Introduction

Despite the best surgical techniques and measures, we still see recurrence rates between 0.5 and 15% in the current literature, following primary hernia repair and this depends on the hernia site, method of repair as well as circumstances of the timing of surgery [1]. With such a growing number of patients presenting with hernia recurrence, it is imperative that general surgeons are familiar and comfortable with various modalities of repair [2].

Re-recurrent inguinal hernia is defined as a recurrence of a hernia which has been repaired at least twice before at the same site [3] (Fig. 1).

Fig. 1
The image of an exposed section of the human body. It shows a large balloon-shaped part on the lower side.

Patient with recurrent hernia after bilateral open repair

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According to the EHS, IEHS Guidelines, and HerniaSurge Group (2018), endo-laparoscopic posterior approach is preferred for recurrences after anterior repair and open anterior approach can be used for recurrence after posterior approach [4].

As the population is aging, the number of cases done laparoscopically has increased and with other challenging factors like robotic prostatectomy, we presume that in the future we are going to experience more cases of either multiple recurrences and recurrence after both anterior and posterior repairs in which there is a lack of data and guidelines to guide surgeons on the choice of treatment [1].

We would stress that these cases can be extremely challenging in which the failure of a previous treatment not only leads to a difficult surgery but also to an outcome that can be suboptimal and poor for the patients. In our modest opinion, these cases for the best of the patients should be referred and treated by Hernia Centers of Excellence where expertise and high volume will make the difference [5].

In this chapter, we aim to outline the key points in the use of endo-laparoscopic techniques for the repair of recurrent and re-recurrent inguinal hernias, based on our experience at a high-volume hernia center.

Indications

Indication for repair of hernia recurrences are similar to primary hernia repair. In patients who have an asymptomatic recurrence, there is a role for watchful waiting as the risk of complications remain low even in the recurrent hernia group [1, 6]. In patients who are symptomatic, repair should be undertaken after evaluation of the recurrence with a balanced discussion considering the patient’s underlying comorbidities and quality of life. Urgent repair should be undertaken in patients who present with complications related to the hernia such as perforation, strangulation, or obstruction [6].

Recurrences are usually classified according to the timing of the recurrence—immediate, early, and late. Although there is no consensus with regards to the actual definitions of the timing and some authors have used a period of 5 years to differentiate between early and late recurrences. Immediate recurrences are usually due to technical issues such as excessive intra-abdominal pressure or trauma to the repair site, as well as the presence of occult hernia which was missed during the initial repair. Early recurrences are generally related to surgeon factors with regards to surgical technique, tissue handling, and the choice of tissue versus mesh repair. Late recurrences are generally due to hernia biology from patient factors such as age-related weakening of the anterior abdominal wall, obesity, smoking as well as the presence of new risk factors such as chronic constipation and retention of urine that can lead to chronic increased abdominal pressure resulting in recurrences [7].

For Re-recurrences, multiple factors will influence the decision on repair: type of previous repair, age, comorbidities (DM, obesity, Diverticular diseases, etc.), concomitant pelvic surgery. An accurate analysis of all risk factors should be balanced with the benefits, patient’s expectations and expected outcome, and ultimately with the surgeon’s experience [8].

Contraindications

In the repair of hernias, contraindications can be divided into general contraindications for surgery due to the risk of anesthesia, specific contraindications to hernia repair as well as contraindications in the consideration of the modality of hernia repair.

Hernia repair in general can be considered as mild to moderate risk procedure. Therefore, generally, most patients would be fit for the procedure. Furthermore, with the advent of options of general, spinal, and even local anesthesia in the course of the repair, the technique can be tailored to minimize the risk of anesthesia, especially in patients with very poor underlying comorbidities (e.g., Poor heart function, poorly controlled cardiovascular risk factors, etc.). However, the surgeon needs to also take into consideration the extent of surgery for these cases and marry the type of anesthesia with the extent of surgery indicated to ensure a good outcome.

Contraindications related to the repair of hernias would include those who would not benefit from the hernia repair (poor quality of life prior to surgery to begin with and are unaffected by the hernia recurrence), lifestyle risk factors for hernia development that the patients are unwilling to modify which would result in further hernia recurrence in the future and futility of the current repair [9].

A specific relative contraindication would be the repair of hernias in pregnant patients soon after delivery. In these patients often the abdominal wall is lax due to the pregnancy. Most guidelines recommend delaying elective hernia repair in pregnant patients until at least 4 weeks postpartum to allow for sufficient time for the abdominal wall to regain sufficient normality prior to repair to allow for a meaningful repair [4, 10].

