Surg Endosc (2013) 27:795–800 and Other Interventional Techniques

DOI 10.1007/s00464-012-2514-y

Repeated laparoscopic treatment of recurrent inguinal hernias

after previous posterior repair
Baukje van den Heuvel • Boudewijn J. Dwars

Received: 18 February 2012 / Accepted: 23 July 2012 / Published online: 6 October 2012
Ó Springer Science+Business Media, LLC 2012

Abstract examination. Four patients developed a port-site hernia.

Background The reported recurrence rates after laparo- Four patients had complaints of postoperative pain and
scopic inguinal hernia repair are 0–4 %. It is unclear which were restricted in daily activities due to groin pain. The
technique could best be offered to a patient with a recurrent mean VAS score (scale 0–100), including the four patients
hernia after a previous posterior repair. The purpose of this with persistent pain, was 5.7 (range, 0–61).
retrospective study was to determine the safety, feasibility, Conclusions It is concluded that repeated laparoscopic
and reliability of a repeated laparoscopic repair (TAPP) for hernia repair (TAPP) is a definite repair for recurrent
a recurrent hernia after a previous posterior inguinal hernia inguinal hernias. The procedure is feasible, safe, and
repair. reliable.
Methods The study group contains 2,594 consecutive
transabdominal inguinal hernia repairs (TAPP). Of these, Keywords Hernia
Endoscopy
53 repairs were attempted in 51 patients for recurrent
hernias after a previous posterior repair. During the follow-
up period, patients were examined for recurrences and for Inguinal herniorrhaphy is the most common operation
presence of a port-site hernia. Pain was scored by the visual performed by a general surgeon. Annually more than 20
analogue pain scale (VAS). million groin hernias are repaired worldwide [10]. In The
Results Fifty-one patients underwent a TAPP repair for a Netherlands, more than 30,000 inguinal hernia repairs are
recurrent inguinal hernia after previous posterior hernia performed annually. There are many different surgical
repair. Two patients presented a bilateral recurrent inguinal techniques described for hernia repair. Most techniques
hernia. In two thirds of the patients, the recurrence was include a tension-free repair with a mesh to cover the
located caudally or medially from the previously placed defect. A relatively new technique for hernia repair is
mesh. Two attempted repairs had to be converted to an the laparoscopic technique, developed in the early 1990s.
open technique due to severe adhesions. One intraoperative The major difference between the open and the laparo-
complication was encountered when the vas deferens was scopic technique is that in an open repair the defect is
ligated during surgery due to adhesions of the previous approached and repaired at the anterior side and in a lap-
placed mesh. Nine patients encountered an adverse event aroscopic repair on the posterior side of the defect. The
postoperatively, but none of them were serious events. No laparoscopic technique has gained increasing popularity
mesh infections were reported. during the past couple of years due to promising results,
The mean follow-up was 70 (range, 1–198) months. At such as lower rates of postoperative pain, rapid return to
follow-up, no recurrences were found at physical normal activities, and a lower incidence of infection [4, 15–
17]. The most commonly used methods of repairing an
inguinal hernia laparoscopically are the transabdominal
B. van den Heuvel (&)
B. J. Dwars
preperitoneal (TAPP) and the totally extraperitoneal (TEP)
General Surgery, Slotervaartziekenhuis, Louwesweg 6,
1066, EC, Amsterdam, The Netherlands techniques. So far, neither technique seems to be superior
e-mail: [email protected] to the other.

