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Ann Surg. Jan 2000; 231(1): 132.
PMCID: PMC1420977

Anterior Tension-Free Repair of Recurrent Inguinal Hernia Under Local Anesthesia

A 7-Year Experience in a Teaching Hospital

Abstract

Objective

To describe a 7-year experience with recurrent inguinal hernia repair performed mainly with tension-free mesh or plug technique under local anesthesia through the anterior approach, and to evaluate the safety and effectiveness of this method of treatment.

Methods

One hundred forty-five elective and 1 emergency herniorrhaphies for recurrent groin hernia were performed in 141 subjects (134 men and 7 women) with a mean age of 65 years (range 30–89). Concomitant medical and surgical problems were present in 73% and 8% of subjects, respectively. In 28 instances, the relapsed hernia had already been operated on once or twice for recurrence. A traditional hernioplasty had been previously performed in the vast majority of cases (136). Tension-free mesh or plug techniques through an anterior approach under local anesthesia were performed in 144 reoperations. Preperitoneal mesh repair and general or spinal anesthesia were used in all but one case when herniorrhaphy was performed during simultaneous operations.

Results

Mean hospital stay after surgery was 1.5 days (range 3 hours–14 days). No perioperative deaths occurred in this series. General complications were one case of acute intestinal bleeding and two cases of urinary retention. Local complications consisted of eight (5.5%) minor complications and one case of orchitis (0.7%) followed by testicular atrophy. In no instance was postoperative neuralgia or chronic pain reported. Two re-recurrences occurred.

Conclusions

Given the low complication rate in this and other reported series and the absence of surgical or general complications described after preperitoneal open or laparoscopic repair and after general and spinal anesthesia, anterior mesh repair under local anesthesia seems to be a low-cost surgical technique that can be safely and effectively used even in a teaching hospital for the treatment of the majority of patients with recurrent groin hernias.

Mesh repairs of inguinal hernia have enjoyed widespread use over the past 10 years and are rapidly and progressively becoming a substitute for traditional operations. The effectiveness and associated low recurrence rate of the techniques have been documented. 1–4 Consequently, recurrent hernia should increasingly become a less common clinical problem. However, the surgical treatment of this event is still not uncommon in clinical practice, given that many surgeons still use traditional hernioplasties and that relapse of hernia after conventional repair may occur also after a long period. 5,6

There is consensus on the use of a prosthetic mesh for the surgical treatment of recurrent groin hernia, but the technique is still debated, largely in terms of the approach to be adopted and the placement site of the mesh. This report describes a 7-year experience of recurrent inguinal hernia repair performed mainly with tension-free mesh or plug technique under local anesthesia through the anterior approach 7 to evaluate the effectiveness and safety of this method of treatment.

METHODS

From April 1991 to October 1998, 141 patients (134 men, 7 women) were treated for recurrent inguinal hernia. Mean age was 65 years (range 30–89); 77 patients were older than 65 years old, 16 of them being older than 80. Duration of hernia ranged from 1 month to 53 years (mean 63 months) and mean time elapsed from primary herniorrhaphy to recurrence was 98 months (range 0–420 months). In 28 instances, the relapsed hernia had already been operated on once or twice for recurrence.

Concomitant medical problems were observed in 73 patients. Cardiovascular diseases were the most frequent (31 cases), followed by urologic disease (20 cases), gastrointestinal and hepatic disease (19 cases), pulmonary disease (8 cases), diabetes (7 cases), and chronic renal failure (1 patient receiving continuous ambulatory peritoneal dialysis).

In five instances recurrence was bilateral. In 14 the relapsed groin hernia was associated with a primary one on the other side, and in one patient with an ipsilateral primary femoral hernia. A total of 146 recurrent hernias were thus observed in the 141 patients. In the majority of cases (135 patients), the hernia was reducible; it was chronically incarcerated in 10 cases and acutely incarcerated with strangulation in 1 patient.

Surgical procedures that had been used for the primary hernia repair, as well as the types of recurrence observed at reoperation and the surgical techniques used for their treatment, are shown in Table 1. In 40 instances, the technique previously used was determined at reoperation. The majority of patients had undergone a traditional anterior hernioplasty. Six preperitoneal hernia repairs without mesh had been performed simultaneously with other surgical procedures, whereas one hernia had been treated laparoscopically by positioning an intraperitoneal mesh. Four of the nine anterior mesh repairs followed by relapse had been performed for recurrent groin hernia.

