European Journal of Cardiovascular Medicine

A hernia is defined as the protrusion of any organ from its designated cavity. The protruding components are typically enclosed within a membranous sac that naturally envelops the cavity." – Sir Astley Cooper The term 'hernia' originates from a Latin word signifying 'a rupture.' The earliest documentation of an inguinal hernia dates back to approximately 1552 BC in ancient Egypt[1]. Seventy-five percent of all abdominal wall hernias manifest in the groin region. The term "groin hernia" was first introduced by Henri Fruchaud in the early 1950s. [2]Groin hernias comprise inguinal hernias (96%) and femoral hernias (4%). [3]Inguinal hernias, among the most ancient ailments of humanity, are highly prevalent, with an estimated lifetime risk of 27% in men and 3% in women. Indirect inguinal hernias are approximately twice as prevalent as direct inguinal hernias, while femoral hernias constitute a negligible proportion. Inguinal hernia repair is among the most frequently conducted surgical procedures. [4] In India, it is estimated that 1,957,850 inguinal hernias occur each year. [5] Groin hernias possess a fascinating surgical history. The management of inguinal hernia is categorized into five distinct periods.[ 6 ]

The period from ancient Egypt to the 15th century is regarded as 'The Ancient Epoch of Inguinal Hernia Repair,' characterized by limited medical knowledge and primitive techniques. 7. Galen rendered a substantial contribution during this period. He stated that a hernia results from a tear in the peritoneum and the subsequent stretching of the underlying fascia. He proposed the amputation of the testis and the ligation of the sac and cord. Paul of Aegina possessed a comparable comprehension of hernia and its management. The second phase of hernia surgery originated during the Renaissance, spanning the 15th to the 17th century. This period is significant due to the extensive research conducted on inguinal hernias, thus it is referred to as the 'Era of the Beginning of Herniology.' Ambroise Paré, a French surgeon, in his work 'The Apologie and Treatise', offered a comprehensive account of inguinal hernia surgery, detailing the reduction of contents and the closure of the defect. Pierre Franco (1500–1561) and Paré (1510–1590) are recognized for executing one of the earliest documented hernia repairs utilizing conservative techniques and a robust bandage.[8]The third era, referred to as the 'Age of Dissection' or the 'Anatomic Era,' commenced in the late 1700s. John Hunter and Sir Astley Cooper Hasselbach, Camper, Scarpa, Richter, and Gimbernat were notable contributors during this period. Fascia transversalis was initially recognized as the principal barrier against herniation by Sir Astley Cooper. No surgically treatable disease, according to him, requires a surgeon to possess such a comprehensive range of expertise and understanding as hernias and their various subtypes.[9] The period known as the 'Era of hernia repair under tension' commenced between the 19th and mid-20th century, coinciding with advancements in anaesthesia and antiseptic methods. Antiseptic and aseptic techniques, high ligation of the hernia sac, and constriction of the deep inguinal ring were three critical principles incorporated into hernia repair methodology. Notwithstanding these advancements, the treatment outcomes were inadequate, as the postoperative mortality rate was 7% and the recurrence rate was 100%. Edoardo Bassini is recognized as the pioneer of contemporary hernia repair, having transformed the surgical approach to hernias by promoting the reconstruction of the posterior wall of the inguinal canal. Bassini's pioneering anatomical dissection, characterized by low recurrence rates, transformed hernia surgery. This method prioritizes complete closure of the hernia sac at the internal ring and suture reinforcement of the posterior inguinal canal. He executed this surgical procedure.

