Hernia Repair: Laparoscopic and Open Surgical Techniques

The decision to repair a hernia is, in most cases, straightforward. The decision about how to repair it is where the nuance lies.

Over the last three decades, laparoscopic techniques have transformed hernia surgery — offering patients less postoperative pain, faster return to activity, and lower recurrence rates for certain hernia types, particularly inguinal hernias. At the same time, open repair remains an important and highly effective option — and for complex incisional hernias and many primary ventral defects, it remains the approach of choice.

At Sulphur Surgical Clinic, our surgeons offer both laparoscopic and open hernia repair, tailoring the approach to each patient’s specific hernia, anatomy, prior surgical history, and goals. This is Part 2 of our Hernia Series.

Principles of Hernia Repair

Regardless of approach, every hernia repair shares two fundamental objectives:

Reduction — returning the hernia contents to the abdominal cavity and excising or reducing the hernia sac
Reinforcement — closing or bridging the fascial defect to prevent recurrence

How reinforcement is achieved — with primary suture repair, prosthetic mesh, or both — is one of the central decisions in hernia management. Understanding the role of mesh is essential to understanding modern hernia surgery.

The Role of Mesh

Prosthetic mesh has fundamentally changed hernia repair outcomes. Prior to its widespread adoption, primary suture-only repairs placed significant tension on native tissue — and recurrence rates of 10 to 15% or higher were common. The introduction of tension-free mesh repair — in which the mesh bridges or reinforces the defect without pulling native tissue edges together under tension — reduced recurrence rates to 1 to 5% for most primary hernias.

Modern surgical meshes are available in a variety of materials (polypropylene, polyester, expanded PTFE, biologic) and configurations. The choice of mesh depends on hernia location, approach, contamination risk, and patient factors. Lightweight macroporous meshes have become the standard for most inguinal and ventral repairs, offering excellent strength with reduced foreign body sensation.

Is mesh always required? For very small primary defects — small umbilical hernias less than 1 to 2 cm in selected patients, or epigastric hernias with minimal tissue tension — primary suture repair may be appropriate. For the vast majority of adult hernias, however, mesh reinforcement is the evidence-based standard and significantly reduces recurrence risk.

Inguinal Hernia Repair

Inguinal hernia repair is the most commonly performed elective general surgery operation in the United States. More than one million inguinal hernia repairs are performed annually. The two principal approaches are laparoscopic and open repair — and both are effective, with the choice influenced by hernia characteristics, laterality, prior surgery, and surgeon and patient preference.

Laparoscopic Inguinal Hernia Repair

Laparoscopic inguinal hernia repair has become the preferred approach at Sulphur Surgical Clinic for the majority of inguinal hernias — particularly bilateral hernias and recurrent hernias following prior open repair. It offers several important advantages over the open approach, including reduced postoperative pain, faster return to normal activity, lower rates of chronic groin pain, and equivalent or superior recurrence rates in experienced hands.

The preferred laparoscopic approach at Sulphur Surgical Clinic is the TEP (totally extraperitoneal) technique:

TEP — Totally Extraperitoneal Repair

The totally extraperitoneal (TEP) approach accesses the preperitoneal space — the tissue plane between the posterior abdominal wall and the peritoneum — without entering the peritoneal (abdominal) cavity itself. This is the key distinguishing feature of TEP: the procedure is performed entirely behind the peritoneum, and the abdominal organs are never directly visualized or at risk of injury from trocar placement.

How TEP is performed:

A small incision is made at or just below the umbilicus. A balloon dissector or blunt dissection is used to develop the preperitoneal space, which is then insufflated with carbon dioxide to create a working cavity. Two additional small trocars are placed in the midline below the umbilicus. Working in this preperitoneal space, the surgeon identifies the hernia defect(s), reduces the hernia sac, and dissects the myopectineal orifice — the anatomic region encompassing the inguinal and femoral spaces — back to the Cooper’s ligament inferiorly and the iliac vessels laterally.

A large piece of prosthetic mesh (typically 15 × 10 cm or larger) is positioned to cover the entire myopectineal orifice, overlapping well beyond the hernia defect in all directions. The mesh is secured with tacks, fibrin glue, or in some cases left unfixed (self-fixating mesh or anatomically positioned mesh in the preperitoneal space), and the pneumoperitoneum is released — allowing the posterior peritoneum to hold the mesh in place through intra-abdominal pressure.

