Recurrent inguinal hernias can be a challenge to treat. No surgeon likes to operate on recurrent hernias, but all surgeons who treat hernias will have patients with recurrences. Patients are usually unhappy with the recurrence, search for another surgeon to deal with it, and want their problem solved as soon as possible.
According to Abe Fingerhut and Mousa Khoursheed, the true recurrence rate is difficult to determine. Although many surgeons state they have low recurrence rates, large series, and national registries indicate that 17% of repairs are for recurrent hernias. Those surgeons “without recurrences” do not see the patient when the recurrence occurs. How many patients do you believe will go to the same surgeon after a recurrence?
The best approach to a recurrence has been a matter of debate. Some factors might influence which approach to choose for the recurrence repair, namely the type of previous repair (tissue or mesh), site of incision, number of defects, size, number of previous operations, and site of recurrence. Must not forget that almost 9% of recurrences are femoral hernias.
The common site of recurrence depends on which technique was used:
After tissue repair – inguinal canal or above pubic tubercule
After anterior mesh repair (Lichtenstein) – over pubic tubercule, lateral to the internal ring or both medially and laterally
After larger mesh through endoscopic route – almost anywhere (occurs due to poor technique, migration, shrinking, plicature)
The type of recurrence (direct or indirect) does not influence the decision on which technique to use. However, it is paramount to know if the prosthesis must be removed (intolerance due to chronic pain, sensation of foreign body, infection). In that case, the best approach would usually be the same as the previous repair (it is easier to remove the mesh). According to Abe Fingerhut and Mousa Khoursheed, in these cases, the “repair could be performed during the same operation of ulteriorly through a different approach.”
For recurrence after a mesh placed posteriorly through laparoscopy, a TAPP repair or an open approach (Lichtenstein or plug and patch) are valid options. If you are dealing with a recurrence of a mesh placed through an anterior approach, a laparoscopic technique (TAPP or TEP) is adequate.
Recently, we treated at Hospital CUF Coimbra (Coimbra, Portugal) a patient with the third recurrence of an inguinal hernia repaired three times with a mesh placed through an anterior approach by other surgeons. The video shows a TAPP repair with a self-fixating mesh to treat the third recurrence of a right inguinal hernia. In this case, we decided on the fixation of the mesh to Cooper's Ligament.
Assist the video "Recurrent inguinal hernia: TAPP repair":
Reference:
Fingerhut, A., Khoursheed, M. Recurrent Inguinal Hernia: The Best Approach. In: Jacob, B.P, Ramshaw, B (eds.) The SAGES Manual of Hernia Repair. New York: Springer; 2013. p. 167-180.
Dr. Carlos Eduardo Costa Almeida
General Surgeon