He first conducted his research in 1884 and published his preliminary findings in 1888.[10] Nonetheless, this newly developed technique presented a unique challenge—surgeons were unable to master the correct execution of natural repairs. The recurrence rates were notably variable, reported to range from 20% to 40%. In reaction to these variable outcomes, the surgical community sought methods to diminish recurrences and achieve consistent, satisfactory results. The method articulated by Canadian surgeon E. Shouldice represented the subsequent major advancement in inguinal hernia surgery. 11 He proposed the concept of interleaving the transverse fascia and reinforcing the posterior wall of the inguinal canal with four layers of fasciae and oblique muscle aponeuroses. 11 George Lotheissen was the inaugural individual to delineate the repair of Cooper's ligament. Anson and McVay further disseminated this concept. The recurrence rate decreased to 3% due to these modifications. Non-mesh hernia repairs were the conventional method for hernia repair procedures for an extended duration. 12 The gold standard for prosthesis-free inguinal hernia treatment is the Shouldice repair, which has undergone enhancements over several decades. Both primary and recurrent inguinal hernias can be addressed through this established surgical technique. The fifth epoch in the history of hernia surgery, extending to the present, is known as the 'Era of Tensionless Hernia Repair.' The concept of tensionless repair acknowledges that tension during the repair process is the principal cause of recurrence. Lichtenstein initially delineated the tensionless technique, which entailed fortifying the posterior wall of the inguinal canal with synthetic material. When necessary, the tension of the sutured layers was further alleviated by incising the rectus abdominal muscle sheath.

During anterior inguinal herniorrhaphy, various methods exist for mesh placement, including the Lichtenstein approach, the plug-and-patch technique, and the sandwich technique, which incorporates both an anterior and a preperitoneal mesh component. [13]

In the early 1900s, the mesh was constructed from various materials, including silver, tantalum, and kangaroo tendons. During this period, mesh production remained in the developmental stage. The production of synthetic meshes commenced in the 1940s and 1950s; however, the effective application of mesh for hernia repair began significantly later with the introduction of polypropylene mesh. Since that time, mesh has gradually become the gold standard for inguinal hernia surgeries due to reduced recurrence rates and surgical simplicity.

Despite being one of the most common procedures in general surgery, inguinal hernia repair is subject to ongoing technical evolution, driven by enhancements to established methods and the introduction of innovative techniques. The benefits of any novel technique must be comprehensively assessed in clinical, social, and financial contexts.

In resource-constrained environments such as India, the cost-effectiveness of treatment and mesh materials for inguinal hernia repair is a significant concern. Although numerous surgical techniques have been developed to address inguinal hernias, the high prevalence of this condition necessitates ongoing advancements in the methods, techniques, and surgical instruments used for repair.

The recently conceived method, 'Endoscopic Anterior Approach Inguinal Hernioplasty' (EAAIH), enables the surgeon to execute endoscopic hernioplasty via the anterior approach. Owing to its intrinsic advantages, it is posited to yield favorable outcomes and is recommended for diminishing patient morbidity regarding recurrence, minimizing intraoperative hemorrhage, shortening operative duration, and lowering the risk of intraoperative bowel and nerve injuries, among other factors. This technique can be advantageous for surgeons owing to its reduced learning curve. Surgeons, in the early stages of their practice, proficiently learn open hernia repair via the anterior approach; however, traditional laparoscopic techniques necessitate access from the posterior aspect of the abdominal wall, which entails a more extended learning curve. Consequently, the new surgeon commences operations in a previously acquainted anterior plane. This study aims to evaluate the efficacy and feasibility of EAAIH in comparison to the conventional posterior approach laparoscopic inguinal hernia repair, specifically Totally Extra Peritoneal Repair (TEP).

Source of Data

All cases of unilateral inguinal hernia operated in the Department of Surgery, M.G.M. Medical College and M.Y. Hospital, Indore (M.P.), were included in this study.

Study Design

This is a prospective Randomized Controlled Trial (RCT) designed to compare outcomes of two surgical approaches for unilateral inguinal hernia repair: endoscopic anterior inguinal hernioplasty and laparoscopic inguinal hernioplasty.

Study Population

All elective cases of unilateral inguinal hernia admitted for surgery and fulfilling the inclusion criteria were considered. The surgeries were conducted in the routine operation theatre of the Department of Surgery, M.G.M. Medical College and M.Y. Hospital, Indore.

Study Period

The study was conducted over a period of 12 months, starting from the date of ethical clearance approval.

Place of Study

M.Y. Hospital, Indore, Madhya Pradesh, India.

Sample Size

All patients attending the outpatient department (OPD) and meeting the inclusion criteria during the 12-month study period were included. There was no predefined sample size; a total enumeration sampling method was followed.

