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Recurrent inguinal and femoral hernia

Recurrent inguinal and femoral hernia
Literature review current through: Jan 2024.
This topic last updated: Oct 05, 2022.

INTRODUCTION — Inguinal and femoral hernias can be caused by either congenital anatomical, tissue, or developmental abnormalities or acquired tissue abnormalities (eg, trauma) [1]. (See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults".)

A primary hernia refers to a hernia that has not been previously repaired. A recurrent inguinal hernia is one that is directly related to the primary hernia repair. Re-recurrence refers to the occurrence of a hernia that has been repaired at least twice before.

Recurrent inguinal and femoral hernia will be reviewed here. The clinical features, diagnosis, and management of inguinal and femoral hernia in adults and children, and repair techniques (open, laparoscopic), are discussed elsewhere. (See "Overview of treatment for inguinal and femoral hernia in adults" and "Inguinal hernia in children" and "Open surgical repair of inguinal and femoral hernia in adults" and "Laparoscopic inguinal and femoral hernia repair in adults" and "Robotic groin hernia repair".)

INCIDENCE OF RECURRENCES — Recurrence rates following a primary hernia repair range from 0.5 to 15 percent depending upon factors including the hernia site (direct, indirect, femoral), type of repair (mesh, no mesh, open, laparoscopic, robotic), and clinical circumstances (elective, emergency) [2-6]. Hernia recurrence is less common with repair of inguinal compared with femoral hernias due to the higher rates of emergency surgery and complications associated with femoral hernia [7,8].

The rate of recurrence for inguinal hernia may be declining due to the more frequent use of mesh in primary hernia repairs. In a retrospective review from Olmsted County, Minnesota, the incidence of recurrent inguinal hernia decreased from 66/100,000 person-years to 26/100,000 person-years from 1989 to 2008 [9]. Despite that, the decrease in recurrences compared with open (tissue) repair has not been consistently observed across the world [10,11].

Not surprisingly, the recurrence rate is higher for repair of recurrent hernias (ie, re-recurrence) compared with repair of primary hernias related to increased complexity of recurrent hernia repair as well as patient factors [10,12-14].

PATTERN OF RECURRENCES — Early recurrences are due to technical factors, whereas late recurrences are due to patient factors. The most common recurrence after an open repair is in the direct space, while an indirect recurrence is most common after a laparoscopic repair.

Timing of recurrence — Hernia recurrence can occur immediately, early, or late in the time course following hernia repair. Some authors have used five years to separate early from late recurrence, although a specific timeframe has not been firmly established [13,15].

Immediate recurrence is most commonly related to technical issues but can also be due to hernias not identified at the time of operation or excessive increases in intra-abdominal pressure or direct trauma. The use of prosthetic material has dramatically diminished technically related immediate recurrences.

Early recurrence is generally related to technical (surgeon) factors [13]. The rate of early recurrent hernias can be minimized by ensuring complete dissection of all the hernia defects, avoiding undue tension with adequate reinforcement of closure, handling tissue gently to prevent devascularization, and preventing infection. Techniques for inguinal and femoral hernia repair are discussed elsewhere. (See "Open surgical repair of inguinal and femoral hernia in adults" and "Laparoscopic inguinal and femoral hernia repair in adults".)

Late recurrences are related to hernia biology, aging, and other patient-related factors. Late recurrences continue to occur, but at a slightly decreased incidence. Specific recommendations such as weight loss in those who have obesity, cessation of smoking, and discontinuation of glucocorticoid therapy, if possible, may decrease the risk for hernia recurrence. (See 'Patient factors' below.)

The majority of recurrences occur within the first three years following hernia repair [12]. In a review of the Danish Hernia Database, 2.8 percent of reoperations were performed in the first 15 months following hernia repair, and 1.6 percent occurred in the subsequent 15 months [2]. In a later review of the Danish Hernia Registry, the mean time interval for recurrent hernia repair was 12.6 months for inguinal hernia and 10.3 months for femoral hernia [4]. The average time from the initial repair to the diagnosis of recurrence in a study focusing on laparoscopic hernia repair was 20 months (range 3 to 84) [16].

