Laparoscopic inguinal hernia repair has become the gold standard for managing groin hernias in many centers worldwide. The advantages—such as smaller incisions, reduced postoperative pain, quicker recovery, and lower recurrence rates—make it highly preferred over conventional open surgery. However, one of the major concerns in developing countries and resource-limited settings is the cost of mesh implants, which are essential for reinforcing the weakened abdominal wall. While premium meshes can be costly, effective repairs can also be achieved with less expensive, good-quality meshes, provided the surgeon follows proper technique and safety principles.

This article explains the easiest and most practical way to perform laparoscopic inguinal hernia repair using affordable mesh, without compromising surgical outcomes.

Background

The two widely accepted laparoscopic approaches for inguinal hernia repair are:

Transabdominal Preperitoneal (TAPP) Repair – where the peritoneal cavity is entered, and the mesh is placed in the preperitoneal space.

Totally Extraperitoneal (TEP) Repair – where the mesh is placed in the preperitoneal space without entering the peritoneal cavity.

Both techniques can be performed with standard polypropylene mesh, which is available at a much lower cost compared to composite or self-fixating meshes. The polypropylene mesh, when used correctly, provides adequate strength and durability.

Step-by-Step Approach
Patient Preparation

Patients are placed under general anesthesia.

The bladder is catheterized if needed to avoid injury.

The patient is placed in the supine position with arms tucked.

Port Placement

For TAPP repair, a three-port technique is commonly used:

A 10 mm umbilical port for the telescope.

Two 5 mm ports in the lower abdomen for working instruments.

For TEP repair, ports are placed in the infraumbilical region and lower midline, with balloon dissection of the preperitoneal space.

Creation of Working Space

In TAPP, peritoneum is incised to expose the myopectineal orifice.

In TEP, a balloon dissector or blunt dissection creates adequate working space.

The hernia sac is carefully dissected and reduced. Special attention is paid to identifying and protecting important structures such as the vas deferens, testicular vessels, inferior epigastric vessels, and nerves.

Mesh Selection

Instead of expensive meshes like composite or pre-shaped 3D meshes, surgeons can use a flat, lightweight polypropylene mesh (size around 10 × 15 cm). This mesh is significantly cheaper but still provides excellent reinforcement when placed correctly.

Key points for mesh use:

The mesh should be large enough to cover the entire myopectineal orifice, including direct, indirect, and femoral hernia sites.

Edges should be trimmed to fit the space without folding.

Mesh sterilization and handling must follow strict protocols to prevent infection.

Mesh Placement

The mesh is introduced into the abdominal cavity through the 10 mm port.

It is carefully unfolded in the preperitoneal space.

The medial edge should cover the pubic bone and Cooper’s ligament, while the lateral edge should extend well beyond the deep inguinal ring.

Superior and inferior coverage must be ensured to prevent recurrence.

Fixation

One of the ways to further reduce costs is to avoid or minimize the use of tackers or fixation devices, which are expensive. Instead, the following approaches can be used:

No-fixation Technique – The mesh is left in place without fixation, relying on intra-abdominal pressure and tissue healing to secure it. This is safe if the mesh is adequately sized.

Glue Fixation – Tissue adhesives like fibrin glue can be used in select cases, though not always necessary.

Limited Suturing – Simple absorbable sutures placed at key points (pubic tubercle and Cooper’s ligament) can secure the mesh effectively at minimal cost.

Peritoneal Closure

In TAPP repair, the peritoneum is closed over the mesh to prevent bowel adhesion. In TEP repair, no closure is required as the peritoneum remains intact.

Completion

Ports are removed, pneumoperitoneum is released, and skin incisions are closed with sutures or surgical glue.

Advantages of Using Less Expensive Mesh

Cost-Effective – Reduces financial burden on patients, especially in low-resource settings.

Widely Available – Polypropylene mesh is easily accessible in most hospitals.

Proven Durability – Decades of clinical use have proven its strength and long-term reliability.

Comparable Outcomes – When placed correctly, recurrence and complication rates are similar to those of more expensive meshes.

Challenges and Precautions

Foreign Body Reaction – Polypropylene may cause more inflammatory response compared to advanced meshes, but this is usually clinically insignificant.

Proper Placement is Critical – Inadequate mesh size or poor positioning can lead to recurrence.

Surgeon Skill – Precision in dissection and placement is vital, as the success depends more on surgical technique than on mesh type.

Infection Prevention – Low-cost mesh must be handled under strict aseptic conditions to avoid mesh infection, which can be devastating.

Conclusion

The easiest and most economical way of performing laparoscopic inguinal hernia repair is to use a flat polypropylene mesh, ensuring that it is of adequate size and placed properly to cover the entire myopectineal orifice. Avoiding expensive fixation devices and relying on no-fixation or minimal suturing further reduces costs without compromising outcomes.

By adopting these practical and safe techniques, surgeons can offer high-quality laparoscopic hernia repair that is affordable, effective, and accessible to patients across diverse healthcare settings.