COLLECTIVE REVIEWS

Management of Recurrent Inguinal Hernias

Kamal MF Itani, MD, FACS, Robert Fitzgibbons Jr, MD, FACS, Samir S Awad, MD, FACS,
Quan-Yang Duh, MD, FACS, George S Ferzli, MD, FACS
The ultimate measure of success of inguinal hernia repair is the
rate of recurrence. Although other procedure-related compli-
cations are important and have been shown to affect health-
related quality-of-life parameters,
1
recurrence is more chal-
lenging for the patients and the surgeon. From the patients
perspective, the initial physical and mental investment in the
operation has failed. A new investment has to be made, with
fewer guarantees for success, more risks for more serious com-
plications, and more time off from work. For the surgeon,
repair of a recurrent inguinal hernia is technically more de-
manding because scar tissue causes the inguinal canal to be
obscured and distorted. In addition, the tissue tends to be
weaker than at the time of primary repair, resulting in a sub-
stantially higher risk for complications or development of an-
other recurrence. Although much has been published about
primary repair of inguinal hernias, less is knownabout the best
approach to address a recurrent hernia. In this review, we ad-
dress the pros and cons of popular surgical approaches and
watchful waiting for recurrent inguinal hernias and indica-
tions for each. In the absence of best evidence in this field, the
authors present an opinion based on their experience and a
reviewof the available literature primarily extracted fromlarge
trials and large cohorts for inguinal hernia repair in general.
EXTENT OF THE PROBLEM
Review of routine hernia practices within the community
have shown recurrence rates of primary inguinal hernia
repairs to vary between 1% and 17%.
2-5
Despite recur-
rence rates being most accurate in prospective randomized
trials, the limitation is that most trials follow patients for
only 2 years, which is too short. In longterm observational
studies, reoperation is used as a proxy for recurrence, with
the accepted recurrence estimated at 1.7 to 2 times the
reoperation rate.
6,7
In a large observational study from
Denmark, reoperation rate after a primary Lichtenstein
repair was 2.4%, 6.2% after a primary nonmesh repair,
3.6% after primary mesh (non-Lichtenstein), and 3.3%
after primary laparoscopic repair.
1
In the same study, rate of
reoperation after repair of a recurrence was higher, at 8.8%.
In a similar observational study from Sweden, the cumula-
tive incidence of reoperation at 24 months was 4.6%(95%
CI, 2.55.8%) for recurrent repair and 1.7% (95% CI,
1.42.0%) for primary repair.
4
In the Danish observational study,
1
90.8% of the recur-
rences occurred in the inguinal canal and 9.2% of the re-
current hernias were found in the femoral area, raising the
question of whether this was a recurrence in the first place
or a missed hernia. Felix and colleagues
8
found an occult
femoral hernia incidence of 9% in their 1996 series of
laparoscopic repair of recurrent inguinal hernia. Mikkelson
and colleagues
9
found the risk of femoral hernia to be 15
times higher after inguinal hernia repair than in the general
population, and Chan and Chan
10
believe that a previous
inguinal hernia repair can precipitate the occurrence of a
femoral hernia. They found that 50.9% of their series of
225 femoral hernia repairs had concurrent inguinal hernia
and 18.2% had previous groin hernia repair.
In this report, we describe the options available to the
surgeon to address a recurrent hernia. Recommendations
are given based on available literature, primary repair per-
formed on the patient, and expertise and familiarity of the
surgeon with various techniques.
Is watchful waiting of a recurrent inguinal hernia
an option?
Inguinal hernias, even when recurrent, are often asymp-
tomatic or minimally symptomatic at the time of diagnosis.
The traditional recommendation has been to repair these
hernias because of a perceived substantial risk of bowel
obstruction or strangulation, or both.
11
The recommenda-
tion is based on empiricism rather than scientific fact be-
cause there are no randomized controlled studies in the
literature that specifically address the issue of observation
of recurrent hernias. In addition, it is commonly believed
Disclosure Information: Dr Itani received research support from Lifecell
Corporation. Dr Fitzgibbons is a consultant and receives research support
from Lifecell Corporation and royalties from Cook Surgical for the
Fitzgibbons-Jenkins Multi Purpose Common Bile Duct Catheter. Dr Duh
is on the clinical advisory board of Covidien. Dr Awad is a speaker and ad
hoc consultant and has received research support fromLifecell Corporation.
Dr Ferzli has nothing to disclose.