Data Collection and Analysis

Patient data were recorded using a structured proforma and subsequently entered into Microsoft Excel. Statistical analysis was performed using SPSS software. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were presented as frequencies and percentages. Appropriate statistical tests (e.g., Chi-square test, Student’s t-test, or Mann–Whitney U test) were applied based on the nature and distribution of the data. A p-value < 0.05 was considered statistically significant.

Inclusion Criteria

1. Patients aged 20 to 60 years.
2. Both male and female patients.
3. Patients diagnosed with unilateral inguinal hernia.
4. Patients consenting to undergo hernia repair via endoscopic anterior approach.
5. Patients with omentum as the content of the hernia sac on ultrasonography.

Exclusion Criteria

1. Patients on anticoagulant therapy.
2. Patients diagnosed with chronic obstructive pulmonary disease (COPD).
3. Immunocompromised patients (e.g., HIV-positive).
4. Patients with extensive intra-abdominal adhesions.
5. Patients with bowel as content of the hernia sac on ultrasonography.
6. Patients with large sliding hernias involving bowel adherence to the sac.
7. Patients with late-diagnosed strangulated hernias and advanced bowel obstruction.
8. History of prior lower abdominal surgery or pelvic radiation.
9. Recurrent inguinal hernia cases.
10. Patients unwilling to provide informed consent.

Methodology

1. Patient Selection
   Eligible patients presenting to the OPD during the study period were enrolled based on inclusion and exclusion criteria. Informed written consent was obtained from all participants.
2. Preoperative Evaluation
   Baseline clinical evaluation and pre-anesthetic assessment were conducted, including the following investigations:

• Complete Blood Count (CBC)
• Liver Function Test (LFT)
• Renal Function Test (RFT)
• Serum Electrolytes
• Ultrasonography (USG) – whole abdomen, pelvis, and local swelling
• Chest X-ray
• Electrocardiogram (ECG)
• Serology for HIV, HBsAg, and HCV

1. Surgical Procedure
   Eligible patients were randomly assigned to undergo either endoscopic anterior inguinal hernioplasty or laparoscopic inguinal hernioplasty.
2. Outcome Assessment
   The two surgical techniques were compared with respect to the following parameters:

• Operating time
• Intraoperative bleeding
• Postoperative pain
• Cosmetic outcome
• Technical ease and challenges

Standard postoperative care was provided to all patients, and outcomes were monitored during the hospital stay and follow-up visits.

Table 1 combining hernia types and the developments in hernia repair techniques (both tension and tension-free) into one unified format for clarity and reference:

Consolidated Table: Hernia Types and Repair Techniques

Table:2 Distribution of Study Population by Age, Gender, and Occupation

Table:3 Study Population Data (Comorbidities, Defect Size, Hernia Type, Recovery, Blood Loss)

Based on the inclusion and exclusion criteria, patients were randomly assigned to two groups of 25 individuals each:

GROUP 1 - Laparoscopic Totally Extraperitoneal (TEP) Mesh Insertion

GROUP 2 - Endoscopic Anterior Approach Inguinal Hernioplasty (EAAIH).

Post-surgery, patients were monitored for a duration of one year.

EAAIH is an innovative method for minimally invasive hernia repair, employing an anterior approach tension-free hernioplasty akin to the Lichtenstein anterior open hernia repair technique. This newly conceived technique has the potential to revolutionize the practice for novice surgeons, allowing them to operate within a familiar anatomical plane (sub-external oblique aponeurosis plane).

Initially, when this technique was conceived, we intended to establish a sub-scarpal plane for mesh placement, analogous to the plane created in the Sub Cutaneous Onlay Laparoscopic Approach (SCOLA) technique for ventral hernia repair. However, due to technical difficulties, the procedure was unsuccessful and had to be converted to an open hernia repair.

Subsequently, we conceived and refined the technique by incising the external oblique aponeurosis to access the sub-aponeurotic plane, thereby creating a space for the placement of the mesh. We achieved success in our initial attempt and faced no significant challenges with this procedure.

