Routine contralateral exploration is advisable during extraperitoneal hernioplasty for left inguinal hernia

Abstract

Controversy still exists as to whether the contralateral groin should be routinely explored during totally extraperitoneal hernioplasty for a clinically unilateral hernia. Bochkarev and colleagues are to be commended for their diligent study, which showed an overall 22% occurrence of occult contralateral hernia among 100 consecutive patients with a diagnosis of pure unilateral inguinal hernia before surgery [1]. They conclude, rather categorically, as in all previous studies of the same disorder, that routine bilateral groin exploration ‘‘appears’’ to be valuable. Interestingly, when we look at their raw data from a slightly differently perspective, two important messages emerge. First, in contradistinction to most previous studies, the current study is particularly revealing in that it specifically mentioned the side of hernia presentation in relation to the exploratory findings. Table 1 of the original paper correlates the number of occult defects with the respective side of the primary hernia at clinical examination. Unfortunately, there is an unintentional mix-up in the numbers of occult defects for the respective left and right hernia groups. The table is herein amended and further simplified/ modified to make the points we raise more easily recognizable (Table 1). It shows that as many as 19 (37%) of 52 patients with clinically unilateral left inguinal hernia have an occult right hernia at exploration, whereas only 3 (6% or 1/16) of 48 patients with right hernia have an occult left hernia at exploration. Notably, these markedly contrasting results are in agreement with those found in two studies published earlier [3, 5]. Indeed, the more recent study, albeit of smaller scale, found that patients with a preoperative diagnosis of left unilateral hernia were 10.5 times more likely to have bilateral inguinal hernia than those with a preoperative diagnosis of right hernia, when adjustment is made for age and sex [5]. Therefore, these few reports make a strong case for exploring the contralateral groin in all patients with a diagnosis of left inguinal hernia at clinical examination. However, it remains doubtful whether right inguinal hernia presentation warrants the additional procedure as a routine, especially in light of the current finding that 15 patients would need to be subjected to unnecessary exploration just to get one incipient unsuspected hernia. Second, the original Table 1 shows two hernia recurrences after bilateral repair in 22 patients (10%). This incidence appears inordinately high. Possibly in bilateral cases, the abdominal wall is inherently weak [4], or alternatively, there remains an underlying cause for persistently elevated intraabdominal pressure. Under such circumstances, a stronger repair is advisable.