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Surgical Endoscopy

, Volume 30, Issue 3, pp 1146–1155 | Cite as

Endoscopic repair of primary versus recurrent male unilateral inguinal hernias: Are there differences in the outcome?

  • F. Köckerling
  • D. Jacob
  • W. Wiegank
  • M. Hukauf
  • C. Schug-Pass
  • A. Kuthe
  • R. Bittner
Open Access
Article

Abstract

Introduction

To date, there are no prospective randomized studies that compare the outcome of endoscopic repair of primary versus recurrent inguinal hernias. It is therefore now attempted to answer that key question on the basis of registry data.

Patients and methods

In total, 20,624 patients were enrolled between September 1, 2009, and April 31, 2013. Of these patients, 18,142 (88.0 %) had a primary and 2482 (12.0 %) had a recurrent endoscopic repair. Only patients with male unilateral inguinal hernia and with a 1-year follow-up were included. The dependent variables were intra- and postoperative complications, reoperations, recurrence, and chronic pain rates. The results of unadjusted analyses were verified via multivariable analyses.

Results

Unadjusted analysis did not reveal any significant differences in the intraoperative complications (1.28 vs 1.33 %; p = 0.849); however, there were significant differences in the postoperative complications (3.20 vs 4.03 %; p = 0.036), the reoperation rate due to complications (0.84 vs 1.33 %; p = 0.023), pain at rest (4.08 vs 6.16 %; p < 0.001), pain on exertion (8.03 vs 11.44 %; p < 0.001), chronic pain requiring treatment (2.31 vs 3.83 %; p < 0.001), and the recurrence rates (0.94 vs 1.45 %; p = 0.0023). Multivariable analysis confirmed the significant impact of endoscopic repair of recurrent hernia on the outcome.

Conclusion

Comparison of perioperative and 1-year outcome for endoscopic repair of primary versus recurrent male unilateral inguinal hernia showed significant differences to the disadvantage of the recurrent operation. Therefore, endoscopic repair of recurrent inguinal hernias calls for particular competence on the part of the hernia surgeon.

Keywords

Inguinal hernia TAPP TEP Recurrent Complications 

The proportion of recurrences in the National Swedish Hernia Registry is 11.2 % [1]. Female sex, direct inguinal hernias at the time of the primary procedure, operation for a recurrent inguinal hernia, and smoking are significant risk factors for recurrence after inguinal hernia surgery [2]. In five meta-analyses, the outcome of open repair was compared with that of endoscopic repair of recurrent inguinal hernias [3, 4, 5, 6, 7]. The last meta-analysis published and which included 1311 patients from six randomized controlled trials (RCTs) and five comparative studies [7] showed that the laparoscopic technique for repair of recurrent inguinal hernia was associated with less wound infection and a faster recovery to normal activity, whereas other complication rates, including the re-recurrence rate, were comparable between the open and the endoscopic approach. Laparoscopic and open procedures could be performed with equal operation time.

On the basis of the meta-analyses, the European Hernia Society recommends endoscopic inguinal hernia techniques for recurrent hernias after conventional open repair [8]. Likewise, the International Endohernia Society recommends, with a high level of evidence, TEP and TAPP for repair of recurrent hernia as the preferred alternative to tissue repair and to the Lichtenstein repair after prior anterior repair [9]. In the Consensus Development Conference of the European Association of Endoscopic Surgery, TEP and TAPP are preferred in patients with a recurrent groin hernia after open repair. Repeat endoscopic repair is only feasible when the surgeon has a high level of experience in repeat endoscopic groin hernia repair [10].

To date, there is only one prospective study, published in German language, with 338 patients comparing endoscopic repair of primary and recurrent inguinal hernias in TEP technique [11]. In the TEP repair group of recurrent inguinal hernias, a higher incidence of injury to the peritoneum and a higher occurrence of bleeding from the epigastric vessels were observed (p = 0.03). The postoperative complication rate was identical in the two groups, amounting to 5.1 and 5.7 %, respectively. No differences were found between the two groups on 1-year follow-up.

By analyzing data from the Herniamed Registry [12], this paper now performs such a comparison in order to get a better estimate of the perioperative and 1-year outcome of repair of primary versus recurrent hernia on the basis of a large patient sample size.

