Inguinal hernias are less common in females compared to males but carry unique clinical considerations. Female inguinal hernias often contain ovaries, fallopian tubes, or other pelvic structures, making careful dissection essential. Laparoscopic repair has become the preferred approach in women due to enhanced visualization, ability to identify contralateral hernias, and reduced recurrence rates, particularly because femoral hernias are more common in females and often missed in open repairs.

The laparoscopic approach can be performed using TAPP (TransAbdominal Preperitoneal) or TEP (Totally Extraperitoneal) techniques. Both approaches are minimally invasive, allowing faster recovery, minimal postoperative pain, and excellent cosmetic outcomes.

Preoperative Evaluation

Clinical Assessment:

Inspect and palpate for groin bulges, which may be subtle.

Evaluate for symptoms such as groin pain, heaviness, or reducibility.

Imaging:

Ultrasound is often sufficient to confirm hernia type and content.

CT scan may be used in complex or recurrent cases.

Patient Counseling:

Discuss laparoscopic versus open repair.

Explain potential findings such as femoral hernia or ovary involvement.

Review postoperative expectations and activity limitations.

Preparation:

Routine labs and anesthetic clearance.

Prophylactic antibiotics if indicated.

Emptying the bladder prior to surgery for better visualization.

Anesthesia and Positioning

The procedure is performed under general anesthesia. The patient is placed in the supine position, with arms tucked and a slight Trendelenburg tilt to allow bowel loops to fall away from the pelvis.

Surgeon stands contralateral to the hernia, assistant on the other side.

Monitor is positioned at the foot end.

In cases of bilateral hernias, laparoscopy provides simultaneous assessment and repair without additional incisions.

Port Placement

TAPP Approach:

Establish pneumoperitoneum via a Veress needle or open technique at the umbilicus.

Insert a 10 mm umbilical camera port.

Two 5 mm working ports are placed in the lower abdomen along the midclavicular lines for dissection and instrument manipulation.

TEP Approach:

Infra-umbilical incision to create a preperitoneal space using a balloon dissector or blunt technique.

Insert a 10 mm camera port and two 5 mm working ports in the suprapubic and midline areas.

Maintain preperitoneal insufflation (8–12 mmHg) for space creation.

Diagnostic Assessment

Visualize the inguinal and femoral regions.

Identify hernia type: direct, indirect, femoral, or combined.

Check for contralateral occult hernia, which is more common in females.

Note any hernia sac contents, such as ovary, fallopian tube, or bladder.

Hernia Sac Reduction

Dissect the hernia sac carefully to avoid injury to reproductive structures.

Reduce contents gently into the abdominal or preperitoneal cavity.

If an ovary or tube is adherent, use blunt and sharp dissection under direct vision.

Achieve hemostasis using bipolar cautery or energy devices.

Defect Preparation

Expose the myopectineal orifice completely, including indirect, direct, and femoral spaces.

Remove preperitoneal fat and ensure a flat surface for mesh placement.

In TAPP, mobilize the peritoneal flap to cover the mesh later.

Mesh Selection and Placement

A lightweight polypropylene mesh is typically used for female patients.

Mesh size should provide at least 3–4 cm overlap beyond all defect margins.

Introduce the mesh through a 10 mm port and position it over the defect.

Fixation can be achieved using tacks, fibrin glue, or sutures, ensuring avoidance of the “triangle of pain” and “triangle of doom.”

In TAPP, peritoneum is closed over the mesh to prevent exposure to abdominal viscera.

Final Inspection

Confirm adequate mesh coverage with no folds.

Ensure hemostasis.

Release pneumoperitoneum gradually while verifying mesh remains flat.

Remove ports and close fascial defect at 10 mm port to prevent port-site hernia.

Skin closure with subcuticular sutures or adhesive for cosmetic result.

Postoperative Care

Early ambulation and oral intake.

Pain management with NSAIDs; opioids only if necessary.

Most patients discharged within 24 hours.

Avoid heavy lifting for 4–6 weeks.

Follow-up to monitor for seroma, hematoma, infection, or recurrence.

Advantages of Laparoscopic Repair in Females

Lower recurrence rate, especially for femoral hernias often missed in open repair.

Minimal postoperative pain and faster return to normal activity.

Cosmetic advantage with smaller scars.

Ability to inspect and repair contralateral hernias during the same procedure.

Reduced risk of nerve injury due to enhanced visualization.

Special Considerations

Always identify and protect reproductive organs.

Femoral hernias are more common in females and should be carefully explored.

Preperitoneal dissection must be gentle to avoid hematoma or nerve injury.

Conclusion

Laparoscopic inguinal hernia repair in female patients is a safe and effective minimally invasive technique. It offers the advantages of precise dissection, reduced postoperative pain, faster recovery, and lower recurrence rates, particularly for femoral hernias and recurrent hernias. With careful technique, proper mesh placement, and attention to reproductive structures, laparoscopic repair provides excellent functional and cosmetic outcomes for female patients.