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The recurrence rates after laparoscopic repair are com- Subsequently, a physical examination was performed
parable to these after open tension-free mesh repair and and the presence of a recurrence or a port-site hernia was
stretch out between 0 and 4 % [6, 13, 15, 22]. It is unclear evaluated. In case of doubt, an ultrasound of the groin and
which technique should be used to correct a recurrent abdominal wall was performed.
hernia after previous laparoscopic repair. The repeated
posterior laparoscopic approach is considered to be more Technique of TAPP repair of a recurrent hernia
difficult, due to scarring of the peritoneum that has after posterior repair
occurred following the previous posterior approach. Due to
this scarring, there is an increased risk of complications, Under general anaesthesia, patients were positioned supine.
and an anterior approach is preferred. The purpose of this A standard transabdominal approach with three trocars was
retrospective study was to determine the safety, feasibility, established. Adhesions were dissected if present. The
and reliability of a repeated laparoscopic repair for a inguinal region was inspected bilaterally. The type of
recurrent hernia after previous posterior inguinal hernia recurrence was identified on the affected side. Preperito-
repair. neal access was gained by an incision of the peritoneum
cranially to the defect and the previous placed mesh. The
mesh was inspected, and no attempts were made to replace
Methods or remove it. The plain between the old mesh and the
abdominal wall was dissected, so that the defect could be
Since 1993, 2,594 inguinal hernias were repaired laparo- clearly visualized. Depending on the size of the encoun-
scopically in the Slotervaarthospital in Amsterdam, The tered defect and the patency of the previous placed mesh, a
Netherlands. All laparoscopic repairs were TAPP repairs. custom-shaped additional polypropylene mesh or a com-
Of these, 53 inguinal hernia repairs were done in 51 plete new polypropylene mesh of at least 8 9 13 cm was
patients for recurrent hernias after a previous posterior added preperitoneally in direct contact with the abdominal
repair. In all patients, a prosthetic mesh—polypropylene or wall. Care was taken to achieve at least a 3 cm overlap of
polyester—was used in the previous posterior repair. Some the mesh covering the defect. The mesh was not fixated
of those patients had been treated initially in our hospital, unless there was doubt about the reliability of the new
and some were referred to us by fellow surgeons. All construction in case of extremely large defects. In that case,
repairs for recurrent hernias were done by one staff sur- staplers were used to fixate the mesh around the defect to
geon, who has extensive experience in TAPP repairs of the abdominal wall or Cooper’s ligament. The peritoneal
inguinal hernias. The first laparoscopic recurrence repair incision was closed with a running suture. Removal of the
was in the early phase of laparoscopic inguinal hernia trocars and closure of the skin was done in a standard
repair and was after about 100 previous primary repairs. manner. Postoperatively, patients were allowed to leave the
Patients were seen postoperatively in a routine matter: hospital as soon as they felt well enough.
1 week after surgery and on indication.
After obtaining approval by the local ethics committee,
these 51 patients were approached by telephone and were Results
invited to attend the outdoor clinic to complete a ques-
tionnaire and to be examined physically. Patients who were From March 1993 to May 2011, 53 TAPP repairs were
not able to visit the outdoor clinic were questioned on the done in 51 patients with a recurrent inguinal hernia after a
telephone. Data of the telephone interviews were included previous posterior repair. Most patients were male (96 %),
for analysis. Details of the operation (operation time, type and the mean age was 62 (range, 33–83) years. The mean
of hernia, type of mesh, affected side, location of the follow-up after the repeated posterior repair was 70 (range,
recurrence, peroperative complications, and conversion) 1–198) months. Four patients had died and four patients
and postoperative course (postoperative complications and were loss to follow-up due to emigration or admission to
days of admission) were collected from the patients’ files elderly homes. Ten patients were not physically able to
and were documented and analyzed. attend the outdoor patient clinic due to comorbidities, and a
Patients were asked about current pain in their operated questionnaire was taken by telephone (Fig. 1). None of
groin. Pain was quantified by the visual analogue pain scale these patients had any complaints, except one who reported
(VAS, 0–100). Secondarily, the patient was asked to indicate a bulge at the umbilicus. The family doctor confirmed a
how strongly he or she agreed on a three-level Likert scale port-site hernia at the umbilicus.
with the statement that the pain in the operated groin restricts In 37 (70 %) patients, the previous posterior technique
the patient in daily activities. The three-level Likert scale used was the TAPP technique, in 12 (23 %) patients the
ranged from agree, no specific opinion, to disagree. TEP technique, and in 4 (8 %) patients another technique

