learning curve to adoption of rTAPP, probably because surgeons utilize previously acquired laparoscopic expertise. Familiarity with the anatomy of the groin region, the anterior abdominal wall, and how the preperitoneal space transitions to the ret­roperitoneal space are critical both for low recurrence rates and avoidance of com­plications. Anatomy, dissection, mesh placement, and peritoneal closure have been discussed in the preceding section.

Inguinal hernias have been recognized in medical writings as early as 1550 BC in the Papyrus Ebers. These writings describe both the appearance of inguinal hernia as well as rudimentary treatments. Greco-Roman scholars, including most notably Galen, began to lay the foundation for understanding the pathogenesis and treat­ment of hernia. Galen described the origin of hernias as rupture of the peritoneum and overstretching of the overlying fascia and muscles. These ancient scholars understood and described the importance of hernia sac ligation, preservation of the testis, and hemostasis which essentially laid the foundation of modern hernia repair concepts [5]. Edoardo Bassini is generally recognized as the rst of many pioneers in modern hernia repair in the late 1800s. He was the rst surgeon to prospectively follow his patients for postoperative outcomes including recurrence and infection. Over 5years, he was able to prospectively gather data on 216 total patients [5]. Using the Bassini technique of “triple layer” closure (transversalis fascia, transver­sus abdominis muscle, and internal oblique muscle) to the inguinal ligament, he was able to achieve historically low recurrence rates (4%) and infection rates (5%). Over the next 100years, several other methods of inguinal hernia repair were pioneered, but all were founded on the basis of tension-free repair using natural tissue planes. In the late 1980s and early 1990s, the advent of synthetic mesh changed the world of hernia repair immensely. Lichtenstein and colleagues popularized the routine use of mesh for tension-free repair of both complicated and uncomplicated hernias [6]. This has been shown in numerous studies to be superior to tissue repair with regard to most measurable data. It should be noted, however, that tissue repair at specialty centers such as the Shouldice Institute may offer similar recurrence rates to TFR [7].