Pre-Op Assessment

All patients undergoing hernia repair should undergo appropriate preoperative assessment for surgery. Evaluation of underlying comorbidities and preoperative optimization should be performed with a referral to anesthesia as required [4].

Specific assessment of the hernia should also be performed. In patients with recurrent hernia with complex anatomy or possible complications, cross-sectional imaging should be performed to further delineate the anatomy as required in order to assist with planning of the hernia repair. A dedicated Informed Consent should be taken highlighting the risk for bladder injury, bowel injury, and injury to the cord structures including vas deferens transection.

A dynamic Ultrasound by an expert radiographer in hernia may be helpful together with a CT Scan for more complex or complicated situations like inguinoscrotal hernia which are not reducible, previous pelvic surgery or radiotherapy, etc. [11].

OT Setup

  • See setup for inguinal hernias in TAPP or TEP chapters

  • Urinary Catheter for complex recurrent and re-recurrent cases

Instrumentations

  • Standard endo-laparoscopic set for Inguinal hernia (see chapter on TEP and TAPP)

Surgical Technique

At present, surgery is the mainstay approach for all recurrent and re-recurrent inguinal hernias. The surgical approach is determined by the nature of the previous repair (mesh vs nonmesh) as well as previous approach (anterior vs posterior). The main principle is the choice of approach should avoid the route of previous approach with a preference for entry through virgin planes to minimize trauma and injury to both cutaneous nerves as well as the cord structures. Previous tissue repair offers more flexibility in view of the absence of a mesh which can potentially complicate the surgical repair of the recurrent hernia due to adhesions to the mesh [2, 4, 10].

Principles of Recurrent Repair

  1. 1.

    Approach through virgin tissue planes

  2. 2.

    Anticipate scarring and distortion of normal tissue planes

  3. 3.

    Reinforcement of the inguinal floor

  4. 4.

    Dissection from normal tissue to scarred tissue and avoiding the use of scarred tissue for repair

  5. 5.

    Tension-free technique for suture lines

  6. 6.

    Leave previous mesh in place and incorporate the edge of the previous mesh into the new repair where possible

  7. 7.

    Dissection to expose and evaluate all hernia orifices to avoid missing an occult hernia

  8. 8.

    Adequate mesh size for coverage of all hernia orifices and to prevent rerecurrence

Challenges and Strategies

In case of post open anterior repair, repair of recurrent hernias can be similar to primary repair through the posterior approach. In some cases, it is difficult to reduce the direct or indirect sac if the prior anterior repair had utilized stitches to plicate the transversalis fascia, inadequate isolation of the sac or if a mesh plug was utilized in the previous anterior repair to fix a direct hernia. Adhesions are the main challenge in the repair of recurrent hernias. Initiating dissection at a more anterior location would ensure safer dissection and a reduction in injury to the vas deferens, corona mortis, or bladder. TEP repair is preferred if the necessary expertise is present; however, TAPP is a good alternative option as well in such recurrent repairs [10, 11].

In cases of re-recurrent hernias, the surgical technique and related repair can be even more tricky should there have been prior anterior and posterior repairs during the first two surgeries. In such cases, one needs to ask what is the best approach? If you attempt endo-laparoscopic repair which approach is the best? Is it even worth the challenges to attempt an endo-laparoscopic repair for re-recurrent hernias?

Treatment of re-recurrent hernias needs to be individualized to the patient. Risk and benefit of the procedure would need to be considered by the attending surgeon after a thorough discussion with the patient [12, 13].

In cases where the patient is elderly (e.g., more than 80 years old) with multiple comorbidities who presents with an asymptomatic re-recurrent hernia, it is prudent to consider that conservative management is a viable alternative given the risk benefit of performing a complex repair for an asymptomatic patient.

In cases whereby the patient is young, fit, and healthy with evidence of a re-recurrent hernia after both an anterior and posterior repair failure, our recommendation is to perform a transabdominal posterior approach (TAPP). Using this approach we are able to make a clear diagnosis of the hernia type, size, and location of the recurrence. Using this method we can also understand the reason for failure having a clear view of the myopectineal orifices during the procedure. We recommend using a urinary catheter during the intraoperative period to keep the urinary bladder decompressed and to prevent bladder injuries during both recurrent and re-recurrent inguinal hernia repairs [14].

In our experience, majority of the recurrences after multiple previous open anterior repairs are usually medial recurrences (70–75%) [1] (Fig. 2).

Fig. 2
An interior view of an uneven section of an internal organ that has a whitish barrier skin on top.

