Outcomes of Bilateral Inguinal Hernia Repair: A Dual-Mesh Laparoscopic TEP Technique

Abstract

Objective:

This study evaluates the long-term safety, efficacy, and recurrence of laparoscopic totally extraperitoneal (TEP) repair for bilateral inguinal hernias using a dual-mesh technique.

Background:

TEP repair is a well-established approach for inguinal hernia, offering advantages such as reduced postoperative pain, faster recovery, and fewer wound complications.

Methods:

A retrospective review was conducted of 426 patients with bilateral inguinal hernias who underwent TEP repair between January 2012 and May 2025. All procedures were performed by a single experienced surgeon using the standardized dual-mesh technique.

Results:

The mean patient age was 48.46 years (range: 17–82). The mean operative time was 47.73 minutes, and the hospital stay was 27.45 hours. The mean follow-up was 74.2 months (range: 12–188). The overall complication rate was low: 34 (7.9%) cases of seroma, urinary retention 2 (0.47%), hematoma 6 (1.4%), hydrocele 3 (0.7%), and no mesh-related infections or chronic pain. Four recurrences (0.94%) were detected, attributed mainly to incomplete dissection, overlooked cord lipomas, or mesh shrinkage. No complications were attributable to the overlapping dual-mesh technique. No intensive care admissions, or deaths occurred.

Conclusion:

Laparoscopic TEP repair with the novel dual-mesh technique provides reliable reinforcement of the myopectineal orifice (MPO), yielding low recurrence rates while avoiding vascular injury or mesh-related complications.

INTRODUCTION

Inguinal hernia is among the most common surgical conditions, with about 20 million repairs performed annually.¹ Although traditionally treated by open anterior repair, minimally invasive surgery has introduced laparoscopic approaches that reshaped hernia management.² The laparoscopic totally extraperitoneal (TEP) technique has become a preferred option for primary, bilateral, and recurrent hernias.

TEP repair is performed in the preperitoneal space without breaching the peritoneal cavity.³ Reported benefits include less postoperative pain, faster recovery, and lower rates of wound and mesh-related complications.⁴ It also facilitates bilateral repair and detection of occult hernias while avoiding risks from intra-abdominal manipulation.⁵

A key principle of TEP repair is reinforcement of the myopectineal orifice (MPO), first described by Fruchaud, which represents the anatomical zone for all groin hernias.⁶ Placement of a large mesh ensures durable coverage of both evident and potential defects, achieved without disturbing the intraperitoneal environment.⁷ Randomized trials and meta-analyses confirm that TEP provides outcomes equal or superior to open repair, especially regarding postoperative pain and recovery.⁷ However, a significant learning curve exists due to restricted working space and altered anatomy.⁸ Despite this, TEP is now incorporated into many international guidelines.⁹

Recurrence remains a critical outcome. Failures are often related to incomplete dissection, improper mesh placement, or insufficient MPO coverage.¹⁰ Mesh shrinkage, with contraction up to 30–50%, may further reduce coverage and predispose to recurrence.¹¹ TEP may also be less suitable in cases of extensive scarring, large scrotal hernias, or when intra-abdominal exploration is needed.¹²

Is laparoscopic TEP repair using a dual-mesh technique safe and effective in reducing recurrence and complication rates in patients with bilateral inguinal hernias?

The present study is based on the hypothesis that laparoscopic TEP repair with a dual-mesh technique offers a durable solution for bilateral inguinal hernias, characterized by low recurrence rates, minimal complications, and favorable long-term outcomes.

MATERIAL AND METHODS

Participants

Between January 2010 and June 2024, a total of 426 patients with bilateral inguinal hernias underwent laparoscopic TEP repair using a standardized dual-mesh technique at a single center. All patients had a minimum follow-up of 12 months.

Inclusion/Exclusion Criteria

Eligible patients were ≥17 years old, met diagnostic criteria for inguinal hernia, were able to communicate normally, had no history of psychiatric illness, and provided written informed consent. Exclusion criteria included severe cardiac, pulmonary, hepatic, or renal dysfunction; prior lower abdominal surgery (e.g., cesarean section, prostatectomy, colectomy); or contraindications to general anesthesia.

Outcomes

The primary outcome was hernia recurrence. Secondary outcomes included operative time, hospital stay, and perioperative complications. Complications (wound infection, hematoma, seroma, urinary retention, scrotal effusion, bladder injury) were recorded. Recurrence was diagnosed during follow-up visits or when patients presented with symptoms, confirmed by ultrasound if needed.

