Inguinal hernia repair is the most common surgical procedure performed, and preliminary estimates suggest that more than 5 million patients may require such procedures each year nationwide. In retrospect, each time a new understanding of the anatomy associated with a hernia was gained, significant advances in hernia surgery were made forward. For example, when the significance of the iliopubic tract was rediscovered, the posterior approach (Nyhus procedure) emerged; when the concept of the muscopubic foramen (Fruchaud’s foramen) was introduced, various preperitoneal repairs such as the Stoppa procedure and the Gilbert procedure followed. In fact, anatomical structures such as the iliopubic fasciculus and the foramen myopubicum originally existed in the human body, but just needed to be observed, discovered, and applied. In this paper, we summarize and sort out some ideas and advances about inguinal anatomy and present our own views in order to help and promote good inguinal hernia surgery for surgeons. 1, the understanding and development of the anatomy of the inguinal region The anatomical development of the inguinal region can be roughly divided into 3 stages. First, in the past 200 years, generations of anatomists and surgeons have worked from cadaver to clinic to recognize and perfect the anatomy of the inguinal region, i.e., the layers and structure of the groin, with 9 layers of tissue from skin to peritoneum. The pathways of hernia surgery and the layers of repair were laid out. For example, the inguinal ligament and pubic comb ligament can be used for suture repair, while the trap ligament can be incised to release the inlay in case of femoral hernia inlay. Second, through repeated practice over the past 35 years, surgeons have further recognized that the anatomic stratification of the inguinal region can change under certain circumstances. For example, the anatomy of the direct hernia triangle is posterior to the muscle as transverse abdominal fascia, preperitoneal fat, and peritoneum, and this hierarchy can be changed if the bladder is very full and the filled bladder shifts to the sides to occupy part of the direct hernia triangle. Therefore, it is sometimes seen clinically that the bladder is inadvertently entered during the search for the hernia sac [1-3]. Third, the development and popularity of laparoscopic techniques in the last 15 years have changed the surgeon’s view and direction of observation in the inguinal region. For a long time, the anatomy of the inguinal region was dissected and observed from the outside to the inside (anterior to posterior). Laparoscopic technology (especially high-definition technology) has greatly changed the observation of the posterior level of the muscle in the inguinal region, and the magnification of the laparoscope extends the operator’s line of sight, making the surgical anatomy clear and accurate, with less bleeding and more precise efficacy. 2. Slope and length of inguinal canal As a hernia surgeon, you should not only be familiar with the anatomical levels of the inguinal region, but also understand and appreciate the concept of slope and length of the inguinal canal. The spermatic cord penetrates the abdominal wall through the inguinal canal after a certain length and obliquity. From a physiological point of view, the longer the length and the greater the obliquity of the inguinal canal, the greater its protective effect. It can also be concluded that reconstruction of the slope and length of the inguinal canal is an important rationale for surgical repair [4]. The first to introduce the concept of inguinal canal slope and length was the Italian surgeon Bassini, the father of modern hernia surgery, who believed that hiatal hernias occur due to straightening of the slope and shortening of the length of the inguinal canal. Therefore, an important principle of Bassini’s repair is to restore the length and slope of the inguinal canal, a principle that applies equally to both classical suture repairs and tension-free repairs with materials. The inguinal canal is very short in newborn infants, which can be less than 1 cm, and the inner and outer rings are very close to each other, but with increasing age the inguinal canal also lengthens to the two outer sides, therefore, congenital hiatal hernias in newborn infants are observable and some of them can heal spontaneously. In addition, high ligation of the hernia sac in children with inguinal hernia should also be considered anatomically as the ligation point should be lateralized to facilitate the restoration of the slope and length of the inguinal canal. 3. fixation of the spermatic cord and spermatic cord The core structure of the inguinal canal is the spermatic cord (round ligament in women). From the late stage of fetal development to birth, the spermatic cord descends with the testes, from behind the abdominal cavity, downward and forward through the abdominal wall of the inguinal region, in the process of the spermatic cord (round ligament for women) through the abdominal wall, in addition to forming the inguinal canal, also brought out the layers of the abdominal wall, from the inside out, the transversus abdominis fascia in the spermatic cord migrated to become the internal spermatic fascia, the transversus abdominis muscle and the internal oblique abdominal muscle migrated to become the levator muscle, the tendon membrane of the external oblique abdominis muscle below the external ring mouth The external oblique tendon membrane of the abdominal muscle migrates below the opening of the external ring to become the external seminiferous fascia. It should be emphasized that in the case of hiatal hernia, the hernia sac is a continuation of the peritoneum along the spermatic cord from above to below, and the hernia sac is surrounded by the internal fascia of the spermatic cord (a continuation of the transversus abdominis fascia) after exiting the internal ring opening. Therefore, the hernia bursa of hiatal hernia is closely associated with the spermatic cord, whereas the hernia bursa of direct and femoral hernia is not closely associated or related to the spermatic cord. Recent studies have revealed a mechanism of fixation of the spermatic cord at both ends of the inguinal canal (inner and outer rings) [5]. In the external ring, this manifestation is more definite, with dense adhesions of the spermatic cord to the tissues surrounding the external ring including the medial and lateral pedicles of the external ring, the pubic tubercle, and the fascia at the base of the inguinal canal, which cannot be separated intraoperatively by blunt separation and require sharp separation with an electric knife or scissors to loosen its fixation. At the opening of the internal ring, there was also a dense fusion-like tissue structure to fix the spermatic cord to the internal ring area. The fixation at the internal ring may be due to adhesions resulting from sphincter closure. Closure of the sphincter occurs after birth, a process that results from programmed death (apoptosis) of the peritoneal epithelium and the change of epithelial tissue to mesenchymal tissue, i.e., mesenchymalization of the epithelium. The mechanism of fixation of the spermatic cord is important to prevent the displacement of the spermatic cord and the occurrence of hiatal hernia. It is conceivable that if the spermatic cord is not well fixed, it could drive the peritoneum to move downward and form a hernia sac as the spermatic cord is displaced downward. The strength of fixation of the spermatic cord is not uniform between the inner and outer annulus, and is relatively weak at the inner annulus, which may also contribute to the occurrence of hiatal hernia. On the other hand, all current techniques of repair with materials, the patch has the effect of fixing the spermatic cord. 4. What is standardization? What is a standardized procedure? Literally, regulation is a ruler, while Fan is a mold, and the two are combined into one word, which means the restraint of thinking and behavior. In other words, a norm is a qualitative information regulation of an operational behavior. The main reason why it is qualitative is because for an operation like hernia surgery, it is impossible to quantify precisely and form a standard. Therefore, the so-called normative surgery (here mainly refers to routine surgery) is the one that requires first of all that the operation is a surgery with separation according to the anatomical level, in place, clear and dry and quiet, with no or little blood in the field of view. Specifically, after opening the extra-abdominal oblique tendon membrane, the extra-abdominal oblique tendon membrane is fully freed, internally up to the inferior arch of the transversus abdominis muscle of the internal oblique muscle and externally down to the inguinal ligament, and the free spermatic cord should be found in a “bloodless plane” above the external ring opening with a length generally less than 2 cm. For the repair and reconstruction of hernias, regardless of whether a patch is used or not, it is necessary to take into account The slope and length of the inguinal canal should be taken into account. The fixation of the spermatic cord should also be taken into account during the repair. We hope that we can do a good job of inguinal hernia repair from anatomical point of view for the benefit of our patients.