published 2020 Apr 21. doi:10.1002/14651858.CD003769.pub5
  4. Hawn MT, Itani KM, Giobbie-Hurder A, McCarthy M Jr, Jonasson O, Neumayer LA. Patient-reported outcomes after inguinal herniorrhaphy. Surgery. 2006;140(2):198-205. doi:10.1016/j.surg.2006.02.003
  5. Ssentongo AE, Kwon EG, Zhou S, Ssentongo P, Soybel DI. Pain and Dysfunction with Sexual Activity after Inguinal Hernia Repair: Systematic Review and Meta-Analysis. J Am Coll Surg. 2020;230(2):237-250.e7. doi:10.1016/j.jamcollsurg.2019.10.010