Surgical Technique

Patients were placed supine in 15° Trendelenburg under general anesthesia. A 15-mm infraumbilical incision was used to access the preperitoneal space, developed with a balloon dissector and insufflated to 12 mmHg. A 45° laparoscope and 2 additional midline trocars were inserted. Dissection identified key landmarks: pubic symphysis, Cooper’s ligament, epigastric and iliac vessels, spermatic cord, and iliopsoas muscle. The Bogros space and peritoneum were mobilized to ensure complete exposure of the MPO. Wide dissection is recommended to facilitate a comfortable repair and to prevent mesh folding. Hernia sacs and cord lipomas were reduced; pseudosac was retracted and fixed to the posterior rectus muscle with an absorbable fixer, when possible, to minimize seroma formation. The spermatic cord was carefully separated and elevated from the surrounding tissues, particularly the external iliac vessels, to create a safe passage for the mesh (Figure 1).

Figure 1.

The cord separate of the vascular surrounding tissue. Intraoperative view showing the spermatic cord carefully isolated from surrounding tissues and the external iliac vessels, creating a safe passage for placement of the under-cord mesh.

Repair involved placement of a rectangular polypropylene mesh (7.5 × 15 cm) beneath the spermatic cord. After fixation with absorbable fixers, a slit was created to accommodate the cord without compression (Figure 2). The slit is created to maintain the cord in position and to prevent compression of the cord and adjacent nerves, which could otherwise lead to chronic pain. A second anatomically contoured mesh was subsequently placed over the MPO and anchored to the previously positioned mesh, medially at the pubis symphysis and laterally near the internal ring, overlapping the subcordal mesh to reinforce the repair (Figure 3). CO₂ was evacuated under direct vision to secure mesh position. Fascial closure of the umbilical port and absorbable skin sutures completed the procedure. This double-mesh technique ensures adequate coverage of the lower MPO, preventing recurrence of the lipoma or hernia sac in this region.

Figure 2.

Positioning the subcordal polypropylene mesh. The subcordal mesh is positioned to cover the inferior portion of the MPO and is fixed medially above the pubis and laterally to the anterior abdominal wall using absorbable fixation. A slit is created in the mesh to accommodate the spermatic cord, ensuring its placement without exerting pressure on the cord structures.

Figure 3.

Final view of mesh repair. The anatomic mesh is positioned above the spermatic cord to ensure broad coverage of the upper portion of the MPO, with an intentional overlap between the 2 meshes to reinforce the repair. The configuration of the meshes ensures broad coverage of the MPO, allowing for the effective repair of all hernia types, including obturator hernias.

All operations were performed by the same senior surgeon to ensure consistency.

Statistical Analysis

Data were analyzed using SPSS for Windows, version 22.0 (SPSS, Chicago, IL). Continuous variables are presented as mean ± standard deviation (SD) depending on the distribution. Categorical variables are reported as frequencies and percentages.

Normality of continuous variables was assessed using the Shapiro-Wilk test. For normally distributed data, comparisons between 2 groups were performed using the independent samples t test, and comparisons among more than 2 groups were performed using 1-way ANOVA. For non-normally distributed data, the Mann-Whitney U test or Kruskal-Walli’s test was used as appropriate.

Categorical variables, including the occurrence of complications, seroma, hematoma, urinary retention, and recurrence, were compared using the χ² test or Fisher’s exact test when expected cell counts were less than 5.

A P-value < .05 was considered statistically significant. All tests were 2-tailed.

RESULTS

A total of 426 patients underwent bilateral TEP repair. The mean age was 41.6 years (range: 17–73), with 396 males and 30 females (Table 1). Most hernias were indirect in 258 (60.6%) patients, while 71 (16.7%) cases were classified as complex, involving both direct and indirect defects (Table 2).

Table 1.

Demographic and Clinical Characteristics of the Study Population

Characteristic	Mean (N = 426)	SD	95% CI for Mean
Age (years)	41.64	11.79	40.80–42.48
Height (m)	1.75	0.08	1.74–1.76
Weight (kg)	79.87	12.46	78.55–81.19
BMI (kg/m²)	25.97	3.60	25.63–26.31
Length of stay (hours)	27.84	8.62	26.91–28.77
Surgery duration (minutes)	50.36	10.49	49.31–51.41
Anesthesia duration (minutes)	65.49	12.89	64.10–66.88
Follow-up (months)	74.21	41.95	70.23–78.19

Abbreviations: SD, standard deviation; M, meters; Kg, kilograms; CI, confidence interval; BMI, body mass index.