Patients and methods

The Herniamed Registry is a multicenter, internet-based Hernia Registry [12] into which 425 participating hospitals and surgeons engaged in private practice (Herniamed Study Group) had entered data prospectively on their patients who had undergone hernia surgery. All postoperative complications occurring up to 30 days after surgery are recorded. On 1-year follow-up, postoperative complications are once again reviewed when the general practitioner and patient complete a questionnaire. This present analysis compares the prospective data collected for all male patients with a minimum age of 16 years, who had undergone elective primary or recurrent unilateral inguinal hernia repair using either transabdominal preperitoneal patch plasty (TAPP) or total extraperitoneal patch plasty (TEP).

In total, 20,624 patients were enrolled between September 1, 2009, and August 31, 2013. Of these patients, 18,142 (88.0 %) had a primary endoscopic repair and 2482 (12.0 %) had a recurrent endoscopic repair. All the patients had to have a 1-year follow-up (follow-up rate: 100 %).

The demographic and surgery-related parameters included age (years), BMI (kg/m2), ASA classification (I, II, III, IV) as well as EHS classification (hernia type: medial, lateral, femoral, scrotal. Defect size: grade I = < 1.5 cm, grade II = 1.5–3 cm, grade III > 3 cm) [13], and general risk factors (nicotine, COPD, diabetes, cortisone, immunosuppression, etc.). Risk factors were dichotomized, i.e., ‘yes’ if at least one risk factor is positive and ‘no’ otherwise.

The dependent variables were intra- and postoperative complication rates, number of reoperations due to complications as well as the 1-year results (recurrence rate, pain at rest, pain on exertion, and pain requiring treatment).

All analyses were performed with the software SAS 9.2 (SAS institute Inc. Cary, NY, USA) and intentionally calculated to a full significance level of 5 %, i.e., they were not corrected in respect of multiple tests, and each p value ≤0.05 represents a significant result. To discern differences between the groups in unadjusted analyses, Fisher’s exact test was used for categorical outcome variables, and the robust t test (Satterthwaite) for continuous variables.

To rule out any confounding of data caused by different patient characteristics, the results of unadjusted analyses were verified via multivariable analyses in which, in addition to primary or recurrent operation, other influence parameters were simultaneously reviewed.

To identify influence factors in multivariable analyses, the binary logistic regression model for dichotomous outcome variables was used. Estimates for odds ratio (OR) and the corresponding 95 % confidence interval based on the Wald test were given. For influence variables with more than two categories, one of the latter forms was used in each case as reference category. For age (years) the 10-year OR estimate and for BMI (kg/m2) the 5-point OR estimate were given. Results are presented in tabular form, sorted by descending impact.

Results

Unadjusted analysis

In the endoscopic recurrent operation group, the recurrent operation was performed for n = 1528/2482 (61.6 %) patients following the open suture technique, for n = 718/2482 (28.9 %) after open mesh repair, and for n = 233/2.482 (9.4 %) following laparoscopic mesh repair. In terms of age, those patients with recurrent operations were significantly older (p < 0.001). No significant difference was noted in BMI (Table 1).
Table 1

Age and BMI of patients with endoscopic primary versus recurrent unilateral inguinal hernia repair in men

 

Operation

p

Primary

Recurrent

Age (year)

Mean ± SD

55.5 ± 15.5

59.0 ± 15.5

<0.001

BMI (kg/m2)

Mean ± SD

25.8 ± 3.4

26.0 ± 3.4

0.107

The unadjusted tests aimed at discerning any relationship between operation type (primary vs recurrent operation), and the categorical influence variables showed a highly significant relationship between the ASA classification, hernia size, and all EHS classifications (in each case, p < 0.001) (Table 2). More recurrent operations were associated with higher ASA classifications, e.g., ASA III/IV: 17.1 vs 12.3 % as well as medial (49.8 vs 36.2 %) and femoral (3.3 vs 1.8 %) EHS classifications. On the other hand, primary operations were associated with larger defect sizes, e.g., EHS grade III: 20.8 vs 17.3 % as well as with a greater number of lateral (74.0 vs 59.2 %) and scrotal (2.8 vs 1.3 %) EHS classifications.
Table 2

Demographic and surgery-related parameters and risk factors of patients with endoscopic primary versus recurrent unilateral inguinal hernia repair in men

 