Anatomic site of recurrence — The anatomic site of recurrence after inguinal hernia repair can be located anatomically at either a direct (medial to the inferior epigastric vessels within Hesselbach's triangle), indirect (lateral to the inferior epigastric vessels), or femoral site (inferior to the inguinal ligament) (figure 1 and figure 2 and figure 3).

Following open inguinal hernia repair (mesh or non-mesh), the most common anatomic recurrence site is a direct hernia [12,17]. Following Lichtenstein repair, a higher-than-expected rate of femoral recurrence has been reported [17,18]. In a study of 34,849 groin hernia repairs, a 15-fold greater incidence relative to the spontaneous incidence of femoral hernia (0.21 versus 0.015 percent) was reported after inguinal herniorrhaphy [18]. These femoral recurrences tended to occur earlier than inguinal site recurrences, leading the authors to speculate these were neglected or missed femoral hernias that were not treated at the time of primary repair. (See "Open surgical repair of inguinal and femoral hernia in adults".)

Following laparoscopic inguinal hernia repair, an indirect recurrence site is the most common anatomic site regardless of whether the initial repair was performed as a totally extraperitoneal (TEP) hernia repair or transabdominal preperitoneal (TAPP) hernia repair (figure 4) [16,19]. The mechanism is unclear but may be related to inadequate dissection of the spermatic cord or, alternatively, herniation of the sac beneath the mesh due to mesh migration, inadequate mesh size, inadequate mesh fixation, or subsequent mesh shrinkage. (See "Laparoscopic inguinal and femoral hernia repair in adults".)

RISK FACTORS — Risk factors for recurrent hernia can be related to the type of prior hernia, technical aspects of that repair, and complications of repair such as infection as well as patient- and surgeon-related factors [3,5,12,13].

Technical factors — The main technical factors associated with recurrent inguinal hernia include hernia repair under tension, most commonly due to non-mesh repair (ie, herniorrhaphy) [5,12,13], inadequate mesh size or potentially inadequate mesh fixation (open or laparoscopic), a missed cord lipoma, or surgeon inexperience. Additionally, excessive dissection and devascularization can also lead to hernia recurrence.

Non-mesh repair – Non-mesh repair, which is less likely to produce a tension-free repair, is an important cause of failed hernia repair. Provided mesh is used, no significant differences have been identified in the incidence of recurrent hernia following primary hernia repair, regardless of operative approach (ie, open versus laparoscopic hernia repair) [3,5,6,20,21]. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Treatment options'.)

Inadequate mesh size or fixation – Another important technical risk factor for hernia recurrence is inadequate overlap at the margin of a hernia defect due to improper mesh sizing, positioning, or fixation. In a review of 32,206 hernias from the Swedish Hernia Registry and the Danish Hernia Database, the overall recurrence rate was 0.7 percent for Lichtenstein repair, which is an open mesh repair (figure 5) [17]. Most recurrences, which were direct hernias located at the pubic tubercle or along the medial edge of the repair, were technical failures attributed to inadequate mesh fixation and inadequate mesh overlap at the pubic tubercle. In one retrospective review of 1983 men undergoing laparoscopic or open (Lichtenstein) repair for primary or recurrent inguinal hernia, the higher recurrence rate for laparoscopic repair was attributed to a smaller size of mesh [21]. (See "Open surgical repair of inguinal and femoral hernia in adults", section on 'Mesh fixation' and "Laparoscopic inguinal and femoral hernia repair in adults", section on 'Mesh placement and fixation'.)

Missed cord lipoma – Herniation of retroperitoneal adipose tissue through the internal ring into the inguinal canal, commonly referred to as a "cord lipoma," is frequently encountered during inguinal hernia repair [22]. As an example, in a study of 498 patients undergoing total extraperitoneal (TEP) laparoscopic inguinal hernia repairs, 27 percent were found to have a cord lipoma [23]. Patients with obesity and those who have a large hernial defect are at a higher risk.

Cord lipomas encountered in the inguinal canal during open hernia repair are usually resected. During minimally invasive repair, cord lipomas in the inguinal canal or the internal ring should either be resected or reduced to the pelvic peritoneal reflection line, followed by the placement of a mesh that separates the reduced lipomas and the internal ring [23].