Table 2.

Categorical Variables (Number and Percentage) and Clinical Characteristics of the Study Population

Characteristic	Number(N = 426)	Percent (%)
Gender
Male	396	92.96
Female	30	7.04
ASA classification
I	253	59.39
II	136	31.92
III	17	8.69
Hernia repair type
Primary	410	96.24
Recurrent	16	3.76
Type of hernia
Indirect	258	60.56
Direct	62	14.55
Direct & indirect	71	16.67
Femoral	35	8.22

Abbreviations: ASA, American Society of Anesthesiologists physical status.

Longer hospital stays were significantly associated with female gender (P = .0263), older age (P = .0056), and higher BMI (P < .0001). Operative times were also significantly longer in females (P = .0374), older patients (P = .0074), and those with higher BMI (P = .0436).

Operative Outcomes

The mean operative time was 50.4 minutes (range: 36–105), with a mean anesthesia time of 65.5 minutes (range: 38–130). Mean hospital stay was 27.8 hours (range: 9–100), with all patients kept overnight. The mean follow-up duration was 74.2 months (SD: 41.9; range: 12–188).

All patients mobilized within 24 hours, resumed light work in 5–7 days, and returned to full activity after 3 weeks. At discharge, 230 patients (53.9%) reported no pain, 172 (40.3%) mild pain, 23 (5.5%) moderate pain, and 1 (0.3%) severe pain. Although some patients experienced mild postoperative discomfort persisting up to 60 days, no cases of chronic groin pain were reported during follow-up.

Complications

The overall complication rate was 4.2% (18/426), excluding seroma formation, which, particularly in direct hernia repairs, is regarded as a common postoperative occurrence rather than a true complication. There were 2 cases of intraoperative bleeding from small branches of the epigastric vessels, which were successfully managed using diathermy. One patient experienced a 1-cm bladder tear, which was sutured laparoscopically, and the hernia repair was completed without further incident. The urinary catheter was removed 1 week later.

Seroma formation, most frequently in the pseudosac of direct hernias and occasionally in indirect hernias, was the most common postoperative event. Most seromas resolved spontaneously, with only a few cases requiring fluid aspiration.

Urinary retention occurred in 1 patient and was managed successfully with catheterization, which was removed after 24 hours. Preoperative assessment routinely includes an evaluation for urinary symptoms, and when indicated, an α-blocker is prescribed approximately 10 days before surgery to reduce the risk of retention.

Hematoma formation, especially in the scrotum in patients with large indirect hernias, was observed in 6 cases; however, no surgical intervention was required as all resolved spontaneously.

Hydrocele developed in 3 patients. These cases were monitored over a prolonged follow-up period to allow for spontaneous resolution; if the hydrocele persisted, a Winkelmann procedure was performed.

Recurrence occurred in 4 (0.94%) patients. All instances of hernia recurrence were detected clinically and subsequently confirmed by ultrasound. These cases involved large defects or combined direct and indirect hernias and were reoperated successfully using a transabdominal preperitoneal (TAPP) approach.

No cases of chronic postoperative groin pain were reported during the follow-up period (Table 3).

Table 3.

Intraoperative and Postoperative Complications

Complication	N	Percentage
Bleeding	2	0.47%
Bladder tear	1	0.23%
Conversion to open	0	0%
Seroma	34	7.98%
Urinary retention	2	0.47%
Infection	0	0%
Hematoma	6	1.41%
Hydrocele	3	0.70%
Recurrence	4	0.94%

Seroma formation, although included here for completeness, was not counted toward the calculated overall complication rate because it is considered a common postoperative sequela rather than a true surgical complication in this context. Abbreviations: N, number.

No complications attributable to the overlapping dual-mesh technique were identified, and no vascular injuries or mesh-related adverse events were observed.

No patients required admission to the intensive care unit, and there were no mortalities.

