Editorial: Open Preperitoneal Techniques in Inguinal Hernia Repair: A useful tool for inguinal hernia repair with excellent patient outcomes

Frederik Berrevoet^*

• Ghent University Hospital, Ghent, Belgium

The open preperitoneal technique has already quite a history and in a narrative review by Marc Soler this evolution in technique and approaches is clearly highlighted. Accessing the hernia through an incision in the lower abdomen, exposing the preperitoneal space, and placing a mesh in the space between the peritoneum and the abdominal wall, this technique o ers a direct view of the hernia defect while avoiding many of the limitations associated with more conventional approaches.Secondly, Ralph Lorenz and colleagues illustrated both the need for standardization of techniques as well as the potential advantages of the di erent open preperitoneal techniques versus the "old establishment" as the Lichtenstein repair and the laparoscopic techniques. Their conclusion is that open preperitoneal approaches for groin hernia repair are straightforward and safe, often yielding results comparable to, or better than other techniques.Despite its promising benefits, the open preperitoneal technique is not without its challenges. The technique requires advanced knowledge of abdominal anatomy, particularly the preperitoneal space, which can be more di icult to navigate than the more peritoneal or retroperitoneal spaces. This might be one of the main reasons these techniques seem not be implemented broadly. In a Delphi consensus paper the acceptance of open preperitoneal repair was analyzed using an international survey among European Hernia Society members and a clear set of recommendations was formulated to help surgeons mastering these techniques, ensuring good patient outcomes in a practical and cost-e ective manner. Like all surgical techniques, the open preperitoneal approach may not be suitable for every patient. Patient factors such as the size of the hernia, the presence of comorbidities, and the level of surgical expertise in the operating room must be carefully considered. One of these challenges is the repair of scrotal hernias. Two papers in this special issue focus on this type of more complicated inguinal hernia. Gillion et al. compared the di erent approaches for scrotal hernias and reflects on both the TIPP, the Lichtenstein and the laparoscopic techniques analyzing a large cohort of patients from the Club hernia registry, while Marc Soler reflects on the Minimal Open Pre-Peritoneal (MOPP) technique. Both analyses show highly acceptable outcomes for the open preperitoneal techniques, even in these more complex indication. The open preperitoneal technique represents an exciting frontier in inguinal hernia surgery. With ongoing advancements in surgical instrumentation and a better understanding of abdominal anatomy, the technique may become a more widely adopted approach, particularly as long-term data solidify its advantages. Although approach as well as outcomes are more similar to those laparoscopic approaches, the open preperitoneal techniques are often categorized with Lichtenstein and tissue-based repairs in the broad category of "open" inguinal hernia repair. In a very interesting paper by Blake et al. from the US, it is stated that these vastly di erent approaches together makes data collection and interpretation very di icult, leaving the surgical community unable to make clinically meaningful changes to improve patient outcomes. They come up with a proposal for a new classification of inguinal hernia repair techniques, so to identify clear benefits and disadvantages, and to facilitate patients selection for a specific approach or technique.As we move toward more patient-centered care, the open preperitoneal approach o ers a promising solution for many patients su ering from inguinal hernias, combining the benefits of reduced complications, better outcomes, and fewer long-term risks. Refinement and innovation are key to improving patient care and quality of life. As with any emerging technique, it requires proper patient selection, skillful execution, and ongoing research to solidify its place as a gold standard in the field of hernia surgery.