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femoral hernia and one (2 %) as a pantaloon hernia. The

left side was affected in 27 (51 %) patients, the right side in
24 (45 %) patients, and 2 (4 %) patients had a bilateral
hernia. The mean length of stay was 2 (range, 1–6) days,
including the day of operation.
The median operating time was 59 min for a recurrent
hernia compared with 35 min for a laparoscopic primary
hernia repair. During the repair, the location of the recur-
rence was assessed with reference to the previous placed
mesh. In two thirds of patients, the recurrence was located
caudally or medially from the previous placed mesh
(Table 2). In six (11 %) patients, no previous mesh was
found or recognized in the scar tissue, and in four (8 %)
patients, it was not reported where the recurrence was
located.
In all but two patients, it was possible to repair the
recurrence with a repeated posterior approach. These two
operations were converted to an open technique due to
severe adhesions and were treated with an anterior mesh
repair. During one repair, the vas deferens was ligated due
to adhesions at the previous placed mesh.
Overall, in 17 (32 %) patients an adverse event occurred
postoperatively. In nine patients a short-term transient
complication occurred, and in eight patients a long-term
complication occurred (Table 3). Two patients presented
Fig. 1 Follow-up patients with recurrent hernia with a hematoma after surgery and four patients with a
(Table 1). The mean number of previous hernia repairs per seroma. One patient required one single aspiration of the
patient, both posterior and anterior, was two (range, 1–5). seroma. Two patients developed a port-site infection,
In 33 (62 %) patients, the number of previous repairs was which was drained and treated successfully. The adminis-
one, meaning that their previous inguinal hernia was tration of antibiotics was not necessary. One patient had
repaired with a posterior repair and that the second pos- complaints of difficult urination postoperatively and
terior repair was done for a first recurrence. Twenty (38 %) symptoms subsided within a month. No mesh infections
patients had two hernia repairs or more in their past med- were found.
ical history, of which one was a posterior repair and at least At the mean follow-up of 70 months, no recurrences
one an anterior repair. We have registered the interval were found. In one case, a recurrence was suspected and an
between the first posterior repair and the second laparo- ultrasound was made and was inconclusive. A laparoscopic
scopic repair in 18 patients and found a mean interval of exploration was done, but no recurrence was found.
40 (range, 1–168) months to develop and detect the Four patients developed a port-site hernia, of which two
recurrence. patients required an operative repair. The other two
Twenty-eight (53 %) recurrent hernias were classified as
a direct inguinal hernia, 21 (40 %) recurrent hernias as an Table 2 Location of recurrence
indirect inguinal hernia, 3 (6 %) recurrent hernias as a
Location N (%)

Table 1 Type of previous repair Caudal of previous mesh 19 (36)

Medial of previous mesh 12 (23)
Technique N (%)
Lateral of previous mesh 4 (8)
TAPP 37 (70) Cranial of previous mesh 2 (4)
TEP 12 (23) Caudomedial of previous mesh 4 (8)
Stoppa 1 (2) Caudolateral of previous mesh 2 (4)
Grid-iron 2 (4) No previous mesh recognised 6 (11)
Wantz 1 (2) Unclear 4 (8)
Total 53 (100) Total 53 (100)

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Table 3 Complications At a follow-up of 0–15 years, we have not found any

