State of the art: open mesh-based inguinal hernia repair

Open inguinal hernia repair remains the most universal, ubiquitous, reliable, and cost-effective method of addressing the global burden of groin hernias. Advances in anatomic understanding and technique have refined a few well-established techniques that can address the majority of the burden of disease with low rates of morbidity, recurrence, and chronic pain. Prosthetic reinforcement has become routine because of the clear reduction in recurrence rates in general practice conferred by mesh and the less-appreciated consideration of simplification of the repair whereby operator variability, hernia type, anatomic variation, patient habitus, tissue deficiencies, and surgical technique are homogenized by reproducible standard techniques. While minimally invasive laparoscopic and robotic approaches have increased in popularity, availability, and reliability, open inguinal-repair techniques continue to provide durability, low risk, minimal cost, ease of training and dissemination, and excellent outcomes and remain a fundamental foundation for the practice and art of hernia surgery. Additionally, as chronic pain and quality of life metrics supersede recurrence as the primary clinical outcome of inguinal hernia repair, the ability to offer a "tailored approach" with several options ranging from tissue- and mesh-based open repairs to minimally invasive prosthetic reinforcement has become an important consideration in providing each patient with different options and the best possibility of a favorable outcome. Paramount to this is a solid understanding of the anatomy and standardization of proper technique for each operation to minimize complications and maximize patient outcomes.