Failure to recognize and manage a cord lipoma could result in recurrent hernia formation [24,25]. By one estimate, missed cord lipomas accounted for 30 to 50 percent of recurrent inguinal hernias following laparoscopic repair [26].

Surgeon inexperience – Low recurrence rates can be achieved for a variety of techniques when the individual performing the surgery has sufficient experience with the specific technique [27,28]. Surgeon experience is particularly important with respect to performing minimally invasive inguinal hernia repair [20,29]. Minimally invasive inguinal hernia repair is complex, and the learning curve is more pronounced compared with that of open hernia repair. A Veterans Affairs study found that a case volume of <250 laparoscopic repairs, rather than a greater volume, was significantly associated with a higher risk for hernia recurrence (10 versus 5 percent) [21].

Patient factors — Patient factors that increase the risk for recurrent inguinal hernia are generally those that disrupt or weaken the tissues, contribute to poor wound healing, or increase the risk for postoperative infection. In addition, patient sex and genetic makeup has also been implicated in some studies.

Wound healing – The most important factors that negatively impact wound healing include [27,28,30] (see "Basic principles of wound healing"):

Prior hernia repair

Smoking

Older age at initial hernia presentation

Diabetes mellitus

Obesity

Renal insufficiency

Deficiency of coagulation factor VIII or vitamin C

Glucocorticoid therapy

Chemotherapy

Increased intra-abdominal pressure (eg, chronic cough, constipation, prostatism, bowel distention, and ascites)

Male versus female – Some studies have found higher hernia recurrence rates for women, while others report the opposite. In studies from the Danish Hernia Registry, the overall reoperation rate was 4.3 percent for women and 3.1 percent for men after 29 month follow-up [4,31]. However, with respect to inguinal hernia only, recurrence rates were 5 percent in men and 4 percent in women over five years [14]. Femoral hernias may be found more often at reoperation in women initially treated for direct or indirect inguinal hernia at the primary operation compared with men (42 versus 4.6 percent in one study [32,33]), suggesting a higher incidence of missed hernia in women, rather than true recurrence.

Family history – Genetic factors may increase the tendency toward recurrent inguinal hernia. In a review of 75 patients with two or more inguinal hernia recurrences, 44 percent had a positive family history of hernia recurrence [30]. Possible mechanisms include a decreased ratio of type I/type III collagen and higher levels of matrix metalloproteinases (MMPs) [34-36].

DIAGNOSIS — The clinical features of recurrent inguinal hernia are similar to those of primary inguinal hernia. Clinical examination by an experienced surgeon should be the first diagnostic tool used and is often sufficient for detecting recurrent inguinal hernia. However, physical examination can be unreliable in patients with obesity or prior mesh placement; following onlay mesh repair, recurrences can occur behind the mesh that may not be detectable by examination alone. Imaging may be needed for patients with clinical history concerning for a possible recurrent inguinal hernia but for whom the physical examination does not clearly demonstrate a recurrent hernia. (See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults", section on 'Clinical features'.)

Systemic symptoms such as fevers, chills, malaise, local findings of pain on palpation, erythema, warmth, swelling, or drainage should raise the suspicion for complications, including acutely incarcerated or strangulated recurrent hernia and mesh infection, which require a change in urgency and approach in evaluation and treatment of the patient. (See "Complications of inguinal and femoral hernia repair", section on 'Deep incisional/mesh infection'.)

MANAGEMENT — The indications and contraindications for repair of recurrent inguinal or femoral hernias are similar to those of the initial repair. (See "Overview of treatment for inguinal and femoral hernia in adults".)

Watchful waiting — Men with asymptomatic recurrent hernia can be safely observed given that the risk of acute incarceration is low. The watchful waiting trial, a trial that randomly assigned 720 men with a minimally symptomatic inguinal hernia to inguinal hernia repair or watchful waiting, included 77 patients (10.6 percent) with recurrent hernia, 43 of whom were assigned to watchful waiting [37]. The rate of hernia-related complications in the watchful waiting group was extremely low (1.8 per 1000 patient-years). However, most patients will eventually require surgery due to pain or discomfort (23 percent at 2 years and 72 percent at 7.5 years in one study [38] and 54 percent at 5 years and 72 percent at 7.5 years in another study [39]).