Advantages of TEP:

No entry into the peritoneal cavity — lower risk of intra-abdominal adhesions and visceral injury
Excellent visualization of the myopectineal orifice and all potential hernia spaces (direct, indirect, and femoral) simultaneously
Reduced postoperative pain compared to open repair
Very rapid recovery — most patients return to light activity within days and to full activity within 2 to 4 weeks
Ideal for bilateral inguinal hernias — both sides can be repaired through the same three incisions in the same operative session
Excellent approach for recurrent hernias after prior open repair (virgin preperitoneal space)

Advantages of Laparoscopic Inguinal Repair Over Open Repair

Multiple randomized controlled trials and meta-analyses have consistently demonstrated that laparoscopic inguinal hernia repair offers:

Less postoperative pain — particularly in the early recovery period
Faster return to work and normal activity — typically 7 to 14 days versus 3 to 6 weeks for open repair
Lower rates of chronic groin pain — one of the most significant quality-of-life outcomes; laparoscopic repair has a meaningfully lower rate of persistent groin discomfort compared to open techniques
Equivalent or better recurrence rates — in experienced hands
Superior outcomes for bilateral hernias — one operation, three small incisions, both sides repaired simultaneously
Preferred approach for recurrence after prior open repair — TEP provides a clean tissue plane in patients who have had prior open Lichtenstein repair, avoiding the scarred anterior approach

Open Inguinal Hernia Repair: The Lichtenstein Tension-Free Repair

The Lichtenstein repair — introduced in the 1980s and refined over subsequent decades — is the gold standard open inguinal hernia repair and the most widely performed hernia operation in the world. It is performed under local, regional, or general anesthesia through a 4 to 6 cm incision in the groin.

How Lichtenstein repair is performed:

The inguinal canal is opened by incising the external oblique aponeurosis. The spermatic cord (or round ligament) is identified and protected. The hernia sac is identified, reduced, and ligated if indirect; the direct defect is reduced if present. A flat piece of polypropylene mesh is then fashioned to fit the inguinal floor and secured to the inguinal ligament, pubic tubercle, and conjoint tendon with sutures — creating a tension-free reinforcement of the posterior inguinal wall. A keyhole in the mesh accommodates the spermatic cord.

Advantages of Lichtenstein repair:

Performed safely under local anesthesia — an important option for patients with cardiac or pulmonary comorbidities
Does not require general anesthesia or laparoscopic equipment
Excellent long-term recurrence rates (less than 1 to 2% in experienced hands)
Shorter operative time in straightforward cases
Preferred approach for recurrent hernias after prior laparoscopic repair

When open repair is preferred:

Patients who cannot tolerate general anesthesia
Contraindications to laparoscopic surgery (severe cardiopulmonary disease limiting pneumoperitoneum tolerance)
Patient preference
Complex groin anatomy where open dissection is safer
Recurrent hernia after prior laparoscopic repair

Umbilical and Epigastric Hernia Repair

Small Primary Defects (< 1–2 cm)

Small umbilical and epigastric hernias — particularly those with narrow fascial defects containing only preperitoneal fat — can often be repaired with primary suture closure. The hernia contents are reduced, the sac is excised, and the fascial defect is closed with interrupted permanent sutures. In carefully selected patients, this provides a durable repair without the placement of prosthetic material.

Larger Defects and Mesh Repair

For umbilical and epigastric defects greater than 1 to 2 cm, or in patients with obesity, connective tissue disorders, or risk factors for recurrence, mesh reinforcement is strongly recommended.

Open mesh repair: A piece of mesh is placed in the preperitoneal (sublay) position — beneath the posterior fascia — or in the onlay position above the fascia. Sublay mesh placement has the lowest recurrence rate and is the preferred technique for larger defects. The mesh is secured circumferentially and the fascial edges are closed over it.

Laparoscopic umbilical/ventral repair: For primary umbilical and ventral hernias of moderate size, a laparoscopic approach is feasible and effective. Trocars are placed to access the abdominal cavity, adhesions to the hernia sac are released, the defect is assessed, and an intraperitoneal onlay mesh (IPOM) is placed using a dual-layer mesh designed for contact with bowel. The mesh is secured with a combination of tacking devices and transfascial sutures.

Laparoscopic repair offers reduced wound complications and shorter hospitalization for appropriate ventral hernias. However, for large defects, complex anatomy, or hernias requiring fascial component separation, open repair remains the approach of choice.

Incisional / Ventral Hernia Repair

Incisional hernias are among the most technically demanding hernia repairs in general surgery. The defect is often large and irregular, the surrounding fascia is scarred and thinned, and the goal — restoring functional abdominal wall integrity — may require substantially more than simply placing mesh over the defect.

Key Principles

Mesh position matters. The strongest repairs place mesh in the retrorectus (sublay) position — behind the posterior sheath of the rectus muscle — or in the preperitoneal position. These positions allow the mesh to be held in place by intra-abdominal pressure and provide broad overlap beyond the defect edges. Onlay mesh (placed on top of the fascia) has higher recurrence and infection rates.