Primary op

Recurrent op

p

n

%

n

%

ASA score

 I

6231

34.35

621

25.02

<0.001

 II

9680

53.36

1437

57.90

 III/IV

2231

12.30

424

17.08

Defect size

 I

2648

14.60

453

18.25

<0.001

 II

11,726

64.63

1599

64.42

 III

3768

20.77

430

17.32

EHS medial

 Ja

6568

36.20

1235

49.76

<0.001

 Nein

11,574

63.80

1247

50.24

EHS lateral

 Ja

13,420

73.97

1469

59.19

<0.001

 Nein

4722

26.03

1013

40.81

EHS femoral

 Ja

322

1.77

83

3.34

<0.001

 Nein

17,820

98.23

2399

96.66

EHS scrotal

 Ja

502

2.77

32

1.29

<0.001

 Nein

17,640

97.23

2450

98.71

Risk factors

 Total

  Ja

4582

25.26

747

30.10

<0.001

  Nein

13,560

74.74

1735

69.90

 COPD

  Ja

866

4.77

165

6.65

<0.001

  Nein

17,276

95.23

2317

93.35

 Diabetes

  Ja

812

4.48

139

5.60

0.014

  Nein

17,330

95.52

2343

94.40

 Aortic aneurysm

  Ja

50

0.28

17

0.68

0.002

  Nein

18,092

99.72

2465

99.32

 Immunosuppression

  Ja

85

0.47

15

0.60

0.354

  Nein

18,057

99.53

2467

99.40

 Corticoids

  Ja

139

0.77

21

0.85

0.627

  Nein

18,003

99.23

2461

99.15

 Nikotin abusus

  Ja

2005

11.05

292

11.76

0.292

  Nein

16,137

88.95

2190

88.24

 Coagulopathy

  Ja

195

1.07

36

1.45

0.103

  Nein

17,947

98.93

2446

98.55

 Antiplatelet therapy

  Ja

1133

6.25

217

8.74

<0.001

  Nein

17,009

93.75

2265

91.26

 Coumarin

  Ja

296

1.63

48

1.93

0.277

  Nein

17,846

98.37

2434

98.07

As regards the risk factors, global analysis, i.e., at least one risk factor, likewise revealed a highly significant difference between the primary and recurrent operation (p < 0.001). Of patients with recurrences, 30.1 % had at least one risk factor, while this applied to 25.3 % of patients with a primary inguinal hernia.

As regards the individual risk factors too, the corresponding rates were sometimes significantly higher for recurrent operations (Table 2).

No difference was observed in the intraoperative complication rates between endoscopic primary and recurrent operations (Table 3). Postoperative complications, complication-related reoperations as well as the recurrence rate, pain at rest, pain on exertion, and pain requiring treatment on 1-year follow-up were significantly higher after endoscopic recurrent operations than after endoscopic primary operation (Table 3).
Table 3

Intra- and postoperative complications, complication-related reoperations, and 1-year follow-up results of patients with endoscopic primary versus recurrent unilateral inguinal hernia repair in men

Unadjusted analysis

Primary op

Recurrent op

p

n

%

n

%

Intraoperative complications

 Yes

232

1.28

33

1.33

0.849

 No

17,910

98.72

2449

98.67

Postoperative complications

 Yes

581

3.20

100

4.03

0.036

 No

17,561

96.80

2382

95.97

Reoperation

 Yes

153

0.84

33

1.33

0.023

 No

17,989

99.16

2449

98.67

Recurrence

 Yes

170

0.94

36

1.45

0.023

 No

17,972

99.06

2446

98.55

Pain at rest

 Yes

740

4.08

153

6.16

<0.001

 No

17,402

95.92

2329

93.84

Pain on exertion

 Yes

1457

8.03

284

11.44

<0.001

 No

16,685

91.97

2198

88.56

Chronic pain requiring treatment

 Yes

419

2.31

95

3.83

<0.001

 No

17,723

97.69

2387

96.17

Multivariable analysis

The results of multivariable analysis of the postoperative complication rates are illustrated in Table 4 (model matching p < 0.001). The probability of postoperative complications was essentially determined by the scrotal EHS classification (p < 0.001). Likewise, a highly significant impact was exerted by hernia defect sizes, age, BMI, and lateral EHS classification on onset of postoperative complications (in each case, p < 0.001). Scrotal EHS classification [OR 2.558 (1.845; 3.548)], larger defect size [II vs I: OR 1.603 (1.202; 2.138); III vs I: OR 2.323 (1.699; 3.177)], and higher age [10-year OR 1.133 (1.067; 1.204)] were conducive to onset of postoperative complications (Table 4).
Table 4

