In the early 1990s tension-free approaches to inguinal hernia repair began to replace primary tissue repairs. The principal reason for this shift was that primary sutured repairs were often associated with tension on the suture line and, consequently, a high recurrence rate and increased postoperative pain [4]. In addition, the use of a tension-free mesh approach allowed patients to resume physical activities and labor much sooner than after a sutured repair [5]. In 2003 it was estimated that 93 % of inguinal hernia repairs utilized mesh, and the Lichtenstein method was the most common approach done [6]. Since primary tissue repairs are infrequently performed now in most surgical training programs, the current generation of surgeons has little if any experience with these techniques in surgical practice. Moreover, the unique aspects of the primary repairs done in athletes by advocates of these approaches differ from standard Bassini and other conventional primary repairs and have not been taught or disseminated into the mainstream surgical community.

A variety of meshes have been used for inguinal hernia repair that include heavyweight bilayer mesh, lightweight polypropylene mesh, and polytetrafluoroethylene (PTFE) or Goretex mesh (W. L. Gore Associates, Newark, DE). Lightweight meshes have generally been preferred in this location because of ease of use, low cost and because they have been associated with less pain, stiffness, and foreign body sensation in the inguinal floor compared to heavyweight meshes [7]. Inguinal floor repair and stabilization using an open mesh technique can be achieved in athletes that are appropriately selected for operation.

The preferred approach that the author has taken to repair of the inguinal floor for athletes with a sport’s hernia pubalgia has been a lightweight tension-free mesh repair. While this approach is taken for the reasons outlined above, there are circumstances in which the use of an open mesh approach may not be appropriate or preferred. Young athletes who have not completed their growth cycle and particularly young females are better served by one of the open primary tissue repairs as have been described elsewhere (see Chaps. 10 and 13). In addition, for athletes who have had a prior open inguinal hernia surgery or even in some cases a prior failed “sport’s hernia” repair, the author has used a laparoscopic preperitoneal mesh repair as described in Chap. 12.

The operative approach for the open tension-free mesh repair utilizes a slightly oblique incision placed over the inguinal canal as for a standard inguinal hernia repair. This approach is most commonly done under local anesthesia with sedation unless an accompanying adductor procedure is done, in which case general anesthesia is typically used. A mixture of 1 % lidocaine and 0.5 % bupivacaine local anesthetic are injected into each successive layer as the dissection proceeds.

One of the typical operative findings is a markedly attenuated external oblique aponeurosis (Fig. 11.4). The external oblique is opened widely through the external ring and the cord structures are encircled. A search is made for the ilioinguinal nerve which is left within its sheath. The base of the cord is opened to search for an indirect hernia sac which is rarely present. The inguinal floor is often markedly attenuated and even bulging in some cases as shown in Fig. 11.5. The floor is reconstructed by suturing a lightweight polypropylene mesh to the transversalis aponeurosis and rectus sheath medially (Fig. 11.6) using interrupted nonabsorbable 0-nylon suture. The lateral side of the mesh is then sutured to the inguinal ligament with a 2–0 running polypropylene suture, and the mesh is split and the two ends are brought together and sutured to the inguinal ligament. The tails of the mesh are sutured to the inguinal ligament and around the cord in effect reconstructing the internal ring not because the pathology is at the internal ring, but in order for the mesh to lie smoothly and evenly across the floor and provide the support needed to take the tension off the rectus and the pubis (Fig. 11.7).

Other tension-free mesh approaches have also been used including bilayer polypropylene mesh [8] and PTFE materials [9]. Biologic mesh has also been used but via a laparoscopic approach [10] and is considerably more expensive and lacking in reported outcomes. Brown and colleagues [9, 11] in Montreal use a PTFE patch that is anchored to the external oblique aponeurosis using interrupted polypropylene sutures to repair the torn margins of the external oblique fascia. The external oblique is then closed loosely over the patch.