Protocol for EAAIH:

1) Establishing ports: Three ports were established: iv. A 10 mm camera port positioned 2 cm superior to the umbilicus and equidistant between the linea alba and the anterior axillary line. v. A 5 mm working port established 7-8 cm superior to the anterior superior iliac spine along the anterior axillary line. vi. A 5 mm working port created at the same level as the second port, immediately lateral to the umbilicus. After inserting the camera port and performing blunt dissection in the subcutaneous fascia, the external oblique aponeurosis is visualized and incised at a specific location. The subaponeurotic plane is attained, and a space is established between the external oblique aponeurosis and the underlying conjoint tendon, extending from the pubic tubercle to the deep inguinal ring. Precautions are implemented to prevent damage to the Ilioinguinal and Iliohypogastric nerves. The spermatic cord and its components, along with the sac, are identified, and the sac is detached from the cord structures and reduced. A polypropylene mesh is positioned and secured with tacks. The external oblique aponeurosis is sutured, the ports are extracted, and the insufflated gas is permitted to dissipate. The skin is sutured using absorbable stitches.

The subsequent observations were derived from the aforementioned study.

The current study revealed that the majority of patients were aged between 41 and 50 years. The proportion of patients within this age range was 36% in the EAAIH group and 30% in the TEP group. The youngest participant in our study was 32 years old, while the oldest was 65 years old.
The results of the current study align with those of Rao et al.5, which indicated that the average age of inguinal hernia presentation was 45.02±22.87 years. The study conducted by Burcharth et al.14 revealed that inguinal hernias are prevalent in this demographic due to their role as the workforce, often engaged in physically demanding occupations such as laborers, farmers, and factory workers, which involve lifting heavy weights. Advancing age and male sex have consistently been regarded as risk factors for the development of inguinal hernia. With advancing age, the likelihood of developing a hernia escalates due to the deterioration of tissues. [14]

Jenkins et al.[15] conducted a study revealing that inguinal hernias account for 75% of all abdominal wall hernias, with a lifetime risk of 27-43% in males and 3-6% in females, which aligns with the current study in which all 50 patients were male. A systematic review by McCormack et al. in 2008 revealed that 96% of the study population across all 41 randomized controlled trials examined were male. 16 The lower incidence in females may be attributed to their reduced participation in strenuous activities such as labor and heavy lifting, anatomical differences such as a more robust fascia transversalis compared to males, and cultural constraints in rural India that lead female patients to seek medical assistance later or, in some instances, not at all. In our study, among 25 patients in the EAAIH group, 9 were farmers, 4 were laborers, 3 were businessmen, and 9 were engaged in diverse occupations such as vendors and drivers. In the TEP group, there were 4 farmers, 2 laborers, 2 businessmen, and 17 individuals engaged in other activities. The research conducted by Burcharth et al.17 and Burgmeier et al.18 assessed all potential risk factors associated with the development of hernias. It was determined that patients who smoke daily have an elevated risk of recurrence, although it remains uncertain whether smoking is a risk factor for primary inguinal hernia. It may be attributable to smoking's role in enhancing collagen degradation and diminishing its synthesis. In our study, 16% of patients in the EAAIH group were smokers, while 20% of patients in the TEP group were smokers.

In our study, constipation was identified as a co-morbidity in only 12% of the EAAIH cohort and 8% of the TEP cohort. Co-morbidities such as Benign Prostatic Hypertrophy (BPH), constipation, and chronic cough contribute to elevated intra-abdominal pressure, thereby precipitating inguinal hernia. In our study, 21 of 25 patients (84%) in the EAAIH Group and 23 of 25 patients (92%) in the TEP Group presented with indirect inguinal hernia, establishing it as the predominant type of hernia in our research. Hammoud et al. indicated in their study that indirect hernias are more prevalent than direct hernias, as two-thirds of inguinal cases were identified as indirect.  Indirect hernias are the most prevalent type of groin hernia in both males and females. Typically, following the descent of the testes, the processus vaginalis undergoes obliteration; however, in certain instances, the processus vaginalis may persist, potentially resulting in an indirect inguinal hernia during infancy or later in adulthood.

