Page 88 - International guidelines for groin hernia management

Hernia

After a failed TEP or TAPP repair, where the extra- Key question
peritoneal space was entered, it is strongly recommended
that an AMR (Lichtenstein)—which does not involve KQ20.f What are the options for a recurrence in a patient
entering the posterior space—be performed. This recom- with postherniorrhaphy chronic groin pain?

mendation remains the same as the EHS recommendation Due to multiple prior interventions, anterior and/or
in 2009. 12 laparoscopic, some patients with rerecurrence will develop
Surgical options for recurrence after anterior and poste- postherniorrhaphy chronic groin pain. A tailored approach
rior repairs is urged, dependent upon the previous interventions and the
significance of the recurrence (e.g., large incarcerated
Key question rerecurrence with small bowel obstruction risk). While an
anterior approach may address the recurrence and poten-
KQ20.e What is the optimal management strategy in a tially alleviate the chronic pain (if neurectomy and
patient with recurrent hernia after failed anterior and pos- meshectomy are done), there are significant risks of tes-
terior (laparoscopic or anterior preperitoneal) repairs? ticular atrophy and even orchiectomy. In addition, subse-

The comparable recurrence rates after primary anterior quent recurrence is highly likely. All this must be
and laparoscopic repair imply that patients are encountered explained to, and discussed with, the patient. Given the
presenting with rerecurrence after a laparoscopic or ante- complexity of these cases and the high risk of complica-
rior preperitoneal repair and at least one anterior repair. tions, it is strongly suggested that patients in this category
Another anterior repair (e.g., Lichtenstein) would be be managed by expert hernia experts.
expected to have a rerecurrence rate of three times that of a
primary hernia repair. In addition, there would be signifi- Conclusion
cant risk of testicular atrophy and/or chronic groin pain. 126 Given the factors cited above, treatment of recurrent and
Relaparoscopy, either with a TAPP technique 126 or a serially recurrent IHs remains challenging. It may be pos-
283
modified intraperitoneal onlay mesh technique, is fea- sible to minimize rerecurrence and other complications
sible, but this decision, and the procedure itself, should be using appropriate surgical technique, accounting for the
in the hands of an experienced laparoscopic hernia previous approaches, and calling upon expert hernia sur-
surgeon. 286 geons to manage these cases.
Surgical options for recurrence with chronic groin pain

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