Received April 2, 2009; Revised July 17, 2009; Accepted July 17, 2009.
From the Department of Surgery, Boston Veterans Affairs Health Care Sys-
tem and Boston University, Boston, MA (Itani); Department of Surgery,
Creighton University, Omaha, NE (Fitzgibbons); Department of Surgery,
Michael E DeBakey Veterans Affairs Medical Center and Baylor College of
Medicine, Houston, TX (Awad); Department of Surgery, San Francisco Vet-
erans Affairs Medical Center and University of California San Francisco, San
Francisco, CA (Duh); and Department of Surgery, State University of New
York Downstate Medical Center and Lutheran Medical Center, Brooklyn,
NY (Ferzli).
Correspondence address: Kamal MF Itani, MD, Boston Veterans Affairs
Health Care System (112A), 1400 VFW Pkwy, West Roxbury, MA 02132.
email: kitani@va.gov
653
2009 by the American College of Surgeons ISSN 1072-7515/09/$36.00
Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2009.07.015
that progression of a hernia is inevitable and that opera-
tions become more difficult the longer the hernia is left
unrepaired.
12
A prospective randomized multicenter trial
of watchful waiting versus Lichtenstein repair with a min-
imum followup of 2 years was published in 2006.
13
The
rate of hernia accident (defined as a strangulation or bowel
obstruction) for all patients (both primary and recurrent)
was calculated at 0.0018 events/patient/year in that study,
or one-fifth of 1% per year. Although the watchful waiting
group had more pain interfering with activities (risk differ-
ence: 2.86; 95% CI, 0.04 to 5.77) and a slightly worse
performance on the physical component of the SF-36 (dif-
ference: 0.16; 95% CI, 1.19 to 1.50), these differences
were not statistically significant; the overall crossover rate
from watchful waiting to operation in that study at 2 years
was 23% and was mostly related to pain. A subset analysis
was performed on 43 patients with recurrent hernia (33
unilateral and 10 bilateral) who were randomized to watch-
ful waiting. By 2 years, 15 patients (35%) had crossed over
and received an operation primarily because of increasing
pain. There were no consequences for delaying operation
and outcomes (ie, pain, quality of life as measured by the
SF-36, and activity) were the same when compared with
those who were randomized to immediate operation.
14
It is safe to conclude that watchful waiting of a recurrent
hernia is acceptable and the recurrent hernia can be ad-
dressed when symptoms evolve.
Open approach of a recurrent inguinal hernia
Considerations for repairing a recurrent hernia from an
open approach should take into account the native anat-
omy of the groin, namely the myopectineal orifice (MPO),
which was originally described by Fruchaud.
15
This ana-
tomic hole located between the false pelvis and the ipsilat-
eral lower extremity is quadrangular in shape and is divided
into a superior and inferior level by the inguinal ligament
(Fig. 1). The MPO allows passage of the spermatic cord
structures superiorly and the femoral vessels inferiorly. The
boundaries of the MPO are the arching fibers of the inter-
nal oblique superiorly, the rectus abdominis muscle medi-
ally, the anterior borders of the iliac bone inferiorly, and the
iliopsoas and iliopectineal arch laterally. The goal of an
open repair in a recurrent hernia is to identify the failure in
coverage of the MPOfromthe initial repair, and attempt to
provide definitive coverage. In addition, five principles,
described by Lichtenstein and colleagues,
16
should be
considered in approaching a recurrent inguinal hernia
anteriorly:
1. Do not depend on fascial structures to close or reinforce
the defect;
2. Reinforce the entire inguinal floor irrespective of the
type of hernia;
3. Avoid all tension on suture lines;
4. Avoid use of scarred or devascularized tissue in the re-
pair of recurrent hernias; and
5. Use a large prosthetic material to reinforce the entire
inguinal floor permanently.
The choice of repair for the recurrent hernia will depend
on the initial repair used. Initial repairs can include primary
conventional tissue repair; primary anterior mesh repair,
such as Lichtenstein onlay patch
16
; plug and patch
17
; Pro-
lene Hernia System(Ethicon)
18
; or primary posterior mesh
repair, such as open posterior mesh repair (eg, Read, Rives,
Stoppa, Kugel)
19-21
or a laparoscopic repair.
