Open preperitoneal techniques: a bridge between anterior open and posterior endoscopic approaches

Abstract

Mesh-based repair is the standard treatment for groin hernias. The HerniaSurge Group guidelines recommend both anterior open repair, such as the Lichtenstein repair, and minimally invasive posterior approaches including totally extraperitoneal repair (TEP) and transabdominal preperitoneal repair (TAPP). Over the past decades, several open preperitoneal techniques (OPPs) have been developed, combining posterior mesh placement with an open surgical approach. However, their role in contemporary hernia surgery remains underrecognized. This narrative review summarizes the historical development, anatomical rationale, and clinical evidence supporting OPPs, including transinguinal preperitoneal repair (TIPP), transrectus sheath preperitoneal repair (TREPP), open new simplified totally extraperitoneal repair (ONSTEP), and minimal open preperitoneal repair (MOPP). Preperitoneal mesh placement allows complete coverage of the myopectineal orifice, which represents the anatomical basis for modern posterior repairs. Registry analyses and comparative studies suggest that OPPs may be associated with lower rates of chronic postoperative pain compared with anterior repairs such as the Lichtenstein technique, while achieving outcomes comparable to those of endoscopic approaches. In addition, these techniques offer several practical advantages, including the possibility of performing the procedure under regional or local anesthesia, lower costs, and broad applicability across various clinical settings. OPPs represent a valuable intermediate option between anterior open and endoscopic repairs. By combining the anatomical advantages of posterior mesh placement with the simplicity of open surgery, they may be particularly useful in selected patients and in complex hernias. Greater recognition and further comparative studies are needed to better define their role in modern groin hernia surgery.

Keywords

Primary groin hernia / Lichtenstein repair / OPPs / TIPP / MOPP / TREPP / laparo-endoscopic repair / robotic hernia repair

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