, Volume 19, Issue 3, pp 355–366 | Cite as

Meta-analysis and review of prospective randomized trials comparing laparoscopic and Lichtenstein techniques in recurrent inguinal hernia repair

  • A. PisanuEmail author
  • M. Podda
  • A. Saba
  • G. Porceddu
  • A. Uccheddu



The hypothesis of this meta-analysis was to assess whether laparoscopic approach shows real benefits over Lichtenstein technique in recurrent inguinal hernia repair.


A literature search for prospective randomized trials comparing laparoscopic and Lichtenstein procedure in recurrent inguinal hernia repair was performed. Trials were reviewed for primary outcome measures: re-recurrence, chronic inguinal pain and ischemic orchitis; and for secondary outcome measures. Standardized mean difference (SMD) was calculated for continuous variables and odds ratio for dichotomous variables.


Seven studies comparing laparoscopic and Lichtenstein technique were considered suitable for the pooled analysis. Overall 647 patients with recurrent inguinal hernia were randomized to either laparoscopic repair (333, 51.5 %, transabdominal preperitoneal approach, TAPP and totally extraperitoneal approach, TEP) or anterior open repair (314, 48.5 %, Lichtenstein operation). Patients who underwent laparoscopic repair experienced significantly less chronic pain (9.2 % vs. 21.5 %, p = 0.003). Patients of the laparoscopic group had a significantly earlier return to normal daily activities (13.9 vs. 18.4 days, SMD = −0.68, 95 % CI = −0.94 to –0.43, p < 0.000001). Operative time was significantly longer in laparoscopic operations (62.9 vs. 54.2 min, SMD 0.46, 95 % CI 0.03, 0.89; p = 0.04). No other differences were found.


Laparoscopy showed reduced chronic inguinal pain and an earlier return to normal daily activities but significantly longer operative time. Despite the expected advantages, the choice between laparoscopy and other techniques still depends on local expertise availability. Only dedicated centers are able to routinely offer laparoscopy for recurrent inguinal hernia repair.


Recurrent inguinal hernia repair Prospective randomized trial Laparoscopic approach Transabdominal preperitoneal approach TAPP Totally extraperitoneal approach TEP Anterior open approach Lichtenstein operation 



This study was supported by a Grant from the University of Cagliari, Italy (CAR 2012). The authors would like to thank Dr. Sergio Licheri for the kind invitation to present part of this study at the 17th National Congress of the Italian Society of Ambulatory and Day Surgery, Cagliari, Italy, May 2–4, 2013 (Italian Chapter of the European Hernia Society).

Conflict of interest

The authors declare no conflict of interest.


