Inguinal hernia repair is one of the most common procedure performed all over the world in adults. The lifetime risk of developing an inguinal hernia has been estimated at 27% for men and 3% for women (1). In general, due to easy recognition as an palpable mass in the groin region patients seek for doctor’s consultation. Usually, it is not a life-threatening condition that may be successfully treated with the surgical manipulation. The emergency operation is necessary in cases of strangulation due to the possible complications such as intestinal necrosis, diffuse peritonitis and septic shock. The “wait and watch” strategy may be applied when it refers to minimally symptomatic or totally asymptomatic patients.

Groin hernias account for up to 75% of all abdominal wall hernias, with the incidence of 97% for inguinal hernia and 3% for femoral hernia. Inguinal hernias are most likely to appear in men (90.2% males vs 9.8% females), whereas 70.2% of femoral hernias appear in women (2). The risk factors for hernia formation may be divided into patient-related and external risk factors. Higher incidence of inguinal hernia is associated with older age, male gender, coexistence of hiatal hernia in men, lower body mass index and Caucasian race (3). Inverse relationship between obesity and lower risk of hernia may be a result of limitations in physical examination in obese patients. Moreover, the visceral fat may act as a barrier against protrusion of the hernia sack (4, 5). Recent studies suggest that smoking may be associated with the increased risk for hernia development due to the changes in collagen metabolism (6, 7). On the other hand, some studies showed negative link between tobacco use and inguinal hernia formation, which still remains unexplained (8, 9). Other patient-related factors identified as a potential risk for the formation of groin hernia include positive family history, chronic obstructive pulmonary diseases, abdominal aortic aneurysm, patent processus vaginalis and connective tissue disorders (10-12). Patients with increased serum levels of matrix metalloproteinase 2 (MMP-2) and matrix metalloproteinase tissue inhibitor 2 (TIMP-2) comparing to general population are also at higher risk of developing hernia (13). External risk factors are identified with cumulative exposures to daily lifting activities (total load, frequent heavy lifting) and prolonged standing and walking (14).

The knowledge of the anteroinferior abdominal wall anatomy is essential for proper understanding of inguinal hernia and its repair. The abdominal wall in groin region is composed of peritoneum, transversalis fascia, internal and external oblique muscles, subcutaneous tissue and skin. Among the structures involved in hernias formation the anatomical area known as myopectineal orifice is considered to have a crucial role. The myopectineal orifice was first described by Dr Henri Fruchaud in 1956 as an area containing natural openings that was additionally weakened during the evolutionary process of human beings (15). This part of abdominal wall is supported only by two thin layers made of the transversalis fascia and the tendinous insertion of transversalis muscle. The orifice is known to be divided into three anatomical triangles: femoral, lateral and medial, that are potential sites for groin hernias formation. The lateral triangle is defined by inguinal ligament inferiorly, the deep inferior epigastric vessels medially and the internal oblique muscle superiorly. The medial triangle, also known as Hesselbach’s Triangle or Hessert’s Triangle, is supported by the fibers of internal oblique muscle superiorly, the rectus abdominis muscle medially, the inguinal ligament inferiorly and deep inferior epigastric vessels laterally. The femoral triangle is bordered by Cooper’s (iliopectineal) ligament inferiorly, inguinal ligament and iliopubic tract superiorly and iliopsoas muscle laterally. The inguinal ligament divides the orifice into two halves. The suprainguinal area of myopectineal orifice contains the internal inguinal ring that allows the passage of spermatic cord in men and the round ligament in women. Whereas, the subinguinal region is opening for the femoral canal and allows the transition of femoral vessels and nerve from abdomen to the lower limb and inversely (fig. 1) (16).

Groin hernia is defined as a protrusion of abdominal content through the area of weakness in groin region. Many different classifications have been described so far, with the Nyhus classification, being the most widely used, especially in the United States. According to anatomy, the Nyhus classification divides groin hernias into femoral and inguinal, which are subdivided into direct (medial) and indirect (lateral) based on their anatomical position towards the inferior epigastric vessels (17). The femoral hernia protrudes into the femoral canal through the fascia transversalis, medially to the femoral vein and below the inguinal ligament. A direct inguinal hernia protrudes trough the transversalis fascia within the Hesselbach’s triangle, medially to the inferior epigastric vessels. Whereas, an indirect inguinal hernia comes out through the internal inguinal ring and is located laterally to the inferior epigastric vessels. Lateral hernia may extend into the scrotum in men or labium majus in women (tab. 1).