22
Primary re-
pairs, such as Kugel patch, Prolene Hernia System, and
plug, that place mesh in the preperitoneal space make sub-
sequent laparoscopic repair more difficult. Recurrence rate
after mesh repair differs with the type of repair and should
Abbreviations and Acronyms
MPO myopectineal orifice
TAPP transabdominal preperitoneal
TEP totally extraperitoneal
Figure 1. Myopectineal orice. This anatomic hole located between
the false pelvis and the ipsilateral lower extremity is quadrangular in
shape and is divided into a superior and inferior level by the inguinal
ligament. The myopectineal orice allows passage of the spermatic
cord structures superiorly (medial triangle) and the femoral vessels
inferiorly (inferior triangle). (Reprinted from: Fagan SP. Abdominal
wall anatomy: the key to a successful inguinal hernia repair. Am J
Surg 2004;188[Suppl]:3S8S, with permission.)
654 Itani et al Management of Recurrent Inguinal Hernias J Am Coll Surg
be taken into consideration when performing subsequent
repairs (Table 1).
The choice of anterior versus posterior open approach
should be guided by the initial repair. A careful review of
previous operative reports is paramount in guiding the sub-
sequent repair. If the initial repair was a tissue repair, then
either the anterior or posterior approaches can be used for
repair of the recurrent hernia (Fig. 2A). If the initial repair
was a mesh repair, then the recurrent repair should prefer-
ably employ an approach in the space in which the tissue
planes have not been violated previously (Fig. 2B). An an-
terior approach is clearly the best choice after failed poste-
rior repair, no matter if it was performed open or
laparoscopically.
The choice of the procedure depends more on the per-
sonal experience of the surgeon than the specific operation.
In an anterior approach, the cord structures have to be
carefully dissected in order to avoid devascularization of the
testicle and injury to the vas deferens and nerve structures.
A mesh repair should be done in those patients with no
previous mesh observing the Lichtenstein principles listed
here. In cases where previous mesh was used, the mesh is
usually severely adherent and fibrosed to the cord struc-
tures and surrounding tissues. Orchiectomy is rarely nec-
essary but should be discussed with the patient before the
operation and performed in case of devasularization of the
testicle. Removal of the mesh is most often impossible and
careful delineation of the anatomy and MPO are most
important. Placement of a new additional mesh according
to the principles listed here is practiced by many. Anchor-
ing the mesh to healthy fascia and inguinal ligament is
paramount for success of the new repair; anchoring the
mesh to the previous mesh repair in areas where the mesh is
well-incorporated to the inguinal ligament laterally and
rectus fascia medially with no evidence of recurrence can
prevent additional dissection and damage to underlying
structures. With close to 9% of recurrences consisting of
femoral hernias, the femoral canal should be carefully ex-
plored by dissecting the area medial to the inguinal liga-
ment. In cases where femoral hernias are present, we would
caution against use of a plug in that area and advocate for
exposure of Coopers ligament and fixation of the new
mesh to Coopers ligament laterally.
The plug repair favored by many in primary hernia re-
pair has been used in recurrent hernias after tissue repair,
with a 1.2% recurrence rate at 10-year followup and no
major complications in one series.
23
Similar results have
been reported previously with plug repair for recurrences
after mesh repair.
24
With the plug repair, many complica-
tions are reported after primary inguinal hernia repair, such
as chronic pain in approximately 6% of cases,
25
scrotal and
pelvic migration of the plug,
26
and erosion of the plug into
the intestine
27
; bladder
28
; and other structures.
The open posterior approach requires implantation of a
mesh behind the transversalis fascia through a transingui-
nal method (Rives); a slit method made in the broad ab-
dominal muscles (Wantz, Kugel); or a lower midline inci-
sion (Stoppa).
29
During the Kugel operation, dissection to
allow enough room to accommodate the patch in a com-
pletely flat position is extremely important. Inadequate
dissection can lead to folding of the mesh, which can
result in a kink in the expanding ring of the patch that
might crack through the transversalis fascia into the in-
guinal canal, causing chronic pain, or into the peritoneal
Figure 2. (A) Recommended approach when primary hernia was
repaired without mesh. (B) Recommended approach when primary
hernia was repaired with mesh.
Table 1. Rerecurrence Rates after Open Inguinal Hernia
Repair Using Various Mesh Techniques
Hernia repair Rerecurrence rate (%)
Lichtenstein onlay 1.38
45,46
Plug and patch 3.56
17,24
Prolene Hernia System NA
Open posterior approach 5.99.7
47,48
Kugel 27.8
49
NA, not available.