Multivariable analysis of postoperative complications

Parameter

p value

Category

OR

95 % CI

EHS scrotal

<0.001

Yes versus no

2.558

1.845

3.548

Defect size

<0.001

II (1.5–3 cm) versus I (<1.5 cm)

1.603

1.202

2.138

III (>3 cm) versus I (<1.5 cm)

2.323

1.699

3.177

Age (10-year OR)

<0.001

 

1.133

1.067

1.204

BMI (5-point OR)

<0.001

 

0.782

0.691

0.884

EHS lateral

<0.001

Yes versus no

0.645

0.499

0.834

EHS medial

0.001

Yes versus no

0.658

0.512

0.845

Operation

0.045

Primary versus recurrent

0.797

0.638

0.995

ASA score

0.067

II versus I

1.030

0.844

1.258

III/IV versus I

1.330

1.005

1.760

Risk factors

0.798

Yes versus no

0.976

0.814

1.172

EHS femoral

0.852

Yes versus no

1.052

0.617

1.792

On the other hand, a 5-point higher BMI [5-point OR 0.782 (0.691; 0.884)] as well as a lateral EHS classification [OR 0.645 (0.499; 0.834)] reduced the risk of postoperative complications. Likewise, a medial EHS classification (OR 0.658 [0.512; 0.845; p = 0.001]) and primary operations [OR 0.797 (0.638; 0.995); p = 0.045] significantly reduced the risk of onset of a postoperative complication. With an overall prevalence of 3.3 %, there would thus be 29 postoperative complications for every 1000 primary operations compared with 36 postoperative complications for every 1000 recurrent operations.

The results of analysis of the reoperation rate are shown in Table 5 (model matching: p < 0.001). Here, too, scrotal EHS classification emerged as the strongest influence factor. The reoperation risk was significantly increased for scrotal EHS classification [OR 2.266 (1.204; 4.264); p = 0.011]. A 5-point higher BMI was shown to be preventive here with regard to the reoperation rate [5-point OR 0.745 (0.589; 0.942); p = 0.014]. Likewise, primary operation significantly reduced the reoperation risk [OR 0.630 (0.428; 0.927); p = 0.019]. With an overall reoperation rate of 0.9 %, that thus corresponds to around seven reoperations for every 1000 patients with primary operation compared with 11 reoperations for every 1000 patients with a recurrent operation.
Table 5

Multivariable analysis of reoperation

Parameter

p value

Category

OR

95 % CI

EHS scrotal

0.011

Yes versus no

2.266

1.204

4.264

BMI (5-point OR)

0.014

 

0.745

0.589

0.942

Operation

0.019

Primary versus recurrent

0.630

0.428

0.927

Defect size

0.021

II (1.5–3 cm) versus I (<1.5 cm)

1.317

0.793

2.188

III (>3 cm) versus I (<1.5 cm)

1.970

1.130

3.436

Age (10-year OR)

0.047

 

1.122

1.001

1.257

Risk factors

0.083

Yes versus no

1.337

0.963

1.858

ASA score

0.083

II versus I

0.821

0.563

1.197

III/IV versus I

1.263

0.759

2.103

EHS femoral

0.462

Yes versus no

1.405

0.568

3.480

EHS lateral

0.735

Yes versus no

1.082

0.686

1.704

EHS medial

0.798

Yes versus no

0.946

0.620

1.445

Conversely, larger hernia defect sizes [III vs I: OR 1.970 (1.130; 3.436); p = 0.021] as well as a higher age [10-year OR 1.122 (1.001; 1.257); p = 0.047] significantly increased the reoperation risk.

Table 6 illustrates the results of multivariable analysis of the parameters implicated in onset of recurrences on 1-year follow-up (model matching: p < 0.001). Here, the BMI emerged as the strongest influence factor (p = 0.004). A 5-point higher BMI increased the recurrence rate [5-point OR 1.304 (1.089; 1.562)]. Likewise, medial EHS classification significantly increased the recurrence rate on follow-up [OR 1.682 (1.144; 2.471); p = 0.008]. The ASA status, too, had a significant effect on the recurrence rate on follow-up, something which, however, cannot be unequivocally specified in the categories (p = 0.039). Conversely, for a primary operation only a tendentially predictive effect could be demonstrated [OR 0.710 (0.491; 1.027); p = 0.069].
Table 6