Surgical repair — Urgent repair is indicated for patients with complications related to the hernia (eg, strangulation, obstruction, perforation). Patients with an uncomplicated but symptomatic hernia should undergo elective hernia repair unless medical comorbidities are prohibitive. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Inguinal hernia'.)

Surgical options — Similar techniques are used to repair recurrent inguinal hernia as are used to repair primary inguinal hernia; however, repair of recurrent inguinal hernia can be more challenging and has a greater risk for complications [27,40,41]. (See "Complications of inguinal and femoral hernia repair".)

The most common techniques used to repair recurrent inguinal hernia are the laparoscopic totally extraperitoneal (TEP), laparoscopic transabdominal preperitoneal (TAPP) patch, open Lichtenstein, plug and patch mesh repairs, and robot-assisted repair. (See "Laparoscopic inguinal and femoral hernia repair in adults", section on 'Techniques for recurrent hernia repair' and "Robotic groin hernia repair", section on 'Recurrent hernias' and "Open surgical repair of inguinal and femoral hernia in adults", section on 'Mesh repairs'.)

For the repair of primary hernia, recurrence rates for open versus laparoscopic repair are similar, provided mesh is used. Similarly, meta-analyses of randomized trials have found no significant differences in hernia re-recurrence for tension-free mesh repair of recurrent hernia using an open versus laparoscopic technique [40-43]. (See "Overview of treatment for inguinal and femoral hernia in adults", section on 'Inguinal hernia'.)

A meta-analysis of four randomized trials [20,44-46] that included 404 patients with recurrent inguinal hernia evaluated tension-free, open, mesh, and laparoscopic (mesh) repairs [41]. Open mesh repairs included the Lichtenstein and giant prosthesis for reinforcement of the visceral sac (GPRVS) techniques. TEP and TAPP procedures were used for laparoscopic repair. Primary outcomes included the rate of re-recurrence and chronic pain. Secondary outcomes included postoperative pain, superficial wound infection, operating time, time to return to daily activities, wound seromas or hematomas, and complications requiring additional surgical procedures. The following findings were noted [41]:

In a pooled analysis, there were no significant differences between laparoscopic and open hernia repair for the primary outcomes of re-recurrence (odds ratio [OR] 0.84, 95% CI 0.33-2.17) or chronic pain (OR 0.91, 95% CI 0.14-5.88).

Laparoscopic repair was associated with significantly less postoperative pain (OR 0.58, 95% CI 0.31-0.84), fewer superficial wound infections (OR 0.29, 95% CI 0.08-0.96), and shorter time to return to daily activities and work (weighted mean difference [WMD] 0.82 days, 95% CI 0.36-1.27 days) but longer operative times (WMD 0.68 min, 95% CI 0.23-1.13). There were no differences identified for wound seroma or hematoma or the need for additional surgical procedures.

A separate meta-analysis that combined the results of five randomized trials [44,45,47-49] and seven other studies (five retrospective and two prospective) assessed outcomes in 1542 patients with recurrent hernias repaired using laparoscopic (TEP or TAPP) or open (Lichtenstein or preperitoneal) techniques [40]. No significant differences were seen for early re-recurrence (relative risk [RR] 0.73, 95% CI 0.21-2.51) or overall re-recurrence (RR 0.72, 95% CI 0.45-1.15). No differences were seen for the various techniques for postoperative wound infection, urinary retention, testicular pain/discomfort, or neuralgia. Comparing laparoscopic techniques, the risk of overall re-recurrence was significantly higher for the laparoscopic TAPP compared with TEP technique (RR 3.25, 95% CI 1.32-7.90). Because of insufficient data, no comparisons were made between TAPP and Lichtenstein, TEP and preperitoneal, or TAPP and preperitoneal. A subsequent meta-analysis that included two additional randomized trials comparing open versus laparoscopic repair found similar results [42].

