The Cooper ligament repair is a primary tissue repair that involves suturing the conjoined tendon (superiorly) to Cooper’s ligament (inferiorly) medial to the femoral vein and to the inguinal ligament at the level of and lateral to the femoral vein. It typically requires a relaxing incision and careful dissection near the femoral vessels. It provides closure of the femoral, indirect and direct spaces, and, as such, can be used to repair any hernia defect that may occur in the groin. However, it is almost always reserved for the repair of femoral hernias. Femoral hernias account for 2% to 4% of groin hernias, are more common in women, and are more apt to present with strangulation and require emergency surgery. The postoperative morbidity and mortality increase significantly in patients undergoing emergent repair. This highlights the importance of repairing femoral hernias in an elective setting and suggests that watchful waiting is not a prudent strategy in patients with femoral hernias, even those who are asymptomatic.

The Cooper ligament repair is rarely performed today, as it has been replaced by tension-free prosthetic mesh repairs. The well-known advantages of tension-free hernia repair have led to the development of various mesh techniques for femoral hernia repair. In addition, a laparoscopic approach provides an excellent repair of femoral hernias. However, there remain clinical situations in which a prosthetic mesh should be avoided and a Cooper ligament repair is indicated. The most common clinical scenario involves an emergent operation for a small bowel obstruction secondary to an incarcerated femoral hernia.