The average duration of hospital stay was 2.60±0.88 days for the EAAIH group and 3.67±1.01 days for the TEP group (p=0.00). Köckerling et al. reported that the average length of hospital stay for patients in the TEP group was 1.88 ± 2.19 days, with a median of 2 days. On average, patients in the TEP group had a longer duration of stay in our study. 36

In a separate study conducted by Salma et al., the average duration of hospitalization in the TEP group was 38.70 hours. 19 Consequently, the EAAIH group exhibits a hospital stay duration comparable to conventional laparoscopic inguinal hernia repair techniques, both of which are significantly superior to open hernia repair. The mean time to resume normal activity was 5 days for the EAAIH group and 7 days for the TEP group. The difference is significant, with a p-value of 0.044. Köckerling et al.20 found that, on average, patients resumed work 8.6 days post-TEP and 14 days post-Lichtenstein hernioplasty (p = 0.006). Consequently, our study indicates that patients in both the TEP and EAAIH groups experienced an expedited return to normal activity.

INTRAOPERATIVE COMPLICATIONS

In our study, none of the patients in either the EAAH or TEP groups exhibited any

Intraoperative injury to the bowel or major vessels. Köckerling et al.36 performed a comprehensive study involving 17,575 patients, revealing that only 80 (1.19%) experienced intraoperative complications, including bowel and major vessel injuries. Consequently, both EAAIH and laparoscopic TEP repair are secure methodologies. 36In our study, blood loss was quantified by the number of gauze pieces utilized in a cohort of 25 patients from both the EAAIH and TEP groups. Within the EAAIH group, the majority of Patients experienced a blood loss equivalent to 1.5 gauze pieces, while the majority of individuals in the TEP group had a blood loss of one gauze piece. No intraoperative injury to any major blood vessel occurred, thus no significant bleeding was reported. Köckerling et al. conducted a study to compare the perioperative outcomes in patients undergoing TEP and TAPP procedures. They found that among 6,700 patients who underwent TEP repair, 53 (0.79%) experienced inadvertent major blood vessel injury intraoperatively. The lateral cutaneous nerve of the thigh and the femoral branch of the genitofemoral nerve are the two nerves most frequently damaged due to the indiscriminate application of tackers adjacent to the spermatic cord. Lateral cutaneous nerve injury is the most frequently injured nerve (2%), leading to paresthesia in the upper region of the thigh. • If pain commences a few days post-surgery, it will likely resolve spontaneously within 2-4 weeks. • However, if pain arises within 24 hours, there is a significant likelihood of permanent nerve damage, potentially leading to chronic numbness. Injury to the genitofemoral nerve (1%) may result in paresthesias, although it is typically inconsequential. In our study, none of the 50 patients experienced nerve injuries. Consequently, both TEP and TAPP are secure procedures.

POSTOPERATIVE COMPLICATIONS

Pain was assessed subjectively using the Visual Analogue Scale (VAS). The acute groin pain was monitored until day 7 post-surgery. It was evaluated using a visual analogue scale ranging from 0 to 10. It was observed in seven patients (28%) in the EAAIH group and nine patients (36%) in the TEP group (p value=0.53). The disparity was statistically negligible. The highest VAS score in the EAAIH and TEP groups was 3 and 5, respectively, which the patients regarded as mild. The discomfort was readily managed with analgesics.

In a study conducted by Hamza et al., 21the mean pain score for 25 patients in the TEP repair group was 3.98 ± 4.35 on the VAS scale. In a separate study conducted by Salma et al.,20 among 60 patients undergoing TEP repair, the majority experienced moderate postoperative acute pain (63.34%, n=19), while 20% (n=6) reported mild pain on day 7 post-surgery.

Acute groin pain may be attributed to the mesh acting as a foreign body, eliciting a localized inflammatory response in the adjacent tissue. Edematous tissue and inflammatory cytokines transmit nociceptive signals to nerve endings, resulting in pain that gradually diminishes as inflammation resolves. In our study, no patients experienced postoperative wound infections.