A large retrospective review of 19,582 operations for recurrent hernia compared laparoscopic repair with other techniques (eg, suture closure, Lichtenstein, plug) [12]. The laparoscopic and open mesh approaches were significantly associated with the lowest rates of re-recurrence following prior open (anterior) repair; however, no technique differed significantly for recurrent hernia repair following prior preperitoneal repair (laparoscopic or preperitoneal [open]).

Given that no significant differences in re-recurrence rates have been demonstrated in randomized trials comparing open and laparoscopic techniques for recurrent hernia repair [20,44-49], the choice of technique is largely anatomically based, depending upon the nature of the prior hernia repair. That said, laparoscopic techniques have the advantages of less pain and a quicker recovery [40,41]; these advantages are considered in our suggested approaches below whenever anatomically feasible.

Anatomic approaches — We suggest an anatomic approach to recurrent groin hernia repair with the goal of avoiding previously dissected tissue planes. In general, failed posterior repairs should be repaired using an anterior approach, and vice versa, failed anterior repairs should be repaired using a posterior approach [31]. Most open repairs are performed anterior to the hernia defect (except the uncommonly performed Kugel repair), and laparoscopic repair is performed posterior to the hernia defect.

Failed posterior repair – For patients with a failed posterior repair (eg, laparoscopic, preperitoneal), a Lichtenstein repair, which has been shown to be superior to other open, anterior repairs, should be used. However, a standard Lichtenstein repair cannot be used if the hernia recurrence is at the femoral site. Under this circumstance, an infrainguinal mesh plug repair or a modified Lichtenstein repair can be used. (See "Open surgical repair of inguinal and femoral hernia in adults".)

Failed anterior repair – For patients with a failed anterior mesh repair (eg, Lichtenstein), a laparoscopic TEP or TAPP repair should be used preferentially over an open preperitoneal approach because laparoscopic repair is associated with fewer perioperative complications and less postoperative pain. Moreover, in the laparoscopic era, more surgeons would be comfortable with the laparoscopic approach compared with the open preperitoneal repair technique. A particular laparoscopic technique (ie, TEP or TAPP) may have advantages under specific clinical circumstances, but for most patients, we suggest a TEP approach, which appears to be associated with a lower risk of re-recurrence following recurrent hernia repair compared with TAPP (discussed in the previous section). However, for patients with prior pelvic surgery, for which TEP repair may not be possible, either a laparoscopic or robotic TAPP or open preperitoneal repair can be used. When the exact location of the recurrent hernia is unclear, a laparoscopic or robotic TAPP approach allows all potential hernia defects (eg, direct, indirect, and femoral) to be seen [16].

For patients with a failed anterior repair performed without mesh, an anterior mesh repair (eg, Lichtenstein) may also be an acceptable option; however, given the challenges of dissection in a reoperative field, most surgeons prefer a laparoscopic (posterior) approach. (See "Laparoscopic inguinal and femoral hernia repair in adults", section on 'Techniques for recurrent hernia repair' and "Laparoscopic inguinal and femoral hernia repair in adults", section on 'Special cases'.)

Failed both anterior and posterior repair – For patients with both failed anterior and posterior repairs, or those with mesh in both anterior and posterior tissue planes (eg, the Prolene Hernia System mesh), the choice of procedure depends upon the location of the hernia. As an example, for a small, medial direct hernia re-recurrence, repair with minimal dissection using an open anterior approach with placement of a mesh plug in the defect is an effective low-risk approach.

The skill set of the surgeon is also an important consideration. It is suggested that such patients should be referred to an expert hernia surgeon as the risk of both complications and re-recurrence can be substantial in this scenario [50].

Recurrent hernia and chronic groin pain – For patients with both a recurrent groin hernia and chronic groin pain from the original hernia repair, a tailored approach, depending on the previous interventions and the significance of the recurrence, is suggested and is best performed by an expert hernia surgeon [50]. Although an anterior approach will permit neurectomy and meshectomy at the time of the hernia repair, there is a potential risk of testicular complications.

The management of neuralgia following hernia repair and recurrent hernia related to mesh infection, which requires mesh removal, is discussed elsewhere. (See "Post-herniorrhaphy groin pain", section on 'Mesh removal' and "Wound infection following repair of abdominal wall hernia".)

