Page 87 - International guidelines for groin hernia management

Hernia

If the primary repair was a tissue repair, then either the provides optimal outcomes while reducing the incidence of
anterior or posterior—either open or endoscopic—ap- chronic pain and allowing earlier return-to-work or physi-
proach can be used for the recurrent hernia repair. If the cal activity. 299
primary repair was a mesh repair, then the entrance point Once an anterior repair has been done, an endoscopic
should be via a space not previously entered. repair will generally go through nearly undisturbed tissue
For non-endoscopic surgeons, an anterior Lichtenstein planes, permitting relative ease of dissection. One study
approach has been recommended after a primary tissue has demonstrated that the rate of recurrence of primary and
repair. 12 Care must be taken to prevent any potential (ad- recurrent IHs is similar. 285 This likely depends on local
ditional) damage to testicular vessels, since this may result expertise in part. It has been demonstrated that endoscopic
in testicular atrophy. 292 According to one study, incidental repair after an anterior repair generally takes longer than a
femoral hernias occur in up to 9% of recurrent IH patients. 7 primary repair and increases the peritoneal tear
Therefore, groin exploration must include the femoral incidence. 300
region. A 2014 meta-analysis summarized findings from six
When laparoendoscopic surgery is not an option, the RCTs and 5 other studies comparing laparoscopic to open
open posterior approach represents an acceptable alterna- procedures in recurrent IH repair. The analysis of 1311
293, 294
tive. This approach involves placing a large mesh patients demonstrated that laparoscopy was associated with
piece posterior to the transversalis fascia via a trans-in- a lower incidence of wound infection and a shorter sick
guinal incision (Rives), or a muscle-splitting incision leave without an increase in operation time. 301
(Kugel and Wantz) or a lower midline incision (Stoppa). 295 While nationwide data on recurrence rates have
A report of 58 Stoppa operations for recurrence reported an remained disappointing high, there is evidence to suggest
overall rerecurrence rate of 12%. 296 Nearly two-thirds of that in highly specialized hernia centers, rerecurrence rates
these occurred in the first few years after the technique was of less than 2% can be achieved. For instance, a large
introduced at the study site. Further experience with the institutional review reported a 2% rerecurrence rate after
technique halved the rerecurrence rate in the same study. TAPP. 83 Yet, another study of over 8000 patients found
R
The Prolene Hernia System operation involves mesh nearly identical rerecurrence rates of 1.1% for both primary
leaflet placements anterior and posterior to the transversalis and recurrent hernia repairs. 302
297, 298
fascia. A connector holds the leaflets together. This A Swedish Hernia Register study of 850 recurrent IHs
technique requires a preperitoneal dissection via the ante- showed that posterior mesh repair (PMR)—either endo-
rior approach, difficult if the patient has already undergone scopic of open preperitoneal—had a lower second recur-
a posterior approach either laparoscopic or open during rence rate versus anterior mesh repair (AMR) (5.6 vs 11%,
primary repair. In addition, any prior anterior intervention p = 0.025). 303 An increased risk [3.21 (CI 1.33–7.44)
would cause scarring, resulting in distorted tissue planes (p = 0.009)] of a second recurrence was seen after anterior
and increasing risk of testicular atrophy and nerve damage. primary repair followed by AMR, and a decreased risk
Since the potential for complications of open recurrent [p = 0.08 (CI 0.01–0.94)] (p = 0.45) after PMR followed
IH repair—including testicular atrophy and/or nerve by AMR. 303
entrapment and damage—is higher than for primary repair, Surgical options for patients with recurrence after TEP/
we strongly suggest that this operation be performed by an TAPP
expert hernia surgeon.
Surgical options for patients with recurrence after anterior Key question
repair
A 2016 study provided strong evidence that endoscopic KQ20.d What is the best operation for a recurrence after
recurrent hernia repair (TEP or TAPP) after anterior repair TEP/TAPP?

123