What is All of the following statements are true about the repair of groin hernias except - and explain in detail?
Shouldice repair is a method of hernia repair in which the inguinal floor is strengthened by just approximation of tissue using non-absorbable sutures. No mesh is used.


Management of Groin hernias (mainly inguinal hernia)  
There are 2 objectives of t/t :
Treatment of the hernial sac
In Indirect hernias, the sac is dissected free from the cord structures and cremastric fibres. The sac is opened and the herniated contents are reduced. Then the sac is ligated at the internal inguinal ring. Alternatively the hernial sac may be invaginated back into the abdomen without ligation.
Direct sacs are usually too broad based for ligation and should not be opened but instead are simply inverted into the peritoneal cavity.
Inguinal floor reconstruction

Management of the hernial sac is sufficient for children and young adults, but some method of reconstruction (repair or strengthening) of the inguinal floor is necessary for all adult hernias to prevent recurrence.
3 broad categories of repair are available


Primary tissue repair
Anterior tension-free mesh repairs
Preperitoneal repairs - open & the laparoscopic approach

a) Primary tissue repair

In this method, the post wall of inguinal canal is strengthened by just approximation of tissues with sutures. There is no use of any prosthetic material.
Primary repairs without mesh were the mainstay of hernia surgery for decades. The advantages are simplicity of the repair and absence of any foreign body in the groin. Disadvantages include higher recurrence rates due to tension on the repair and a slower return to unrestricted physical activity. Consequently, tension free mesh repairs have now become the dominant method of inguinal hernia repair.
Commonly performed primary tissue repairs are


Bassini repair
Halsted repair
McVay (Cooper ligament) repair
Shouldice repair
Darn repair


Darn repair gets its name from the way a long nylon suture repeatedly passed between the tissues to create a weave that one might consider similar to mesh.

Anterior tension-free mesh repair
Recognizing that tension in a repair is the principal cause of recurrence, current practices in hernia management employ a synthetic mesh prosthesis to bridge the defect

Recurrence rate is quite low with these techniques
Common employed techniques are

 Lichtenstein repair
In Lichtenstein repair a piece of polypropylene mesh is used to reconstruct the inguinal floor.

The mesh is sutured to the abdominal fascia.
Recurrence rate is quite low

Patch and plug technique
In this method, a plug of the mesh is inserted into the hernial defect (i.e. an internal ring in an Indirect hernia) and sutured in place. Then another piece of mesh is placed over the inguinal floor which may or may not be sutured to the fascia.
Laparoscopic and Preperitoneal repairs

The laparoscopic hernia repair is based on the technique of 'Stoppa', who used an open preperitoneal approach to reduce the hernia and placed a large piece of mesh to cover the entire inguinal floor and myopectineal orifice. Preperitoneal hernia repairs may also be performed without mesh, but its rarely used now.
In Laparoscopic hernia repair, the preperitoneal space is reached by either transabdominal laparoscopy (TAPP) or by a totally extraperitoneal repair (TEP)
Both techniques are similar in actual repair but differ in the manner by which the preperitoneal space is accessed.

TAPP (Trans-abdominal pre-peritoneal)

in the TAPP repair, the peritoneal space is entered by conventional laparoscopy and then the preperitoneum overlying the inguinal floor is dissected away as a flap.

TEP (totally extraperitoneal repair)

in TEP repair the preperitoneal space is accessed without entering the peritoneal cavity.

Choice of Anesthesia


Here there is a difference of opinion b/w Schwartz Surgery (8/e, p 1368) & Washington Manual of Surgery (4/e, p 511)

According to the Washington Manual of Surgery

local anaesthesia is the preferred anaesthetic for elective open repair.
Laparoscopic hernia repair has been carried out under local or regional anaesthesia, but is more commonly done under General anaesthesia.

According to Schwartz Surgery

General anaesthesia is the preferred choice for open as well as laparoscopic repair.