Type of complication N (%)
recurrences in our series of 53 TAPP repairs. We therefore
consider the repeated laparoscopic repair as reliable and
Short-term and peroperative 9 (17) definite. Reported recurrence rates after laparoscopic repair
Hematoma 2 (4) of a recurrent hernia vary among different studies between 0
Seroma 4 (8) and 20 % and seem to be much related to the learning curve
Transient urination complaints 1 (2) of the operating surgeon [4, 5, 11, 16]. Leibl et al. [14] found
Infection trocar side 2 (4) in their series of 46 TAPP repairs for recurrent inguinal
Long-term 8 (15) hernias after a previous TAPP repair no recurrences at a
Persistent pain 4 (8) mean follow-up of 26 months. Knook et al. [12] repaired 34
Portsite hernia 4 (8) recurrent hernias with a TAPP after previous laparoscopic
Total 17 (32 %) repair and found no recurrences at 35 months of follow-up.
It is thought that recurrences after laparoscopic repair
occur due to technical errors and therefore occur early.
patients had asymptomatic port-site hernias and were Phillips et al. [19] found that the recurrences after laparo-
treated conservatively. scopic repair occur on average 5 months after surgery; Felix
Four patients had complaints of pain in their groins et al. [6] found 6 months after surgery, Deans et al. [3] found
postoperatively and were restricted in daily activities due to 8 months after surgery, and Feliu et al. [5] within 12 months
pain. In one of these patients, a recurrence was suspected after surgery. The mean interval that we registered between
and an anterior exploration was undertaken. During the first posterior repair and the second laparoscopic repair
exploration, no recurrence or evident cause of the pain was was 40 (range, 1–168) months. We consider our follow-up
found. In one patient with persistent pain, an ultrasound of period of 70 months sufficient to detect recurrences.
the groin showed some protrusion of the mesh through the Many authors have tried to identify reasons for inguinal
abdominal wall. This patient indicated a VAS score of 61, hernias to recur after laparoscopic repair. Insufficient mesh
the highest in our series, but had no specific opinion about size is one of these identified reasons for hernias to recur
being restricted in daily activities. The other two patients [6, 15, 19]. A new inguinal hernia could develop when the
showed no abnormalities during physical examination or at insufficient abdominal wall is not adequately covered by
imaging. Both patients were restricted in daily activities prosthetic mesh but also could the primary hernia recur. A
and were referred to the anesthesiologist for pain consul- slit in the mesh is identified as a reason for recurrences to
tation, with no result. develop [6, 7, 14]. Insufficient mesh fixation and mesh
At 70 months of follow-up, 42 patients were able to migration also are quoted as reasons for hernias to recur [6,
indicate a VAS score. The mean VAS score, including the 7, 14]. However, Choy et al. [2] tested mesh migration
four patients with persistent pain, was 5.7 (range, 0–61). If before and after mesh fixation with staplers immediately
the VAS scores of the four patients with persistent pain are after surgery in 32 patients, by stressing the position of the
excluded from analysis, the mean VAS score at is 1.8 patient by flexing and extending the operation table. Intra-
(range, 0–23). abdominal reinspection showed no mesh migration in any
of the patients. We do not fixate the prosthetic mesh in a
routine matter in primary laparoscopic hernia repair. In
Discussion recurrent hernias, we do fixate the additional mesh in case
of doubt about the reliability of the new construction. In
Almost 10–15 % of all hernia repairs concern repairs of that case, staplers are used to fixate the mesh around the
recurrent groin hernias and is therefore considered an defect to the abdominal wall or Cooper’s ligament.
important surgical problem [9, 20]. The risk for recurring In our series, we found that the majority of recurrences
increases every time a hernia recurs as demonstrated by the was caudally or medially located from the previous placed
outcomes of the Swedish Hernia Register. At 24 moths of mesh. In other studies, similar results have been found.
follow-up, the risk for having a reoperation is 4.6 % after Chowbey et al. [1] treated four recurrent inguinal hernias
recurrent hernia repair compared with 1.7 % after primary after TEP repair with a TAPP repair. They found one missed
hernia repair [8]. A definite method still needs to be found medial hernia, and in three cases the mesh had medially
for dealing with recurrent groin hernias to prevent that rolled up from its initial position. Deans et al. [3] found in ten
surgical repair fails in 1 of 20 patients. The purpose of this cases of a recurrent hernia after a previous TAPP repair that
retrospective study was to evaluate the reliability, feasi- the mesh had rolled away from the medial border, exposing
bility, and safety of a TAPP repair for recurrent inguinal Hesselbach’s triangle. All ten recurrences were medial
hernias after previous posterior repair. recurrences. Knook et al. [12] found in their series of 34