  1. 1.
    Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R Jr, Dunlop D, Gibbs J, Reda D, Henderson W (2004) Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 350:1819–1827CrossRefPubMedGoogle Scholar
  2. 2.
    Itani KMF, Fitzgibbons R Jr, Awad SS, Duh Q-Y, Ferzli GS (2009) Management of recurrent inguinal hernias. J Am Coll Surg 209:653–658CrossRefPubMedGoogle Scholar
  3. 3.
    Dedemadi G, Sgourakis J, Karaliotas C, Christofides T, Kouraklis G, Karaliotas C (2006) Comparison of laparoscopic and open tension–free repair of recurrent inguinal hernias: a prospective randomized study. Surg Endosc 20:1099–1104CrossRefPubMedGoogle Scholar
  4. 4.
    Kumar S, Nixon SJ, Macintyre IMC (1999) Laparoscopic or Lichtenstein repair for recurrent inguinal hernia: one unit’s experience. J R Coll Surg Edinb 44:301–302PubMedGoogle Scholar
  5. 5.
    Karthikesalingam A, Markar SR, Holt PJE, Praseedom RK (2010) Meta-analysis of randomized controlled trials comparing laparoscopic with open mesh repair of recurrent inguinal hernia. Br J Surg 97:4–11CrossRefPubMedGoogle Scholar
  6. 6.
    Yang J, Tong DN, Yao J, Chen W (2013) Laparoscopic or Lichtenstein repair for recurrent inguinal hernia: a meta-analysis of randomized controlled trials. ANZ J Surg 83:312–318CrossRefPubMedGoogle Scholar
  7. 7.
    Eklund A, Rudberg C, Leijonmarck C-E, Rasmussen I, Spangen L, Wickbom G, Wingren U, Montgomery A (2007) Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and Lichtenstein repair. Surg Endosc 21:634–640CrossRefPubMedGoogle Scholar
  8. 8.
    Voyles CR, Hamilton BJ, Johnson WD, Kano N (2002) Meta-analysis of laparoscopic inguinal hernia trials favors open hernia repair with preperitoneal mesh prosthesis. Am J Surg 184:6–10CrossRefPubMedGoogle Scholar
  9. 9.
    Rahr HB, Bendix J, Ahlburg P, Gjedsted J, Funch-Jensen P, Tønnesen E (2006) Coagulation, inflammatory, and stress responses in a randomized comparison of open and laparoscopic repair of recurrent inguinal hernia. Surg Endosc 20:468–472CrossRefPubMedGoogle Scholar
  10. 10.
    Kouhia STH, Huttunen R, Silvasti SO, Heiskanen JT, Ahtola H, Uotila-Nieminen M, Kiviniemi VV, Hakala T (2009) Lichtenstein hernioplasty versus totally extraperitoneal laparoscopic hernioplasty in treatment of recurrent inguinal hernia—a prospective randomized trial. Ann Surg 249:384–387CrossRefPubMedGoogle Scholar
  11. 11.
    Demetrashvili Z, Qerqadze V, Kamkamidze G, Topchishvili G, Lagvilava L, Chartholani T, Archvadze V (2011) Comparison of Lichtenstein and laparoscopic transabdominal pre-peritoneal repair of recurrent inguinal hernias. Int Surg 96:233–238CrossRefPubMedGoogle Scholar
  12. 12.
    Dedemadi G, Sgourakis G, Radtke A, Dounavis A, Gockel I, Fouzas I, Karaliotas C, Anagnostou E (2010) Laparoscopic versus open mesh repair for recurrent inguinal hernia: a meta-analysis of outcomes. Am J Surg 200:291–297CrossRefPubMedGoogle Scholar
  13. 13.
    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Mother D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. Br Med J 339:b2700CrossRefGoogle Scholar
  14. 14.
    Higgins JPT, Altman DG (ed) (2008) Cochrane handbook for systematic reviews of interventions (version 5.0.1). In: the Cochrane collaboration. Available from Accessed Sep 2008
  15. 15.
    Beets GL, Dirksen CD, Go PM, Geisler FE, Baeten CG, Kootstra G (1999) Open or laparoscopic pre-peritoneal mesh repair for recurrent inguinal hernia? A randomized controlled trial. Surg Endosc 13:323–327CrossRefPubMedGoogle Scholar
  16. 16.
    Feliu X, Torres G, Vinas X, Martinez-Rodenas F, Fernandez-Sallent E, Pie J (2004) Preperitoneal repair for recurrent inguinal hernia: laparoscopic and open approach. Hernia 8:113–116CrossRefPubMedGoogle Scholar
  17. 17.
    Alani A, Duffy F, O’Dwyer PJ (2006) Laparoscopic or open preperitoneal repair in the management of recurrent groin hernias. Hernia 10:156–158CrossRefPubMedGoogle Scholar
  18. 18.
    Mahon D, Decadt B, Rhodes M (2003) Prospective randomized trial of laparoscopic (transabdominal preperitoneal) vs. open (mesh) repair for bilateral and recurrent inguinal hernia. Surg Endosc 17:1386–1390CrossRefPubMedGoogle Scholar
  19. 19.
    Bignell M, Partridge G, Mahon D, Rhodes M (2012) Prospective randomized trial of laparoscopic (transabdominal preperitoneal-TAPP) versus open (mesh) repair for bilateral and recurrent inguinal hernia: incidence of chronic groin pain and impact on quality of life: results of 10-year follow-up. Hernia 16:635–640CrossRefPubMedGoogle Scholar
  20. 20.
