Inguinal Hernia With M. Rosen
With Dr. Michael Rosen · hosted by Dr. Jeffrey Ponsky · Jeffrey Ponsky
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Podcast
Inguinal Hernia: Adult
31 min · Published Jan 2017
Podcast
Inguinal Hernia With M. Rosen
Jeffrey Ponsky · 31 min · Published Oct 2015
Podcast
Inguinal Hernia With M. Rosen
Jeffrey Ponsky · 31 min · Published Oct 2015
Video
2026 Laparoscopic Pediatric Hernia Repair
123 min · Published Jun 2026
Video
Groin Controversies - Todd Ponsky: Update Course 2014
Dr. Todd Ponsky · 28 min · Published Nov 2018
Video
Focus on Technique- Laparoscopic Pediatric Hernia Repair 2015
Dr. Todd Ponsky · 140 min · Published Mar 2014
Video
V119 Use of transoral incisionless fundoplication for recurrent reflux after foregut surgery
Jeffrey Ponsky · Published Jul 2026
Video
From Idea to Ubiquity
Jeffrey Ponsky · Published Jul 2026
Video
Intra-operative Bile Leak During Cholecystectomy
Jeffrey Ponsky · Published Jul 2026
Video
Acute Cholecystitis
Todd Ponsky · Published Jul 2026
Podcast
Behind The Knife: The Surgery Podcast / Innovations in Surgery: PEG Tube
Jeffrey Ponsky · Published Jul 2026
Podcast
Spotify – Web Player
Jeffrey Ponsky · Published Jul 2026
Only a few other public items share this expert — go deeper there →
Video
Jeffrey L. Ponsky Master Educator in Endoscopy
Jeffrey Ponsky · Published Jul 2026
Podcast
Butts & Guts
Jeffrey Ponsky · Published Jul 2026
Video
StayCurrent Forums
Jeffrey Ponsky · Published Jul 2026
Video
V119 Use of transoral incisionless fundoplication for recurrent reflux after foregut surgery
Jeffrey Ponsky · Published Jul 2026
Video
StayCurrent Forums Trailer
Jeffrey Ponsky · Published Jul 2026
Podcast
Update Course Rewind: Pediatric Biliary Stones - Preventing Gallstone Pancreatitis 2024
Jeffrey Ponsky · 3 min · Published Aug 2025
What the experts said
For an 89-year-old with asymptomatic hernia, observation is appropriate because in a couple years they might not have symptoms, but in younger patients the odds are against them living without it becoming symptomatic.
Inguinal hernia repairs can be done under local anesthesia in patients with severe comorbidities, and it is worse for them to present with an emergency problem in the middle of the night.
The primary advantage of laparoscopy in skilled hands is that mesh is placed away from nerves, and the risk of chronic pain is lower than in open inguinal hernias.
For young, healthy, active patients with unilateral hernia who are not anesthetic risks, laparoscopic repair is preferred in experienced hands, offering about a week to 10 days earlier recovery than open repair.
Disadvantages of laparoscopic repair include operating near intestines with risk of intestinal injury and risk of injury to major blood vessels, though these risks should be incredibly low if planes are known.
In elderly patients or anyone on anticoagulation who needs to restart quickly, open operation is preferred to avoid dissecting the retroperitoneal space.
In a 78-year-old patient with symptomatic hernia on one side and asymptomatic hernia discovered laparoscopically on the other side, the asymptomatic side should not be repaired due to doubled anesthetic time and increased hematoma risk.
In younger active patients, an asymptomatic contralateral hernia discovered laparoscopically should be repaired because the chance of it becoming symptomatic is much higher.
Previous lower abdominal surgery increases risk of enterotomy and OR time for laparoscopic repair; if patient hasn't had open inguinal hernia, open approach is preferred.
Previous prostate surgery cases are unpredictable laparoscopically and can be brutal; in current practice these get open inguinal hernia repair.
The most important part of any laparoscopic repair is parietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly), a principle promoted by Rene Stoppa during open preperitoneal repairs.
The inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view, scary to make holes, and taken very close off the vessels.
For large direct hernias, mesh choice should change to a heavier weight material.
Heavyweight mesh is around 90 grams per meter squared (Marlex or Prolene), midweight is 40-50 grams per meter squared, and lightweight (Ultrapro) is less than 30 grams per meter squared.
Advantage of lighter weight mesh is less foreign body and less contraction; disadvantage is half the material with risk of fracturing, particularly in direct hernias where it's a bridge.
Heavier weight mesh rarely breaks but sometimes people feel it in their groin if there are wrinkles or buckles, which can cause issues.
For inguinal hernia repair, should never use smaller than a large preformed mesh because you need to cover the whole myopectineal orifice.
If struggling with mesh placement during laparoscopic repair, it's not that you're not a good enough laparoscopic surgeon, it's that you didn't dissect out the space enough - you need to take out the mesh and dissect bigger.
Mesh should be fixed in place; options include Protack tacks, glue, or no fixation, though for big direct hernias everybody uses fixation.
There is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes; permanent fixation is used because if absorbable fixation goes through a nerve, it's the neuroma that causes the problem, not the tack.
For incarcerated femoral hernia with bowel compromise, make a vertical incision for vascular-type exposure, dissect onto hernia sac, bring out compromised intestine infrainguinally, resect and anastomose, then reduce.
To reduce incarcerated femoral hernia without dividing inguinal ligament, release the lacunar ligament medially (which gives off from the inguinal ligament) to gain an extra centimeter of space.
A 'reverse McVay' repair can be performed from below for femoral hernias, taking the inferior border of the inguinal ligament and sewing it down to Cooper's ligament starting immediately lateral to the femoral vein.
Mesh plugs are not preferred for femoral hernias because femoral hernias tend to occur in thin women and there have been DVTs due to irritation on the femoral vein.
For recurrent hernias, operate where nobody has been before; if both spaces have been operated, go where you're best.
For bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach, but if learning, avoid bilateral and recurrent hernias laparoscopically because it makes it twice as hard despite these patients getting the most benefit.
For really big inguinal scrotal hernias that can't be reduced in office, open operation is preferred; when younger, these were done laparoscopically but now all done open.
For incarcerated hernias, TAP approach is preferred over TEP because you want the contents out of the hernia; can laparoscopically cut the internal ring at the two o'clock position relative to epigastric vessels to help reduce.
In the Fitzgibbon VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, the risk of presenting with an emergency problem requiring operation due to incarceration or strangulation was less than 1% (actually one-third of 1%).
In the Fitzgibbon study over two years, almost one-third of observed patients went on to develop symptoms and need an operation, and by five years almost three-quarters developed symptoms.
There is a real learning curve to laparoscopic inguinal hernia repair, with some studies showing 200 to 250 cases required.
According to Stoppa's original descriptions, for unilateral inguinal hernia repair, never use less than a 15 by 15 centimeter (6 by 6 inch) piece of mesh, which is much bigger than the vast majority of laparoscopic meshes being placed.
There is mounting evidence that medium-weight polypropylene can be placed in a contaminated field, with several series in ventral hernias supporting this.