Laparo-endoscopic mesh repair of moderate to large direct inguinal hernia defects often leads to seroma formation. Seroma formation occurs due to the mesh acting as a foreign body, which triggers a localized inflammatory response in the adjacent tissue, resulting in the accumulation of clear fluid in that region. In our study, the EAAIH group had 2 (8%) patients, while the TEP group had 3 (12%) patients who developed seroma in the postoperative wound.

Berney et al.22 reported a seroma formation rate after TEP repair ranging from 0.5% to 12.2%. Increased seroma incidence correlates with larger hernia defect sizes and the method of mesh fixation, specifically whether tackers or adhesive was employed. Köckerling et al. (23) discovered that seroma constituted the highest percentage of postoperative complications, specifically 2.1% of the study population that utilized tackers, with p < 0.001.
The current study reported no instances of hematoma formation in the EAAIH group, while one case (4%) was observed in the TEP group. Köckerling et al. (24) demonstrated that 1.15% of the total study population in the TEP group developed postoperative wound hematomas. Haematoma formation was confined to the wound site, with no accompanying scrotal haematoma. It was effectively managed through conservative means. In the current study, 3 (12%) instances of postoperative urinary retention (POUR) were observed in the EAAIH group, while 2 (8%) instances were noted in the TEP repair group. Garg et al.25 found that tackers, frequently utilized for mesh fixation, are linked to a considerable risk of postoperative urinary retention (POUR), with incidence rates ranging from 8% to 27.3%. Our study revealed no instances of postoperative wound infection in either the EAAIH or TEP groups. Uncontrolled RBS predisposes the patient to protracted wound healing and renders the patient immunocompromised. The infection was confined to superficial tissue layers and did not present with any systemic symptoms such as fever. It was effectively managed with routine aseptic dressings and an escalation of antibiotics. The mean surgical duration in our study for EAAIH was 110-130 minutes, while for TEP it was 90-110 minutes. This aligns with the research by Sharma et al., 26which indicated that the average duration for TEP surgery was 120.89 ± 29.28 minutes. Our study revealed that, during the one-year follow-up period, the sole chronic complication that persisted in certain patients was pain. Following a hernia repair, Alfieri et al.27 characterized chronic pain as discomfort lasting a minimum of six months. The persistent inflammation surrounding the mesh after three months necessitates an extended duration, as improvement may occur between three and six months.Amid et al.28 proposed that nerves become ensnared in "meshoma," which forms when the mesh contracts due to folding and wrinkling. Radiological imaging further corroborated this theory. The current study revealed that the prevalence of chronic pain after 6 months was 12% in the TEP group and 4% in the EAAIH group (p value = 0.082).

At the conclusion of one year, the incidence of chronic pain, as assessed by the VAS scale, markedly diminished, with no patients in the EAAIH group reporting pain, while only one patient (4%) in the TEP group reported mild pain (VAS score 3).

Due to the multitude of contributing factors to chronic pain, it is unfeasible to identify a singular element as the origin of a patient's distress. Elevated preoperative pain scores were correlated with a heightened probability of chronic pain, as demonstrated in a study by Franneby et al. 29. Factors such as youth, the nature of the surgical procedure, and any postoperative complications may contribute to the development of chronic pain. In the present study, both the frequency and intensity of discomfort diminished over time.

RECURRENCE

Recurrence constitutes a significant complication of inguinal hernia surgery. In our study, patients were monitored for one year post-operation, and no patients in either group experienced hernia recurrence. A study by Lamb et al., which compared TEP and TAPP regarding recurrence over a follow-up period of 1-11 years, revealed that hernia recurrence occurred in 55 cases (3.27), p= 0.020. Recurrence was observed in 10% of a surgeon's initial 20 cases, 4% of the subsequent 60 cases, and decreased to below 2% thereafter. The primary causes of recurrence are inadequate inferior and lateral mesh placement and/or insufficient exposure of the deep inguinal ring. Ryberg et al. reported that the recurrence rate following TEP surgery ranges from 0% to 0.4%. Factors contributing to recurrence encompass the patient's advanced age, obesity, smoking, occupation, and inadequate surgical repair techniques. The literature presents sufficient evidence indicating various patient-related factors that contribute to recurrence. Numerous studies have highlighted the significance of mesh placement in preventing recurrence of inguinal hernias.