Multivariable analysis of recurrence in 1-year follow-up

Parameter

p value

Category

OR

95 % CI

BMI (5-point OR)

0.004

 

1.304

1.089

1.562

EHS medial

0.008

Yes versus no

1.682

1.144

2.471

ASA score

0.039

II versus I

0.955

0.675

1.352

III/IV versus I

1.598

0.981

2.603

Operation

0.069

Primary versus recurrent

0.710

0.491

1.027

Defect size

0.171

II (1.5–3 cm) versus I (<1.5 cm)

0.702

0.483

1.022

III (>3 cm) versus I (<1.5 cm)

0.801

0.510

1.258

EHS scrotal

0.204

Yes versus no

1.635

0.766

3.491

Risk factors

0.370

Yes versus no

0.858

0.614

1.199

Age (10-year OR)

0.649

 

1.025

0.921

1.140

EHS femoral

0.702

Yes versus no

1.192

0.484

2.940

EHS lateral

0.984

Yes versus no

0.996

0.670

1.480

The results of multivariable analysis of pain at rest on 1-year follow-up are summarized in Table 7 (model matching: p < 0.001). That was highly significantly influenced by the operation type (p < 0.001). A primary operation reduced the risk of pain at rest [OR 0.661 (0.550; 0.794)]. With an overall prevalence of 4.3 %, that corresponds to 35 patients with pain at rest for every 1000 primary operations compared with 51 patients with pain at rest for patients with recurrent operations.
Table 7

Multivariable analysis of pain at rest in 1-year follow-up

Parameter

p value

Category

OR

95 % CI

Operation

<0.001

Primary versus recurrent

0.661

0.550

0.794

BMI (5-point OR)

<0.001

 

1.284

1.172

1.406

Defect size

<0.001

II (1.5–3 cm) versus I (<1.5 cm)

0.666

0.561

0.791

III (>3 cm) versus I (<1.5 cm)

0.551

0.437

0.694

Age (10-year OR)

0.056

 

0.952

0.905

1.001

EHS femoral

0.154

Yes versus no

1.358

0.892

2.069

Risk factors

0.188

Yes versus no

1.113

0.949

1.305

EHS scrotal

0.410

Yes versus no

0.808

0.486

1.342

ASA score

0.446

II versus I

1.038

0.880

1.225

III/IV versus I

1.177

0.909

1.523

EHS medial

0.502

Yes versus no

0.931

0.755

1.147

EHS lateral

0.676

Yes versus no

1.050

0.835

1.320

Likewise, BMI and hernia defect size had a highly significant impact (in each case, p < 0.001). A higher BMI increased the risk of pain at rest [5-point OR 1.284 (1.172; 1.406)]. On the other hand, a larger defect size reduced the risk of pain [II vs I: OR 0.666 (0.561; 0.791); III vs I: OR 0.551 (0.437; 0.694)].

Equally, pain on exertion on follow-up, whose results are summarized in Table 8 (model matching: p < 0.001), was highly significantly influenced by the operation type (p < 0.001).
Table 8

Multivariable analysis of pain on exertion in 1-year follow-up

Parameter

p value

Category

OR

95 % CI

Operation

<0.001

Primary versus recurrent

0.667

0.581

0.765

Age (10-year OR)

<0.001

 

0.834

0.804

0.865

Defect size

<0.001

II (1.5–3 cm) versus I (<1.5 cm)

0.721

0.635

0.819

III (>3 cm) versus I (<1.5 cm)

0.610

0.514

0.724

BMI (5-point OR)

<0.001

 

1.175

1.096

1.259

EHS lateral

0.149

Yes versus no

0.883

0.746

1.046

EHS scrotal

0.166

Yes versus no

0.766

0.525

1.117

ASA score

0.198

II versus I

1.062

0.943

1.195

III/IV versus I

1.198

0.984

1.459

EHS medial

0.466

Yes versus no

0.943

0.806

1.104

Risk factors

0.605

Yes versus no

1.032

0.916

1.163

EHS femoral

0.673

Yes versus no

1.076

0.766

1.510

Conduct of a primary operation was associated with highly significantly less pain on exertion [OR 0.667 (0.581; 0.765)]. With an overall prevalence of 8.4 %, that corresponds to onset of pain on exertion in around 68 out of every 1000 patients with primary operations compared with 99 out of every 1000 patients with recurrent operations.