    Saber A, Ellabban GM, Gad MA, Elsayem K (2012) Open pre-peritoneal versus anterior approach for recurrent inguinal hernia: a randomized study. BMC Surg 12:22CrossRefPubMedCentralPubMedGoogle Scholar
  21. 21.
    Farooq O, Batool Z, Din AU, Ullah AA, Butt Q, Kibryia RI (2007) Anterior tension-free repair versus posterior preperitoneal repair for recurrent hernia. J Coll Physicians Surg Pak 17:465–468PubMedGoogle Scholar
  22. 22.
    Lichtenstein IL, Shulman AG, Amid PK, Montllor MM (1989) The tension-free hernioplasty. Am J Surg 157:188–193CrossRefPubMedGoogle Scholar
  23. 23.
    Sevonius D, Gunnarsson U, Nordin P, Nilsson E, Sandblom G (2011) Recurrent groin hernia surgery. Br J Surg 98:1489–1494CrossRefPubMedGoogle Scholar
  24. 24.
    Mok KT, Wang BW, Chang HT, Liu SI, Jou NW, Tsai CC, Chen IS (1998) Laparoscopic versus open preperitoneal prosthetic herniorrhaphy for recurrent inguinal hernia. Int Surg 83:174–176PubMedGoogle Scholar
  25. 25.
    Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, Becker BJ, Sipe TA, Thacker SB (2000) Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group. JAMA 283:2008–2012CrossRefPubMedGoogle Scholar
  26. 26.
    Haapaniemi S, Gunnarsson U, Nordin P, Nilsson E (2001) Reoperation after recurrent groin hernia repair. Ann Surg 234:122–126CrossRefPubMedCentralPubMedGoogle Scholar
  27. 27.
    Bisgaard T, Bay-Nielsen M, Kehlet H (2008) Re-recurrence after operation for recurrent inguinal hernia. A nationwide 8-year follow-up study on the role of type of repair. Ann Surg 247:707–711CrossRefPubMedGoogle Scholar
  28. 28.
    Kraus MA (1993) Nerve injury during laparoscopic inguinal hernia repair. Surg Laparosc Endosc 4:342–345Google Scholar
  29. 29.
    Wanz GE (1982) Testicular atrophy as a risk inguinal hernioplasty. Surg Gynecol Obstet 154:570–571Google Scholar
  30. 30.
    Nordin P, Haapaniemi S, van Der Linden W, Nilsson E (2004) Choice of anesthesia and risk of reoperation for recurrence in groin hernia repair. Ann Surg 240:187–192CrossRefPubMedCentralPubMedGoogle Scholar
  31. 31.
    Gianetta E, Cuneo S, Vitale B, Camerini G, Marini P, Stella M (2000) Anterior tension free repair of recurrent inguinal hernia under local anesthesia: a 7-year experience in teaching hospital. Ann Surg 231:132–136CrossRefPubMedCentralPubMedGoogle Scholar
  32. 32.
    Medical Research Council Laparoscopic Groin Hernia Trial Group (2001) Cost–utility analysis of open versus laparoscopic groin hernia repair: results from a multicenter randomized clinical trial. Br J Surg 88:653–661CrossRefGoogle Scholar
  33. 33.
    Wellwood J, Sculpher MJ, Stoker D, Nicholls GJ, Geddes C, Whitehead A, Singh R, Spiegelhalter D (1998) Randomized controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost. Br Med J 317:103–110CrossRefGoogle Scholar
  34. 34.
    Campanelli G, Pettinari D (2006) Nicolosi FM, Cavalli M, Contessini Avesani E. Inguinal hernia recurrence: classification and approach. Hernia 10:159–161CrossRefPubMedGoogle Scholar
  35. 35.
    Wake BL, McCormack K, Fraser C, Vale L, Perez J, Grant AM (2005) Transabdominal pre-peritoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic technique for inguinal hernia repair. Cochrane Database Syst Rev 1:CD004703PubMedGoogle Scholar
  36. 36.
    Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, de Lange D, Fortelny R, Heikkinen T, Kingsnorth A, Kukleta J, Morales-Conde S, Nordin P, Schumpelick V, Smedberg S, Smietanski M, Weber G, Miserez M (2009) European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 13:343–403CrossRefPubMedCentralPubMedGoogle Scholar
  37. 37.
    Miserez M (2007) Alexandre JH, Campanelli G, Corcione F, Cuccurullo D, Hidalgo Pascual M, Hoeferlin A, Kingsnorth AN, Mandala V, Palot JP, Schumpelick V, Simmermacher RKJ, Stoppa R, Flament JB. The European hernia society groin hernia classification: simple and easy to remember. Hernia 11:113–116CrossRefPubMedGoogle Scholar
  38. 38.
    Shaikh I, Olabi B, Wong VMY, Nixon SJ, Kumar S (2011) NICE guidance and current practice of recurrent and bilateral groin hernia repair by Scottish surgeons. Hernia 15:387–391CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag France 2014

Authors and Affiliations

  • A. Pisanu
    • 1
    Email author
  • M. Podda
    • 1
  • A. Saba
    • 1
  • G. Porceddu
    • 1
  • A. Uccheddu
    • 1
  1. 1.Department of Surgery, Clinica ChirurgicaUniversity of Cagliari, Azienda Ospedaliero-Universitaria, Presidio Policlinico di MonserratoMonserratoItaly

Personalised recommendations