This study aimed to compare a newly conceived technique for invasive inguinal hernia repair—Endoscopic Anterior Approach Inguinal Hernioplasty (EAAIH)—with Totally Extra Peritoneal Repair (TEP) techniques. The research involved 50 patients diagnosed with primary unilateral inguinal hernia at the Department of Surgery, Mahatma Gandhi Memorial Medical College, and Maharaja Yashwant Rao Hospital, Indore, M.P. During the study, the following observations were recorded: Hernia is more common in the middle-aged demographic [41-50 years] and predominantly affects males [all 50 patients in the study were male]. 2. Early postoperative complications, such as urinary retention, acute postoperative pain, seroma formation, and hematoma formation, were comparable in both the EAAIH and TEP groups.

The duration of surgery and hospital stay were comparable in both the EAAIH and TEP groups.

No notable differences were detected between the two groups regarding long-term complications such as chronic pain. Patients in both groups reported mild pain. From the aforementioned, the following conclusions can be confidently derived: The newly conceived and developed technique—EAAIH—is comparable to the established TEP technique regarding success rate, intraoperative and postoperative complication rates, scar cosmesis, and recurrence rates. EAAIH provides surgeons with the added benefit of accessing the hernia from the anterior plane of the abdominal wall. Junior surgeons initially learn to repair hernias via the anterior plane in open surgery, making them more adept at utilizing the anterior approach when performing hernia repairs through EAAIH. Consequently, EAAIH may provide surgeons with a more abbreviated learning curve compared to TEP and TAPP. In the application of the EAAIH technique, only two nerves, namely the Ilioinguinal and Iliohypogastric nerves, are encountered in the superficial plane, in contrast to the Ilioinguinal and Iliohypogastric nerves, the Genital and Femoral branches of the Genitofemoral nerves, the Femoral nerve, the Lateral cutaneous nerve of the thigh, and the Anterior cutaneous nerve of the thigh in TEP techniques. This diminishes the likelihood of nerve injury.Given that the The peritoneal cavity remains unentered, thus eliminating the risk of bowel and major vessel injury during EAAIH. EAAIH can be confidently endorsed as an effective method for inguinal hernia repair. Nonetheless, due to the limited sample size and brief duration of this study, further research is required to clarify the advantages and disadvantages of this innovative technique.