Table thumbnail
Table 1. SURGICAL PROCEDURES ADOPTED FOR PRIMARY REPAIR, TYPES OF RECURRENCE OBSERVED AT REOPERATION, AND APPROACHES USED FOR TENSION-FREE MESH OR PLUG RE-REPAIRS

Two preperitoneal mesh re-repairs were performed simultaneously with other operations; conversely, all the other recurrences were repaired using the anterior tension-free mesh technique. The aponeurosis of the external oblique muscle was routinely opened to explore the preexisting herniorrhaphy for its entire length. The majority of relapses, including 90 after Bassini (50 indirect, 26 multiple, 14 direct), 8 after preperitoneal, 2 after Shouldice, and 1 after intraperitoneal mesh laparoscopic repair, were re-repaired with the anterior tension-free technique proposed by Lichtenstein et al 5 for the primary operation with the aim of reinforcing the floor of the inguinal canal while treating recurrence. The plug repair 8 was used in only eight instances in the presence of a small defect of the previous hernioplasty. In 37 cases in which the defect of the herniorrhaphy was >1.5 cm, a patch under- or overlying the defect was positioned and sutured in place with multiple nonabsorbable sutures. This last technique was used to operate on the nine recurrences after anterior mesh repair, the two after McVay hernioplasty, and 26 direct relapses after Bassini operation. The hernia sac was not opened but was simply isolated and inverted in almost all cases (141). All bilateral inguinal hernias as well as the femoral one associated with a groin hernia on the same side were treated at the same time. An aspiration drain was positioned in 36 cases and was removed after 24 to 48 hours.

Other concomitant surgical procedures were two incisional hernia repairs, one umbilical hernioplasty, one varicocele operation, one prostatectomy, two bilateral saphenectomies, and one abdominal aorta aneurysm repair.

In the majority of cases (138), hernioplasties, including all repairs of the chronically incarcerated hernias, repairs of primary inguinal, femoral, and umbilical hernias associated with recurrence, and the varicocele operation, were performed under local anesthesia. Spinal anesthesia was used in one case of bilateral hernioplasty and in the two instances in which a bilateral saphenectomy was performed. General anesthesia was used in the emergency herniorrhaphy for strangulation and in the four instances in which incisional hernia repair, prostatectomy, and abdominal aorta aneurysm repair were done.

A urinary catheter was positioned before surgery in the emergency hernioplasty and in patients undergoing major abdominal procedures. Antibiotics were not routinely administered.

Discharge of patients undergoing simple elective herniorrhaphy under local anesthesia was scheduled for the same day as or the day after surgery. Follow-up examinations at 1 month and yearly thereafter until the fifth postoperative year were scheduled for all patients.

RESULTS

Mean hospital stay after surgery was 1.5 days (range 3 hours–14 days). Thirty-five patient were discharged the day of surgery and 66 the day after.

There were no perioperative deaths. Acute intestinal bleeding from diverticular disease, which required several blood transfusions and a prolonged hospital stay, occurred in one patient undergoing elective hernioplasty under local anesthesia. There were two cases of urinary retention after elective repair under spinal and local anesthesia.

Local complications consisted of four cases of hematoma of the scrotum (2.7%), three cases of edema of the cord (2%), one wound infection (0.7%), and one case of orchitis (0.7%). In this last patient, testicular atrophy was observed at clinical examination at 1 month. In no instance was postoperative neuralgia or chronic pain reported.

Three subjects older than 65 died of unrelated causes 1 to 2 years after reoperation. The follow-up rate at 1, 2, 3, 4, and 5 years was 93% (114), 86% (83), 79% (57), 80% (39), and 68% (19), respectively.

Two recurrences occurred during the first year after anterior mesh repair for relapse after traditional hernioplasty (1.8%). No other recurrence was observed in the other patients who underwent follow-up examinations. Conversely, nine contralateral inguinal and one ipsilateral femoral hernias were detected and subsequently treated.

DISCUSSION

Few hernia relapses have been observed after primary groin hernia repair using a prosthetic mesh, despite the widespread use of these techniques and the high number of procedures performed. Nearly all the reoperations were performed for recurrence after traditional hernioplasty; in these patients, the mean time elapsed from primary repair to recurrence was approximately 9 years. Further, some of the reoperations were done recently in patients who had undergone the primary operation a few months to 2 years earlier. These observations confirm the possibility of long-term recurrence after traditional herniorrhaphy, and likewise indicate that conventional approaches have still not been entirely abandoned.