655 Vol. 209, No. 5, November 2009 Itani et al Management of Recurrent Inguinal Hernias
cavity with resulting bowel perforation.
29,30
Although a
softer/absorbable rim has been developed, there are no
longterm studies about its use in the inguinal area.
The Prolene Hernia System placed through an anterior
approach combines the placement of a mesh leaflet poste-
rior to the transversalis fascia and an anterior mesh leaflet
anterior to transversalis fascia. Both leaflets are held to-
gether by a connector. The Prolene Hernia System has not
been studied in a large series of recurrent inguinal hernias.
With a Prolene Hernia System, the surgeon will have to
obtain access to the preperitoneal space, which is difficult
in hernias repaired previously through the posterior ap-
proach (open or laparoscopic), and the surgeon will also
face all the challenges described here in hernias repaired
previously through the anterior approach.
LAPAROSCOPIC REPAIR OF RECURRENT
INGUINAL HERNIA
From the discussion here, it is almost intuitive that a lapa-
roscopic posterior repair, when expertise is available, is a
preferable approach after failed anterior repair. A recent
prospective randomized trial has shown that laparoscopic
repair is superior to open Lichtenstein repair for recurrent
inguinal hernia.
31
In the large Danish observational study,
the cumulative reoperation rate after primary Lichtenstein
repair was substantially reduced after laparoscopic opera-
tion for recurrence (1.3%), compared with open repairs for
recurrence (11.3%).
32
The posterior laparoscopic approach
for recurrent inguinal hernia not only provides the techni-
cal advantage of operating through unscarred tissue, but
has the added benefits of other advantages of minimally
invasive procedures, including less postoperative pain; ear-
lier return to work and activity; and low incidence of
wound and mesh infection, as demonstrated by a number
of retrospective and randomized prospective studies.
1,33-38
In athletes and obese patients, the laparoscopic approach
also offers less dissection through thick layers of muscles or
fat. In patients with testicular atrophy on the contralateral
side of a recurrent hernia repaired with the anterior ap-
proach, the laparoscopic repair provides less chance of in-
juring the spermatic cord structures.
Laparoscopic inguinal hernia repair also provides the
benefit of a panoramic view of all the potential hernia
spaces, ie, direct and indirect; femoral; and obturator her-
nias, allowing identification of missed femoral and con-
comitant ipsilateral and contralateral hernias. All of these
potential weakened areas can be addressed laparoscopically
during the same setting.
The two most common types of laparoscopic repair are
the transabdominal preperitoneal (TAPP) repair and the
totally extraperitoneal (TEP) repair. These techniques have
dissection of the preperitoneal space in common, to iden-
tify the inguinal anatomy; reduce the hernia sac; and place
a mesh to cover the hernia defect. The TAPP repair starts
with a standard intraperitoneal laparoscopy followed by
incising the peritoneum to gain entry into the preperito-
neal space. The TEP repair establishes the preperitoneal
space without intentionally entering into the abdominal
cavity.
Presence of prosthetic material in the preperitoneal space
from a previous hernia repair results in a technical chal-
lenge if a laparoscopic repair is considered. This is usually
encountered after previous repairs performed with a plug,
Prolene Hernia System, and Kugel meshes. These devices
result in scarring in the preperitoneal space, making dissec-
tion more difficult. They also create an obstacle to placing
a new mesh and make the peritoneal closure in a TAPP
repair more difficult. Removal of the plug or posterior leaf-
let of a Prolene Hernia System is not simple and cannot be
easily accomplished with ENDO SHEARS (Covidien). It
is our experience that the electrocautery cuts the protrud-
ing aspect of the mesh more effectively. With a Kugel mesh,
if the ring has to be removed it should be done through a
separate incision.
In cases where a laparoscopic approach is undertaken for
a previous flat mesh placed through a posterior open or
laparoscopic repair, it is best to leave it in place to avoid risk
of injury to the iliac vein or bladder. The new mesh can be
laid on top of the old, correcting any technical failure from
a slipped or misplaced prior mesh. This approach should be
reserved for surgeons with advanced laparoscopic expertise
in this field.
TEP versus TAPP
There are no multicenter prospective randomized studies
comparing TEP and TAPP repairs for recurrent inguinal
hernia. Most nonrandomized studies find equivalent rates
of recurrence and complications between TEP and TAPP
repair.
39
A recent Cochrane review looking at TAPP versus
TEP for inguinal hernia repair suggests that TAPP is asso-
ciated with higher rates of port-site hernias and visceral
injuries, and there appear to be more conversions withTEP.