Likewise, age, hernia defect size, and BMI exerted a highly significant impact on pain on exertion (in each case, p < 0.001). In this regard, the probability of occurrence of pain on exertion declined with higher age [10-year OR 0.834 (0.804; 0.865)] as well as in the presence of larger hernias [II vs I: OR 0.721 (0.634; 0.819); III vs I: OR 0.610 (0.514; 0.724)]. Conversely, a 5-point higher BMI increased the risk of pain [5-point OR 1.175 (1.096; 1.259)].

The results of analysis of pain requiring treatment are shown in Table 9 (model matching: p < 0.001). There is hardly any difference between these results and those obtained for pain on exertion. Here, too, the hernia defect size, BMI, operation type, and age played a highly significant role (in each case, p < 0.001). A larger defect size [II vs I: OR 0.502 (0.408; 0.619); III vs I: OR 0.404 (0.299; 0.545)], primary operation [OR 0.605 (0.480; 0.763)], and older age [10-year OR 0.880 (0.825; 0.940)] reduced the risk of chronic pain requiring treatment. Conversely, the risk of pain was increased by a 5-point higher BMI [5-point OR 1.405 (1.257; 1.570)].
Table 9

Multivariable analysis of chronic pain requiring treatment in 1-year follow-up

Parameter

p value

Category

OR

95 % CI

Defect size

<0.001

II (1.5–3 cm) versus I (<1.5 cm)

0.502

0.408

0.619

III (>3 cm) versus I (<1.5 cm)

0.404

0.299

0.545

BMI (5-point OR)

<0.001

 

1.405

1.257

1.570

Operation

<0.001

Primary versus recurrent

0.605

0.480

0.763

Age (10-year OR)

<0.001

 

0.880

0.825

0.940

Risk factors

0.027

Yes versus no

1.258

1.026

1.542

ASA score

0.261

II versus I

1.071

0.863

1.327

III/IV versus I

1.318

0.942

1.844

EHS femoral

0.332

Yes versus no

1.308

0.760

2.249

EHS medial

0.429

Yes versus no

0.893

0.675

1.182

EHS scrotal

0.668

Yes versus no

0.865

0.447

1.676

EHS lateral

0.960

Yes versus no

0.992

0.732

1.345

With an overall prevalence of 2.5 %, the impact of the operation type on onset of pain requiring treatment would mean that some 19 out of every 1000 patients with primary operation suffer from pain requiring treatment compared to 31 out of every 1000 patients with recurrent operation.

Analysis of the intraoperative complications (model matching: p > 0.001) showed that only for medial EHS classification was a significant relationship identified. Here, the risk of intraoperative complications was reduced for patients with medial EHS classification [OR 0.564 (0.372; 0.855)]. No significant impact was identified for any of the other parameters.

Discussion

The heterogeneous nature of recurrent hernias makes RCTs in this field difficult and time-consuming, particularly when the previous repair has to be taken into consideration [1]. Accordingly, to date there are no RCTs comparing the outcome of endoscopic repair of primary versus recurrent hernias. Large hernia registries are a valuable way of obtaining information on recurrent groin hernia surgery [1].

In this present analysis of data from the Herniamed Registry [12], the outcome of endoscopic repair of 18,142 primary hernias was compared with that of 2482 recurrent inguinal hernias on the basis of the perioperative complications and the 1-year follow-up. To enhance comparability, only male unilateral inguinal hernias for which the corresponding 1-year follow-up information was available were analyzed.

Based on the Guidelines der European Hernia Society [8], the International Endohernia Society [9], and the European Association of Endoscopic Surgery [10], endoscopic repair of recurrent inguinal hernias was performed in 61.6 % of cases following previous open suture technique, in 28.9 % following previous open mesh repair, and only in 9.4 % of cases after previous endoscopic mesh repair.

The potential risk factors identified for onset of recurrences following inguinal hernia surgery were high age, higher BMI, smoking, hernia type, and certain diseases (COPD, diabetes mellitus, aortic aneurysm, immunosuppression, etc.) [2].

Certain conclusions can be drawn, with regard to onset of inguinal hernia recurrences, from the proportion of these risk factors implicated in the two comparison groups. For example, this present analysis did not identify any significant difference between the two comparison groups in terms of mean BMI, proportion of smokers, and immunosuppressed patients. However, significant differences were found between the primary and recurrent inguinal hernia groups with regard to age, proportion of patients with a history of COPD, diabetes mellitus, and aortic aneurysm as well as patients who had to take platelet aggregation inhibitors.