Defect bridging versus fascial closure. Whenever possible, the fascial edges of an incisional hernia should be re-approximated — closing the defect primarily — with mesh used to reinforce the repair rather than bridge across a persistent defect. Bridged repairs (where the mesh spans an unclosed defect) have substantially higher recurrence rates.

Component Separation

For very large or complex incisional hernias in which the fascial edges cannot be brought together without excessive tension, component separation techniques are used to recruit additional tissue. The anterior component separation (Ramirez technique) involves releasing the external oblique aponeurosis laterally, allowing the rectus muscle complex to be advanced medially toward the midline — often providing 5 to 10 cm of additional tissue on each side. Posterior component separation with transversus abdominis release (TAR) allows even greater medialization and simultaneous creation of a large retromuscular mesh space.

These are complex operations with longer recovery times but provide durable, tension-free repairs for patients who would otherwise face very high recurrence rates.

Open Retromuscular Repair (Rives-Stoppa)

The Rives-Stoppa repair is the reference standard for open incisional hernia repair. It involves developing the retrorectus space bilaterally, closing the posterior fascial layer, and placing a large piece of mesh in the retromuscular position with broad overlap in all directions. The anterior fascia is then closed over the mesh. This technique has consistently produced the lowest recurrence rates among open incisional hernia repairs.

Femoral Hernia Repair

Femoral hernias are repaired through either an inguinal approach (with mesh repair of the femoral orifice from above), a preperitoneal approach (open or laparoscopic, allowing direct visualization of the femoral ring), or a crural approach from below the inguinal ligament. The laparoscopic preperitoneal approach (TEP) provides excellent exposure of the femoral space and is increasingly preferred when the diagnosis is confirmed preoperatively.

In cases of incarcerated or strangulated femoral hernia requiring emergency repair, the approach is dictated by the clinical situation — often requiring a combined inguinal and abdominal approach to safely reduce and inspect the bowel.

Anesthesia and Setting

The vast majority of elective hernia repairs are performed as outpatient procedures — patients arrive, have surgery, and go home the same day. This includes:

Laparoscopic inguinal hernia repair (unilateral and bilateral)
Open Lichtenstein inguinal repair
Umbilical and epigastric hernia repair

Complex incisional hernia repairs — particularly those requiring component separation — may require a short inpatient stay.

Anesthesia choices depend on the approach and patient factors:

Laparoscopic repairs require general anesthesia
Open inguinal repair can be performed safely under local anesthesia with IV sedation — an important option for higher-risk patients
Open umbilical and ventral repairs typically use general or regional anesthesia

Recovery and Return to Activity

Recovery from hernia repair varies by procedure type and individual patient factors. General expectations:

Laparoscopic inguinal hernia repair: Most patients return to desk work within 5 to 7 days and to full unrestricted activity within 2 to 4 weeks. Pain is typically well-managed with oral analgesics and resolves within the first week.

Open inguinal repair: Return to light activity in 2 to 3 weeks; full activity in 4 to 6 weeks. Groin discomfort may persist slightly longer than with laparoscopic repair.

Umbilical/epigastric repair: Light activity within 1 to 2 weeks; full activity in 3 to 4 weeks depending on mesh size and approach.

Complex incisional hernia repair: Longer recovery — 4 to 8 weeks before return to unrestricted activity, with abdominal binder use for support.

Hernia Surgery at Sulphur Surgical Clinic

Our board-certified surgical team at Sulphur Surgical Clinic provides comprehensive hernia care for patients across Southwest Louisiana, including:

Laparoscopic inguinal hernia repair (TEP) — our preferred approach for bilateral hernias, recurrent hernias, and active patients
Open Lichtenstein tension-free inguinal repair — the gold standard open technique, performed under local anesthesia when appropriate
Umbilical and epigastric hernia repair — primary suture and mesh techniques
Open ventral/incisional hernia repair — including complex repairs with retromuscular mesh placement
Component separation for large abdominal wall defects when indicated

If you’ve been told you have a hernia — or if you’ve noticed a bulge in your groin, abdomen, or along a prior scar — we’d welcome the opportunity to evaluate you, explain your options clearly, and help you decide on the right repair strategy for your lifestyle and goals.

Complete the SSC Hernia Series

Part 1: Abdominal Wall Hernias — Types, Symptoms, and When to See a Surgeon
Part 2 (this post): Hernia Repair — Laparoscopic and Open Surgical Techniques

To schedule a hernia consultation at Sulphur Surgical Clinic, call (337) 527-6363 or visit sulphursurgicalclinic.com. Serving patients at two convenient locations: 914 Cypress Street, Sulphur LA 70663 and our new Lake Charles office at 1920 W Sale Rd, Lake Charles LA 70605.