Medial recurrence after open mesh repair and TEP mesh repair

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Re-recurrences after both anterior and posterior repairs are usually because of improper previous mesh placement, which could be placement of the mesh too high or the repair of a large direct hernia (15–20% of the time), resulting in either medial or lateral recurrences (Figs. 3, 4, 5, 6, and 7).

Fig. 3
An interior view of a section of a human body with whitish skin on top. A medical instrument holds a tape-like thing at a region on the section.

Recurrence with mesh shrinkage

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Fig. 4
An interior view of a section of a human body. It has a small bulge and many veins running over it.

Recurrence due to mesh placed higher on the myopectineal orifice

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Fig. 5
An interior view of a section of a human body. It shows a medical instrument at a spot on the section. Text on the area reads previous mesh migrated into the direct defect.

Medial recurrence after large direct hernia repair and mesh displaced inside the hernia

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Fig. 6
An interior view of a section of a human body. It shows many veins and a dense region.

Rerecurrence after previous TEP mesh repair

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Fig. 7
An interior view of a section of a human body. It has a small hollow spot, marked by an arrow as medial recurrence. Another region is marked by an arrow as an old mesh.

Medial recurrence after previous TEP

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Our recommended approach for such cases can be outlined below

  • Initiation of the dissection where the posterior myopectineal orifice of Fruchaud (MPO) is not covered by mesh.

  • Attempt to reduce the hernia sac or excise it.

  • Attempt to get a strong medial fixation point for the next mesh, and if you cannot dissect up to the Cooper’s ligament because of high risk for bladder injury, then consider overlapping the new mesh to the old and use titanium fixation above the pubis arch [15]. Consider an Intraperitoneal onlay (IPOM) or transabdominal partial extraperitoneal mesh placement (TAPE) and fix it using staplers on top and the upper medial side of the old mesh (Fig. 8).

  • Fixing the mesh medially to the Cooper’s ligament using tackers in both approaches is important and during IPOM repair the lower edge of the mesh needs to be sutured to the peritoneum to prevent further recurrences. Close the direct defect using nonabsorbable sutures (Figs. 9 and 10. Usmani et al. have described primary closure of direct inguinal hernia defects with a barbed suture (TEP/TAPP plus technique) which is also supported and recommended by the International Endohernia Society’s Update of Guidelines in 2015 [16]. This technique is known to reduce the incidence of seroma and recurrence rates in large direct inguinal hernia repairs.

  • In some patients, a thin layer of fat may allow you a good dissection plan between the mesh and the MPO. The surgeon needs to be extra cautious in the lower area where the Vas deferens, spermatic artery and veins, and iliac vessels are located.

  • Consider distorted anatomy always in the repair of re-recurrent hernias.

  • Authors have devised this algorithm which can be used to decide on a tailored approach to manage cases of recurrent and re-recurrent inguinal hernia (Fig. 11).

Fig. 8
An interior view of a section of a human body. It has many different regions with different textures. An area on the top side shows a dark color patch, which spreads horizontally.

After laparoscopic IPOM Plus repair for re-recurrent inguinal hernia

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Fig. 9
An interior view of a section of a human body. It has a thread-like thing placed at a hollow spot on the surface. The text on the section reads large medial defect right side.

Direct Defect Closure as a measure to prevent recurrence and reduce seroma

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Fig. 10
An interior view of a section of a human body. A thread-like thing is placed on a region of the section.

After the closure of medial defect

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Fig. 11
A flow diagram represents steps for recurrent and re-recurrence. It has 7 levels each with nodes for showing different approaches. The diagram illustrates the connections and dependencies of every node. At every level, a different number of nodes represents options and the nodes following represent possible outcomes or actions of the previous nodes.

Algorithm for repair of recurrent and re-recurrent groin hernias

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Complications and Management

Complications related to the repair of recurrent hernias are similar to the complications of repair of primary hernias. However, specific to the repair of recurrent hernias, the surgeon should be mindful that distorted anatomy, nonvirgin planes, and the presence of possible previous meshes do increase the risk of postoperative pain. Dissection through previous plans also increases the risk of bowel, bladder, and vessel injury especially through the posterior approach for recurrent and re-recurrent hernias as adhesions would have developed from the previous surgery.

Postoperative Care

  • See chapter on hernia postoperative care.

Conclusion

Recurrent hernias will become a predictably bigger problem in the future with the increasing number of hernia cases being done worldwide. Although challenging, it is imperative that general surgeons are knowledgeable in various approaches of repair to arm themselves with the skills in dealing with these cases based on the initial repair approach. Re-recurrences which are even more challenging should be referred to specialist hernia centers where possible as their repair might require further advanced techniques.