On comparing the perioperative outcome of endoscopic repair of primary versus recurrent male unilateral inguinal hernias, no significant difference was discerned with regard to the intraoperative complications (1.28 vs 1.33 %; p = 0.849), but definitely were for the postoperative complications (3.20 vs 4.03 %; p = 0.036) and the complication-related reoperation rates (0.84 vs 1.33 %; p = 0.023). Likewise, multivariable analysis confirmed that the recurrent operation, in addition to scrotal hernia, larger defect size, higher age, and higher BMI, had a negative impact on postoperative complications. That was also true for the complication-related reoperation rates. And while the differences between the two groups are significant in view of the large sample size, the absolute values clearly show that even recurrent hernias can be operated on with a very low perioperative complication rate when using an endoscopic repair technique. Accordingly, patients should be informed in an informed consent discussion that the risk associated with endoscopic inguinal hernia repair is higher for a recurrent operation compared with a primary operation.

Equally, significant differences were seen for all criteria in the results of 1-year follow-up for endoscopic primary repair of primary versus recurrent male unilateral inguinal hernias. For example, significant differences were noted in the recurrence rates (0.94 vs 1.45 %; p = 0.023), pain at rest (4.08 vs 6.16 %; p < 0.001), pain on exertion (8.03 vs 11.44 %; p < 0.001), and chronic pain rate requiring treatment (2.31 vs 3.83 %; p < 0.001). However, multivariable analysis identified the significant impact exerted by the recurrent operation on the recurrence rate only as a trend. Rather, a higher BMI value, higher ASA classification, and medial hernia classification were responsible for re-recurrence.

Multivariable analysis identified the significantly negative impact exerted by a recurrent operation on pain at rest, pain on exertion, and pain requiring treatment. Furthermore, a higher BMI value, smaller defect size, and younger age were implicated in onset of pain after endoscopic inguinal hernia repair.

The present data thus clearly demonstrate that even when an endoscopic recurrent operation is performed in accordance with the guidelines, a poorer outcome must be expected because of the previous operation.

In the vast majority of cases, this is due to the fact that even when operating in another anatomic layer for the recurrent operation only rarely is no scarring encountered from the previous operation. As such, the conditions under which a recurrent operation is conducted are generally worse than those prevailing at the time of the primary operation, i.e., not just following previous endoscopic primary hernia operations. Therefore, a recurrent operation, i.e., also following previous open suture and mesh repair, calls for a particularly experienced surgeon. Accordingly, recurrent operations should always be performed by very experienced endoscopic hernia surgeons.

In summary, this present analysis of data from the Herniamed Registry is the first such analysis to demonstrate on the basis of a large prospective patient group the differences in outcome for up to 1 year between endoscopic repair of primary and recurrent inguinal hernia. Even when proceeding in compliance with the guidelines of the international specialist societies, more unfavorable outcomes must be expected for recurrent inguinal hernia. Hence, repair of recurrent hernias calls for particular expertise on the part of the endoscopic hernia surgeons.

Notes

Acknowledgments

Ferdinand Köckerling—Grants to fund the Herniamed Registry from Johnson & Johnson, Norderstedt, Karl Storz, Tuttlingen, pfm medical, Cologne, Dahlhausen, Cologne, B Braun, Tuttlingen, MenkeMed, Munich and Bard, Karlsruhe

Compliance with Ethical Standards

Disclosures

D. Jacob, W. Wiegank, M. Hukauf, C. Schug-Pass, A. Kuthe, and R. Bittner have no conflicts of interest or financial ties to disclose

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Copyright information

© The Author(s) 2015

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  • F. Köckerling
    • 1
  • D. Jacob
    • 1
  • W. Wiegank
    • 1
  • M. Hukauf
    • 2
  • C. Schug-Pass
    • 1
  • A. Kuthe
    • 3
  • R. Bittner
    • 4
  1. 1.Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical SchoolVivantes HospitalBerlinGermany
  2. 2.StatConsult GmbHMagdeburgGermany
  3. 3.Department of General and Visceral SurgeryGerman Red Cross HospitalHannoverGermany
  4. 4.Hernia CenterWinghofer MedicumRottenburg am NeckarGermany

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