DISCUSSION

The optimal approach to inguinal hernia repair depends on a combination of patient characteristics and surgeon expertise. Patient-specific factors such as the type and complexity of the hernia (e.g., primary vs recurrent, unilateral vs bilateral), age, comorbidities, and history of prior abdominal surgery play a decisive role.¹³ The laparoscopic approach offers a significant advantage over the open technique, as it allows the use of larger meshes, thereby ensuring more comprehensive coverage of the preperitoneal space. The present study demonstrates that the laparoscopic TEP approach for bilateral inguinal hernia repair is a safe and effective technique, yielding low complication and recurrence rates when performed with meticulous surgical technique and sound anatomical knowledge.¹⁴ With a mean follow-up exceeding 6 years, the study findings confirm that TEP repair provides durable and reliable long-term outcomes.

Recurrence rates for laparoscopic inguinal hernia repair vary substantially in the literature, with large systematic reviews reporting a range from 0% to 16.7% and a median recurrence rate of approximately 0.6%. The recurrence rate observed in our series (0.94%) is therefore within the expected range and comparable to established benchmarks in high-quality studies.^15,16

A crucial factor in achieving optimal outcomes with laparoscopic hernia repair is the surgeon’s level of experience. The learning curve for mastering the TEP approach is well recognized as relatively long.¹⁷ As surgical experience increases, the rates of conversion to open surgery, intraoperative and postoperative complications, and recurrences decrease significantly.¹⁸ When performed by an experienced surgeon, however, the TEP approach offers clear advantages, including avoidance of intraperitoneal entry, which minimizes the risk of visceral injury and adhesion formation.

Minimally invasive inguinal hernia repair has gained broad acceptance because of its association with reduced postoperative pain, shorter recovery times, faster return to work, and better cosmetic results compared to conventional open repair.¹⁹ Since its introduction, the TEP technique has been recognized as technically demanding, particularly in large, complex, or recurrent hernias, further underscoring the importance of the surgeon’s expertise.

Recurrence remains one of the most important outcomes to monitor following hernia repair. It is multifactorial and continues to pose a challenge in surgical practice. In the present series, we observed 4 recurrences among 426 patients. Detailed evaluation of these cases yields important insights into modifiable factors that support the maintenance of low recurrence rates in TEP repair.

One key factor is the adequacy management of the preperitoneal dissection. Incomplete dissection of the preperitoneal space is one of the most frequent causes of recurrence in laparoscopic hernia repair. Adequate exposure of the MPO is critical to ensure that the mesh fully covers all potential sites of herniation.²⁰ Limited dissection reduces the available space for mesh placement, increasing the risk of uncovered weak areas through which herniation can recur.²⁰ The MPO includes multiple potential hernia sites, such as direct, indirect, and femoral defects.¹⁴ Failure to identify and fully expose these areas can result in missed defects and subsequent recurrence.

In our series, 2 of the 4 recurrences occurred in patients with large combined direct and indirect hernias, in whom the lateral or inferior dissection may have been insufficient, leaving residual defects. This finding underscores the importance of extending the dissection laterally to the iliopsoas muscle and inferiorly to the obturator foramen, while carefully developing both the Bogros and Retzius spaces.²¹ Such thorough dissection allows the mesh to be deployed without tension or folding, ensuring complete coverage of all potential hernia sites.²¹

A second factor contributing to recurrence is inadequate management of the hernia sac. In direct hernias, the pseudosac must be fully reduced or inverted and, if necessary, secured to the rectus muscle to reduce the risk of postoperative seroma and residual defects. In cases of indirect hernias, careful dissection and complete separation of the hernia sac as high as possible from the spermatic cord structures is equally vital to prevent tension on the cord. If the sac is not sufficiently mobilized and retracted cranially, it can exert downward traction on the mesh, displacing it or creating a gap at the internal ring, which may allow the hernia to reform at the same or adjacent site.

In our study, at least 1 recurrence appeared to be due to incomplete reduction of the indirect sac, highlighting the importance of delicate but thorough sac dissection, particularly in large indirect hernias with deep inguinal rings.²²

Another important consideration is the detection and removal of spermatic cord lipomas. These are frequently associated with indirect hernias and can be mistakenly identified as the hernia sac itself.²³ If not excised, a residual lipoma can protrude through the internal ring postoperatively, mimicking recurrence and producing symptoms such as persistent bulging or discomfort.²⁴ More critically, untreated lipomas can interfere with proper mesh placement and prevent full defect coverage, contributing to true recurrence.¹¹ For this reason, thorough inspection for cord lipomas should be a routine component of the dissection. All fatty tissue traversing the deep inguinal ring should be gently mobilized in a cephalic direction and reduced en bloc with the contiguous Bogros space. Failure to address these compromises the tension-free nature of the repair. Accurate distinction between cord fat and lipoma is crucial, since incorrect handling can adversely affect testicular blood supply.