Mesh — Inguinal hernias should be repaired using a tension-free mesh repair whenever possible [31]. More than 90 percent of surgeons in the United States incorporate mesh as a component of a tension-free repair to reduce the risk for recurrence [6,51]. The use of mesh to provide additional tissue support seems appropriate given that recurrent inguinal hernia may be linked to altered extracellular matrix biology [36].

The use of mesh appears to be equally important for the repair of recurrent inguinal hernia. In a review of the Danish Hernia Database, among 2117 patients with hernia recurrence, 3.1 percent (187 patients) had re-recurrence following recurrent repair [10]. Following primary hernia repair using a Lichtenstein technique, a significantly lower rate of re-recurrence was found in patients who underwent subsequent mesh repair compared with non-mesh repair. The re-recurrence rates were as follows:

Laparoscopic (mesh): 1.3 percent

Mesh (non-Lichtenstein): 7.2 percent

Lichtenstein: 11.3 percent

Non-mesh: 19.2 percent

There is a paucity of data about the preferred type of mesh for recurrent hernia repair. We use polypropylene mesh in most cases, but if the mesh cannot be covered with peritoneum and will be exposed to the intestinal contents, we substitute coated polypropylene mesh. There are insufficient data on the long-term durability of biologic mesh in recurrent inguinal hernia. (See "Complications of inguinal and femoral hernia repair", section on 'Mesh migration and erosion'.)

The previous mesh should be left in place, provided it is well incorporated, there is no evidence for infection, and it is not felt to be a source of chronic groin pain.

Anesthesia — Open mesh repairs can be performed using local, regional, or neuraxial anesthesia, whereas laparoscopic repairs usually require general anesthesia. Whether the type of anesthesia used at the time of hernia repair impacts the risk for recurrent inguinal hernia is controversial.

An increased risk for recurrent hernia was reported in the past for hernia repair using local anesthesia compared with general or regional anesthesia [52]. A later multivariate analysis using data from 59,823 hernia repairs from the Swedish Hernia Registry found an overall increased risk for recurrence when the repair was performed using local anesthesia compared with a regional or general anesthesia, a difference that was apparent for primary inguinal hernia repair but not for recurrent inguinal hernia repair [53]. In a review of the Danish Hernia Database (43,123 hernia repairs), there were no overall differences in the hernia recurrence rate (3.5 percent) based upon the type of anesthetic [54]. Although hernia recurrence was more common using a local anesthetic for direct (medial) versus indirect (lateral) hernia repair (7 versus 2 percent), this difference was attributed to the location of health care delivery. The rate of hernia recurrence was much lower at private hospitals, where local anesthetic use was uniform, compared with the university hospital setting.

When a laparoscopic approach is chosen for recurrent inguinal hernia repair, general anesthesia is usually required. Although local or regional anesthesia is often used for open repair of primary hernia, we prefer to use general anesthesia or neuraxial anesthesia for recurrent inguinal hernia given the more extensive dissection that is usually needed.

OUTCOMES — Repair of recurrent inguinal hernias can be more complicated than primary inguinal hernia repair and is associated with higher rates of recurrence (ie, re-recurrence) and other complications [10,40].

In a review of the Danish Hernia Database, 187 patients among 2117 (8.8 percent) who underwent repair of a recurrent hernia had a failed repair (ie, re-recurrence) [10]. In a longer-term study, the rate of re-recurrence was 29 percent after a median of 5.5 years [14]. Patients who experience repeat hernia recurrences may have abnormally weakened tissues that can be explained by biologic or genetic factors. (See 'Patient factors' above.)

OCCULT HERNIAS — Occult hernias are asymptomatic hernias not detectable on physical examination. They are not recurrent hernias, as they are generally on the contralateral side of the primary groin hernia repair (except in case of a missed femoral hernia in patients with a diagnosed inguinal hernia and vice versa).

Groin hernia formation is considered a bilateral process by etiology. In those with a primary unilateral groin hernia, the lifetime risk of developing a contralateral groin hernia is not known precisely [55]. A number of observation studies have reported finding a contralateral occult hernia in 5 to 58 percent of patients undergoing laparoscopic totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) repair of a unilateral primary groin hernia [56,57]. However, the natural history of these small, incidentally discovered defects is poorly understood, and the clinical relevance of repair is unknown [58-60]. As such, we suggest the following for laparoscopic and robotic groin hernia repair, during which a contralateral exploration or repair is feasible [50].