1. Ebbell, B. The Ebers Papyrus: The Greatest Egyptian Medical Document. H. Milford and Oxford University Press, 1937.
2. Stoppa, R. "[Henri Fruchaud (1894–1960), Man of Courage, Anatomist and Surgeon]." Histoire des Sciences Médicales, vol. 31, 1997, pp. 281–286.
3. Kingsnorth, A., and K. LeBlanc. "Hernias: Inguinal and Incisional." The Lancet, vol. 362, 2003, pp. 1561–1571.
4. Rutkow, I. M., and A. W. Robbins. "Demographic, Classificatory, and Socioeconomic Aspects of Hernia Repair in the United States." Surgical Clinics of North America, vol. 73, no. 3, 1993, pp. 413–426.
5. Rao, S. S., et al. "Clinicoepidemiologic Profile of Inguinal Hernia in Rural Medical College in Central India." Journal of Mahatma Gandhi Institute of Medical Sciences, vol. 21, no. 2, 2016, p. 116.
6. Lau, W. Y. "History of Treatment of Groin Hernia." World Journal of Surgery, vol. 26, no. 6, 2002, pp. 748–755.
7. Read, R. C. "The Development of Inguinal Herniorrhaphy." Surgical Clinics of North America, vol. 64, no. 2, 1984, pp. 185–196.
8. Wickersheimer, E. "A. Paré, The Apologie and Treatise... Containing the Voyages Made into Divers Places, with Many of His Writings upon Surgery." Revue d’Histoire des Sciences, vol. 6, no. 1, 1953, p. 88.
9. Cooper, S. A., et al. The Anatomy and Surgical Treatment of Inguinal and Congenital Hernia. T. Cox, 1827.
10. Bassini, E. "Uber die Behandlung des Leistenbeuches." Langenbeck's Archiv für Klinische Chirurgie, vol. 40, 1890, p. 429.
11. Shouldice, E. E. "The Treatment of Hernia." Ontario Medical Review, vol. 20, 1953, pp. 670–684.
12. McVay, C. B. "Inguinal and Femoral Hernioplasty." Minnesota Medicine, vol. 32, no. 6, 1949, pp. 599–605.
13. Lichtenstein, I. L., et al. "The Tension-Free Hernioplasty." American Journal of Surgery, vol. 157, no. 2, 1989, pp. 188–193.
14. Burcharth, J., et al. "Nationwide Prevalence of Groin Hernia Repair." PLOS ONE, vol. 8, no. 1, 2013, e54367.
15. Jenkins, J. T., and P. J. O'Dwyer. "Inguinal Hernias." BMJ, vol. 336, no. 7638, 2008, pp. 269–272.
16. McCormack, K., et al. "Laparoscopic Techniques versus Open Techniques for Inguinal Hernia Repair." Cochrane Database of Systematic Reviews, 2003, no. 1, CD001785.
17. Burcharth, J., et al. "Patient-Related Risk Factors for Recurrence after Inguinal Hernia Repair." Surgical Innovation, vol. 22, no. 3, 2015, pp. 303–317.
18. Burgmeier, C., J. Dreyhaupt, and F. Schier. "Gender-Related Differences of Inguinal Hernia and Asymptomatic Patent Processus Vaginalis in Term and Preterm Infants." Journal of Pediatric Surgery, vol. 50, no. 3, 2015, pp. 478–480.
19. Köckerling, F., et al. "TEP versus TAPP: Comparison of the Perioperative Outcome in 17,587 Patients with a Primary Unilateral Inguinal Hernia." Surgical Endoscopy, vol. 29, no. 12, 2015, pp. 3750–3760.
20. Salma, U., et al. "A Comparison of Postoperative Pain and Hospital Stay between Lichtenstein's Repair and Laparoscopic TAPP Repair." Pakistan Journal of Medical Sciences, vol. 31, no. 5, 2015, pp. 1062–1066.
21. Hamza, Y., et al. "Four-Arm Randomized Trial Comparing Laparoscopic and Open Hernia Repairs." International Journal of Surgery, vol. 8, no. 1, 2010, pp. 25–28.
22. Berney, C. R. "The Endoloop Technique for the Primary Closure of Direct Inguinal Hernia Defect." Hernia, vol. 16, 2012, pp. 301–305.
23. Köckerling, F., et al. "Seroma Following TAPP: Incidence, Risk Factors, and Preventive Measures." Surgical Endoscopy, vol. 32, no. 5, 2018, pp. 2222–2231.
24. Köckerling, F., et al. "TEP versus TAPP: Comparison of the Perioperative Outcome in 17,587 Patients." Surgical Endoscopy, vol. 29, no. 12, 2015, pp. 3750–3760.
25. Garg, P., et al. "Laparoscopic TEP Inguinal Hernia Repair with Nonfixation of the Mesh." Surgical Endoscopy, vol. 23, 2009, pp. 1241–1245.
26. Sharma, D., et al. "Prospective Randomized Trial Comparing TAPP and TEP for Bilateral Inguinal Hernias." International Journal of Surgery, vol. 22, 2015, pp. 110–117.
27. Alfieri, S., et al. "International Guidelines for Prevention and Management of Postoperative Chronic Pain." Hernia, vol. 15, no. 3, 2011, pp. 239–249.
28. Amid, P. K. "Radiological Images of Meshoma: A New Phenomenon." Archives of Surgery, vol. 139, 2004, pp. 1297–1298.
29. Fränneby, U., et al. "Risk Factors for Long-Term Pain after Hernia Surgery." Annals of Surgery, vol. 244, no. 2, 2006, pp. 212.
30. Lamb, A. D., et al. "Recurrence after TEP Laparoscopic Repair." The Surgeon, vol. 4, no. 5, 2006, pp. 299–307.