Management of Recurrent Inguinal Hernia

Abstract

Inguinal hernia is a common problem, and inguinal hernia repair is one of the most commonly performed procedures by general surgeons. There are many ways to repair an inguinal hernia, but no one method is perfect, and recurrent inguinal hernia remains a common diagnosis. Recurrences may be defined as early or late, with technical error most often contributing to early recurrence and patient factors and mesh factors most often contributing to late recurrence. Technical factors that contribute to hernia recurrence include tension on the repair, incomplete dissection of the myopectineal orifice, insufficient reduction of the hernia sac, insufficient reduction of lipomas, or inadequate mesh implant size. Patient factors that contribute to recurrence include any cause of increased strain on the repair (obesity, coughing), poor wound healing, and postoperative seroma, hematoma, or wound infection. Mesh factors include mesh folding, eventration, shrinkage, and migration. Presentation of a recurrent inguinal hernia is variable but is often described as a vague discomfort in the groin that progresses to a groin bulge. It is important to note that there are many causes of groin pain after an initial inguinal hernia repair that are not caused by a recurrent hernia. Diagnosis of a recurrent inguinal hernia is most often clinical and based on a patient history and physical exam; however, when the diagnosis is unclear, imaging can be of value. Re-repair is indicated for symptomatic recurrent inguinal hernias. The technique for repair of a recurrent inguinal hernia is based on the prior repair(s). The main tenet for re-repair is to approach the hernia through undistributed tissue planes. In general, this means that in cases of prior anterior (open) repair, the hernia should be approached posteriorly (through open or minimally invasive laparoscopic or robotic techniques). For cases of prior posterior repair, an anterior approach should be used. In the era of improving laparoscopic and robotic skill and technology, however, even hernias initially repaired using minimally invasive techniques may be able to be safely and effectively re-repaired using laparoscopic or robotic approaches.