Vascular injuries and deep or mesh infections were found to
be rare, with no obvious difference between the groups.
40
A number of studies have looked at TAPP repair for
recurrence after TEP or TAPP as the primary repair modal-
ity (TAPP after TEP or TAPP). Most of these studies have
shown excellent results but were done by experts in that
field.
37,40,41
Relative contraindications for laparoscopic repair
As in other laparoscopic operations, TEP and TAPP per-
formed for recurrent hernias have some relative contrain-
656 Itani et al Management of Recurrent Inguinal Hernias J Am Coll Surg
dications that are similar to those performed for primary
hernia, ie, repair requires general anesthesia and muscle
relaxation. Patients with severe cardiac or pulmonary dis-
eases are better treated with open repair with local anesthe-
sia. The extensive preperitoneal space is usually created by
blunt dissection in the case of TEP and by peeling the
peritoneum in the case of TAPP, so patients who are anti-
coagulated or are at risk for bleeding should have open
repair. It is also more difficult to create the preperitoneal
space if the patient had previous preperitoneal dissection,
such as for a prostatectomy, or operations involving the
iliac vessels or a preperitoneally located transplanted kid-
ney. For these patients, the advantage of laparoscopic repair
is outweighed by the disadvantage of technical difficulty in
creating the preperitoneal space to place the mesh. Patients
with large scrotal hernias or ascites are also better treated
with open hernia repair.
Problems with laparoscopic repair
There are two main reasons why laparoscopic primary and
recurrent inguinal hernia repair has not gained full accep-
tance. Injuries to bowel, bladder, and major vessels are very
rare but potentially life-threatening complications that oc-
cur more frequently in laparoscopic repair than in open
hernia repair. A long learning curve also poses an obstacle.
Although 250 cases is frequently quoted as distinguishing
an experienced versus inexperienced surgeon for laparo-
scopic hernia repair, the Veterans Affairs study was not
specifically designed to determine the learning curve of the
surgeons.
42
In retrospect, the Veterans Affairs studys re-
quirement that surgeons had already performed 25 laparo-
scopic hernia repairs before joining the study was an un-
derestimation. Arecent study fromEdinburgh showed that
recurrence rate after TEP repair plateaus to about 2% after
80 cases.
43
Cost of laparoscopic repair can be in the same
range as open repair if the surgeon avoids using expensive
disposable instruments.
Recurrent inguinal hernias in women
Most of the discussion here relates to the repair of inguinal
hernias in men. Very little is published on groin hernias in
women and most of our knowledge in this area comes from
the large Swedish hernia registry, where 6,895 women with
inguinal hernias were followed prospectively.
44
In 267 re-
pair for recurrent hernias, 41.6%of women diagnosed with
a direct or indirect inguinal hernia at the primary operation
were found to have a femoral hernia at the time of reopera-
tion. In a multivariate analyses of relative risks for reopera-
tion, the risk was reduced when transabdominal preperito-
neal laparoscopic repair was performed at the time of
primary repair. After adjusting for all other factors (eg, mode
of admission, reoperation, suture material, hernia type, meth-
ods of repair, postoperative complications, methods of anes-
thesia), womenwere foundtohave a higher riskof reoperation
for recurrence than men.
This study points to considerable differences that need
to be taken into consideration when addressing recurrent
hernias in women as compared with men. Although the
principles delineated here for men apply to women, sur-
geons must be aware of the very high incidence of recur-
rence in the form of a femoral hernia in women.
The higher rerecurrence rate of inguinal hernia after a
previous recurrence results from distortion of the normal
anatomy and from replacement of the fascial strength layer
with weaker scar tissue. Although watchful waiting is ac-
ceptable in asymptomatic patients and does not represent
greater risks than in patients with primary hernia, many
patients will ultimately require rerepair. For recurrent in-
guinal hernias, it is now accepted that a laparoscopic pos-
terior repair is a preferable approach after failed anterior
repair; an anterior approach would seem to be the best
choice after failed posterior laparoscopic or open repair.
It is imperative that the surgeon caring for patients with
recurrent inguinal hernias make every effort to obtain the
previous operative report in order to anticipate any poten-
tial difficulties in the rerepair and to help guide the choice
as to the best reoperative approach. In the final analysis, it
is the surgeons training and experience with a particular
anterior or posterior technique that determines what the
best and safest repair is for the patient.
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