The contralateral groin should be inspected at the time of a TAPP repair, and an occult contralateral hernia can be repaired if the patient has consented to it. However, a preventive bilateral repair should not be performed without evidence of a contralateral hernia.

The contralateral groin should not be explored at the time of a TEP repair performed for a unilateral groin hernia without contralateral symptoms.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Groin hernia in adults".)

SUMMARY AND RECOMMENDATIONS

Incidence – Recurrence rates following a first-time groin hernia repair range from 0.5 to 15 percent depending upon factors including the hernia site (direct, indirect, femoral), type of repair (mesh, no mesh, open, laparoscopic, robotic), and clinical circumstances (elective, emergency). (See 'Incidence of recurrences' above.)

Pattern of recurrence – Most early recurrences are due to technical factors, whereas late recurrences are due to patient factors. The most common recurrence after an open repair is a direct (or medial) hernia, while an indirect (or lateral) recurrence is most common after a laparoscopic repair. (See 'Pattern of recurrences' above.)

Risk factors – Risk factors associated with a failed primary inguinal hernia repair include technical issues (eg, non-mesh repair, inadequate mesh size or fixation) and/or patient-related factors (eg, poor wound healing). (See 'Risk factors' above.)

Diagnosis – The clinical features of recurrent inguinal hernia are similar to those of primary inguinal hernia. Clinical examination by an experienced surgeon is usually sufficient for detecting recurrent inguinal hernia with few patients requiring imaging. (See 'Diagnosis' above.)

Management – The management of recurrent inguinal and femoral hernia is similar to that of primary inguinal and femoral hernia. (See "Overview of treatment for inguinal and femoral hernia in adults".)

Watchful waiting – Men with asymptomatic recurrent hernia can be safely observed given that the risk of acute incarceration is low. However, most will eventually require surgery due to pain or discomfort. (See 'Watchful waiting' above.)

Surgical repair – Since re-recurrence rates for open versus laparoscopic repair are similar, the choice of technique for repair of recurrent inguinal hernia largely depends on the anatomy. The surgical technique used for primary hernia repair must be identified to plan recurrent hernia repair. (See 'Anatomic approaches' above.)

In general, we suggest repairing failed posterior repairs using an anterior approach, and vice versa, repairing failed anterior repairs using a posterior approach (Grade 2C). The goal is to avoid previously dissected tissue planes.

-For patients with recurrent inguinal hernia previously repaired by a posterior approach (eg, laparoscopic repair), we further suggest a Lichtenstein repair, rather than other open anterior techniques (Grade 2C).

-For patients with recurrent inguinal hernia previously repaired by an anterior approach, we further suggest a laparoscopic approach, rather than an open preperitoneal approach (Grade 2C). We also suggest a totally extraperitoneal (TEP) preperitoneal hernia repair over the transabdominal preperitoneal (TAPP) hernia repair approach when anatomically feasible (Grade 2C). The re-recurrence rate is lower after a TEP repair.

As with repair of primary hernia, the technique that is ultimately used to repair recurrent inguinal and femoral hernia should be the one the surgeon is most comfortable with and is the most experienced performing. (See 'Technical factors' above.)

Outcomes – Repair of recurrent inguinal hernia is challenging, and failure rates are higher compared with those of primary hernia repair. Re-recurrence following recurrent inguinal hernia repair can be as high as 20 percent, depending on the time course of follow-up, but is independent of approach (ie, open or laparoscopic). (See 'Outcomes' above.)

Occult hernias – Occult contralateral hernias (asymptomatic, not detectable on examination) can exist in 5 to 58 percent of patients who present with a primary unilateral hernia. For patients undergoing a unilateral laparoscopic or robotic repair, we suggest (see 'Occult hernias' above):

Inspecting the contralateral groin and repairing an occult contralateral hernia if the patient consents to it (Grade 2C).

Not exploring the contralateral groin at the time of a TEP repair (Grade 2C).

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Topic 15099 Version 21.0

References

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