Surgeons should master the laparoscopic anatomy of the inguinal region before performing laparoscopic inguinal hernia repair and should be particularly aware of the anatomy of the inguinal nerves.

Surgeons should be appropriately trained in all techniques for laparoscopic hernia repair, including the totally extraperitoneal (TEP), enhanced or extended view TEP (eTEP), transabdominal preperitoneal (TAPP), and intraperitoneal onlay mesh (IPOM) techniques, in addition to primary closure of defects. Comprehensive training allows surgeons to offer the appropriate procedure according to individual patient characteristics and to convert from one procedure to another if necessary.

One of the best ways to avoid pain after inguinal hernia repair is to avoid operating on patients with unusual preoperative inguinal pain or inguinal pain that is disproportionate to the hernia. Pain is usually not a remarkable symptom of inguinal hernias, except in complex cases. Many patients with disproportionate preoperative pain have a different cause for their pain and develop chronic pain after hernia repair.

We recommend administration of a first-generation cephalosporin during the induction of anesthesia. We do not routinely use prophylactic antithrombotic medication, but use pneumatic compression devices in all patients.

Patients should be reexamined while standing immediately before surgery, and the physical examination findings should be compared with the laparoscopic findings. This is an excellent method for ensuring that hernias are not missed.

We prepare the skin, drape the patient, and set up the equipment while the patient is still awake (but sedated) so that surgery starts almost immediately after the induction of anesthesia, thereby reducing costs and facilitating a faster recovery. Optimal muscle relaxation is important to ensure a fast and easy procedure, and the anesthesiologist should be asked to provide a short period of full relaxation before the start of the operation.

We inject long-acting local anesthetic into the skin before incision to reduce postoperative pain [1]. Surgeons should be able to perform surgery both in a triangulated position and with the camera lateral to the working ports, so that they can adapt to different setups.

When using the TEP technique, the use of a balloon trocar to create the surgical space makes the procedure easier and faster and reduces blood loss, which may result in less postoperative pain [2].

The eTEP technique creates a larger surgical space and allows a more versatile distribution of ports than the TEP technique. The eTEP technique takes advantage of the fact that the preperitoneal space can be reached from almost any part of the anterior abdominal wall [3]. A video showing this technique can be found online [4].

The creation of large peritoneal flaps during the TAPP procedure facilitates complete dissection of the myopectineal orifice of Fruchaud, placement of a large mesh, and perfect apposition of the peritoneal edges at the end of the procedure. This is a faster, less expensive, and less painful alternative to closing the peritoneum using tacks, glue, or sutures. The peritoneal edges come together as CO₂ is carefully released, and the wound heals quickly. The findings of an experimental study support this approach [5]. We have never closed the peritoneum, and other groups have also reported that they do not close the peritoneum. We have not experienced any cases of bowel obstruction or fistula using this approach. For the same reason, we do not close accidental tears created during the TEP or eTEP procedures. A video showing peritoneal apposition at the end of a TAPP procedure can be found online [6]. However, not physically closing the peritoneal edges is controversial, and most consensus statements recommend some type of peritoneal closure, with suture closure being the most frequently used. The recent development of barbed sutures has increased the ease of peritoneal closure.

We advise a stepwise approach to dissection. In the TEP procedure, we dissect Cooper’s ligament (both ligaments in cases of direct hernias), free the lax transversalis fascia from preperitoneal structures in cases of direct hernias, dissect the space of Bogros, divide the posterior transversalis fascia that usually overlaps the indirect sac and peritoneum at the level of the internal ring, and finally identify the indirect sac. A video showing the seldom-mentioned posterior transversalis fascia is available online [7]. Cauterization should be performed with care and avoided at the “triangle of doom” and the electrical hazard zone or “triangle of pain.” The use of fine, low-voltage instruments and bipolar cautery helps to avoid damage to sensitive structures and to prevent residual hematoma , which is one of the most commonly cited causes of postoperative pain.

One rarely mentioned cause of pain after hernia surgery is grasping and traction of the cord structures, which is common during open surgery. This pain may be caused by injury to the vasa nervorum. In laparoscopic repair, traction may occur during separation of an indirect sac from the cord structures, as some surgeons grasp the cord structures to dissect them from the sac. We advise pulling the sac medially while dissecting the fibrous and fatty tissues next to the cord structures, using fine Maryland forceps without directly touching the cord structures. As dissection progresses, the sac can be grasped more laterally and rotated medially. This process is continued until the hernia sac is separated from the vas deferens and the spermatic vessels by a bluish transparency. Videos of these maneuvers are available online [8, 9]. It is then possible to deal with the sac in two ways. If the sac does not extend deeply into the scrotum, it can be reduced completely. In cases of large inguinoscrotal hernias, attempting to completely reduce the sac risks damage to the cord structures and the development of orchitis. Failure to deal with the distal sac, however , carries the risk of formation of large and sometimes cumbersome hematomas, seromas, or pseudohydroceles. Repeated drainage and occasionally surgery may be necessary in such cases.

We previously described a technique for managing the distal sac in large inguinoscrotal hernias [10]. After ligating the sac and dividing it distally, at the level of the internal ring, we reduce the distal sac by pulling it out of the scrotum and fixing it high and laterally to the posterior inguinal wall with tacks or sutures. Using this maneuver, we were able to reduce the incidence and severity of seromas, with no cases of postoperative orchitis, testicular pain, or neuralgia [10]. A video showing this maneuver is available online [11].

The next step is parietalization of structures, which consists of proximal dissection of the sac and peritoneum to allow proper placement of the mesh over the cord structures. Extensive proximal dissection helps to prevent recurrence by rolling of the mesh or a sac sliding under the mesh. Parietalization is complete when upward traction of the sac does not move the cord structures. A video showing parietalization is available online [12].