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patients with a recurrent hernia after laparoscopic repair that minimal intervention (e.g., aspiration of one seroma and
in the majority of the cases a medial hernia occurred. They draining a wound infection). Knook et al. [12] repaired 34
assume that either the previous placed mesh did not have recurrent hernias with a TAPP after previous laparoscopic
sufficient overlap medially or that the mesh had moved lat- repair and found a postoperative complication in seven
erally, exposing Hesselbach’s triangle, allowing a new patients (21 %): six hematomas and one urinary retention.
medial hernia to occur. Attention should be paid to position Four of 51 (7.8 %) patients had complaints of postop-
the prosthetic mesh covering the internal ring and the com- erative pain and were restricted in daily activities due to
plete triangle of Hesselbach’s with sufficient overlap. groin pain. It has become clear in recent studies that
Reentering the pre-peritoneal space is considered to be chronic pain after hernia repair has been underestimated.
difficult. The European Hernia Society guidelines published This rate is comparable to reported rates. Nienhuijs et al.
in 2009 recommend an anterior mesh repair for a recurrent [18] found in their review an incidence of chronic pain
hernia after previous posterior repair [21]. A posterior repair after a mesh-based repair of 11 %. Langeveld et al. [13]
is recommended in patients with a recurrence after an ante- reported that chronic pain 1 year after laparoscopic or open
rior repair. However, it remains unclear what technique and inguinal hernia repair is present in one in four patients.
approach is recommended in cases when patients have had Four patients developed a port-site hernia, of which two
both an anterior and a posterior repair. Thirty-eight percent required an operative repair. The incidence of port-site her-
of the patients in our series had both an anterior and posterior nias in our series is quite high (7.8 %). It might be due to the
repair in their past medical history. assumed weakened quality of collagen and increased chance
To reenter the pre-peritoneal space, great understanding of developing a defect at the trocar site. It also might be
of the groin anatomy and surgical experience is required to explained by the omission of physical examination during
recognize all vital structures and to prevent collateral long-time follow-up in other published series and that the
damage. Dissection of the peritoneum is hindered by incidence cited so far is an understatement of the true inci-
changed anatomy and scar tissue of the previous posterior dence. The port-site hernias in our series were all discovered
repair and prosthetic material. during physical examination. We do recommend in accor-
When a recurrent hernia is approached transabdomi- dance with European Hernia Society guidelines to pay
nally, the surgeon is able to identify the defect in the attention to closing the fascia at the trocar sites of 10 mm or
abdominal wall before dissection through scar tissue. more in these collagen-compromised patients to prevent the
Seeing and localizing the defect, the surgeon can go development of a port-site hernia [21].
straight to target and minimize the amount of dissection The very long-term results of our series of almost
through scar tissue. This TAPP-technique therefore is 6 years follow-up, with no recurrences after this TAPP-
better technically feasible and safer than the total extra- repair of their recurrent hernias, convinced us to offer
peritoneal approach (TEP), because the chance of collateral patients this repair as a definite treatment. This posterior
damage in the repeated repair is minimized. repair can be offered to any patient with a recurrent hernia;
The reported conversion rate of a repeated TAPP repair after a previous anterior repair, after a previous posterior
is 0 % [3, 6] and of a repeated TEP repair up to 24 % [7]. repair, or after both repairs.
Felix et al. [6] reoperated 33 patients after a laparoscopic
repair and completed the repair with a TAPP technique in
all patients. In four cases, the laparoscopic technique was Conclusions
combined with an anterior approach. Knook et al. [12]
repaired 34 recurrent hernias with a TAPP technique after From the long-term results of our series of 53 repeated
previous laparoscopic repair and reported no conversions. laparoscopic hernia repairs (TAPP), it is concluded that the
The results from our series match the published rates and procedure is a definite repair for any recurrent inguinal
show that the repeated laparoscopic repair is feasible in hernia. The procedure is feasible, safe, and reliable.
most cases. It was possible to complete the repair in 51
(96.2 %) of the 53 recurrent hernias. Disclosures Both authors have no conflicts of interest or financial
ties to disclose.
The complication rate in our series is comparable to com-
plication rates after open or laparoscopic repair of a primary
inguinal hernia and is therefore considered to be safe [13].
Postoperatively an adverse event occurred in nine (17 %) References
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