Mesh behavior is another factor that influences long-term durability.²⁵ Although modern meshes are designed to be biocompatible and dimensionally stable, mesh shrinkage remains a potential cause of recurrence.^13,26 Polypropylene mesh, which we used in this study, is widely accepted for its strength, flexibility, and cost-effectiveness. However, inadequate sizing, folding, or insufficient fixation may lead to mesh displacement and subsequent recurrence, reflecting technical shortcomings.²⁷ Previous reports have shown that mesh shrinkage can vary from 10% to as much as 30% of its original size.^11,13,28 If not properly accounted for, this can leave parts of the MPO insufficiently covered, increasing the risk of recurrency.

In our technique, we addressed this by using a dual-mesh approach: a rectangular subcordal mesh placed beneath the spermatic cord, combined with an anatomically contoured overlay mesh to reinforce the upper MPO with wide overlap. The purpose of this configuration is to prevent retroperitoneal fat tissue or the peritoneal sac from herniating beneath the mesh, thereby minimizing the risk of recurrence. Nasr et al have reported that lipomas may mimic the symptoms of a true hernia; accordingly, we take precautions to prevent the lipoma from extending through the internal ring.²⁶ Both fixation points secure the upper mesh to the underlying subcordal mesh, ensuring broad overlap between the layers, which reinforces the repair and improves stability. The fixation above to the pubic symphysis and the lateral internal oblique muscle helps to maintain mesh position during the healing process.

Although lightweight, microporous meshes are associated with reduced chronic groin pain and diminished foreign body sensation, their lower material density may increase susceptibility to shrinkage.^13,29 This trade-off must be carefully considered when selecting the mesh type, particularly for larger or more complex defects.

Importantly, our study found no cases of chronic postoperative groin pain and no mesh-related infections, supporting the safety and effectiveness of the materials used. Nevertheless, continuous vigilance and precise technique are essential to counter mechanical factors that can lead to mesh displacement or shrinkage over time.

Beyond recurrence, our overall complication rates were low and consistent with published data. Seroma formation was the most common postoperative complication, occurring in 7.9% of patients, mostly within the pseudosac of large direct hernias. This aligns with existing studies, which report seroma rates of up to 7.2%.³⁰ Most resolved spontaneously or required only simple aspiration. Urinary retention was rare (less than 0.5%) and was managed effectively with short-term catheterization. Hematomas and hydroceles were uncommon and did not require further intervention.³¹ Notably, no patients required intensive care admission, no major complications occurred, and there were no perioperative or postoperative deaths.

Key strengths of this study include the large patient cohort, consistent use of a standardized surgical technique performed by a single skillful surgeon, and a prolonged follow-up period, allowing meaningful assessment of long-term outcomes.

The main limitations are its retrospective design and the absence of a control group. Additionally, the procedures were performed by a single surgeon, which may limit generalizability to centers with varying levels of experience.

Future prospective studies comparing this technique to other laparoscopic or open approaches could further clarify its relative benefits, especially for complex or recurrent cases.

In conclusion, our findings confirm that the TEP approach, when performed with a standardized, meticulous surgical technique—including complete dissection of the preperitoneal space, kindly handling of the hernia sac and any cord lipomas, and secure dual-mesh placement with wide overlap—can achieve durable, reproducible results with minimal complications. This underscores that the success of laparoscopic hernia repair relies not only on the approach itself but also on the surgeon’s experience, careful technique, and respect for anatomical detail.

This study has several limitations. Its retrospective design limits causal inferences and may introduce documentation bias. The absence of a control group prevents comparison with other surgical techniques. Additionally, all procedures were performed by a single surgeon at one center, which may affect the generalizability of the findings.

The study proposes a TEP repair technique using 2 meshes to achieve wide coverage of the MPO, which may reduce recurrence rates without increasing complication rates or causing adverse effects from the additional foreign material.

CONCLUSION

Laparoscopic TEP repair with a novel dual-mesh technique provides wide, secure coverage of the MPO, ensuring durable repair without compromising patient safety. This approach yields low recurrence and complication rates with excellent long-term outcomes. The technique’s strength lies in its ability to maximize preperitoneal reinforcement while avoiding sequelae, representing a safe and reproducible advancement in minimally invasive hernia repair.