It has been reported that a direct suprapubic recurrence develops more frequently after traditional hernioplasty. 9 Others have found almost the same incidence of direct and indirect recurrence, 8 with a lower rate of multiple 8 or pantaloon 10 relapses. In this series, the same number of direct and indirect recurrences were treated. In >30% of indirect relapses, at reoperation a partially or totally preserved cremaster muscle was detected. Further, there were eight instances in which multiple direct defects were found, whereas 18 pantaloon relapses were detected by careful exploration of the cord after section of the residual or intact cremaster. These findings, which are in accord with the observations of others, 11,12 indicate that recurrence after traditional repair may be due either to inaccurate execution of the technique or to an overlooked hernia at the primary operation. Similarly, it became apparent that in this series, all recurrences after anterior mesh repair for primary hernia and three for hernia relapse were due to inadequate size or poor fixation of the mesh to the pubic tubercle 13 or to the surrounding structures, 7 whereas an unrecognized second defect was probably the cause of one re-relapse.

Preperitoneal (rather than anterior) repair has been advocated as the preferred technique for the treatment of recurrent groin hernia, especially after the introduction of surgical laparoscopy. This claim is supported by the greater effectiveness that theoretically ensues from placing the mesh posteriorly to the muscoloaponeurotic layer of the abdomen, based on Pascal’s principle 14 and by the fact that the technique facilitates both the detection of multiple defects and the dissection of the sac, with a reduced incidence of postoperative neuralgia and orchitis. 15,16

With the exception of some excellent 17,18 or disappointing 19 results, a re-recurrence rate ranging from 1% to 3% has generally been reported after posterior open 9,14,20 or endoscopic 10 repair for recurrent groin hernia. This percentage does not substantially differ from the 1.6% re-relapse rate documented in a large series of open anterior mesh repairs performed in a specialized center. 8 These results, unlike those of others, 20 are confirmed by this series of reoperations performed in a teaching hospital.

Orchitis with testicular atrophy occurs more frequently after anterior repair for relapsed groin hernia due to the presence of a cicatrixed cord. The incidence of this complication can be substantially reduced by dividing the hernia sac high in the inguinal canal, suturing the proximal edge, and leaving its distal portion in place, thus refraining from cord dissection. 15 In the present series, this procedure was used in only five instances in which a huge hernia was present. Nevertheless, there was a low incidence of both cord and testis complications in this series, presumably because of the infiltration of local anesthetic, which facilitates dissection and thus reduces the risk of damaging spermatic veins and the blood supply of the testis.

Postoperative neuralgia has been described after both anterior and posterior hernioplasty. 15,21,22 Conversely, after posterior open or laparoscopic repair, many serious abdominal complications related to the surgical technique itself and to the presence of the mesh in the preperitoneal space (e.g., bladder, bowel, and vascular injuries) have been reported. 17,23–26 These complications, to our knowledge, have not been described after open anterior mesh repair. Moreover, for endoscopic approaches, the pathophysiology of the pneumoperitoneum, with its hemodynamic and cardiopulmonary effects, should be taken into account. 27–29

Laparoscopic hernia repair is more expensive than open anterior hernioplasty, 30,31 but some have argued that the costs are offset by less postoperative pain and faster rehabilitation. 30,32 Disability, as underlined by others, 33 is the most nebulous, subjective, and nonquantifiable of all postoperative variables. In any case, in our experience of >1,000 open tension-free hernioplasties for primary or recurrent groin hernia, parenteral antiinflammatory/analgesic drugs were required by only a few patients, and nearly all patients could return to normal activity and driving within 5 days after surgery.

Groin hernia is a common pathologic entity, and its incidence is high in adults older than 65. 5 Because life expectancy has dramatically increased (at present it is slightly less than 80 years in developed countries 34), the number of surgical procedures performed for hernia will most likely rise in the future. Further, geriatric patients who are candidates for herniorrhaphy often have concomitant diseases that increase the surgical risk. 35 Cardiovascular, pulmonary, and urinary complications can occur after hernioplasty, especially if the procedure is performed under general or spinal anesthesia. 36–38 Conversely, patients who receive local anesthesia do not generally have serious intra- or postoperative complications. 37,39 Local anesthesia is also considered acceptable in terms of costs. Consequently, to increase safety and, if possible, to reduce costs, the surgical treatment of a common disorder such as groin hernia should be performed using surgical techniques that, proven to be effective, can be carried out under local anesthesia. In keeping with this policy, nearly all patients in this series underwent anterior tension-free mesh or plug hernia repair under local anesthesia; other surgical and anesthetic techniques were used only for incidental situations. The rate of minor local complications was low, as was the recurrence rate, and there were no major general postoperative problems.

In conclusion, based on the results and the low complication rate of this and other reported series and the absence of major surgical or general complications after preperitoneal open or laparoscopic repair and after general and spinal anesthesia, anterior mesh repair under local anesthesia seems to be a low-cost surgical technique that can be safely and effectively used even in a teaching hospital setting for the treatment of the majority of recurrent groin hernias.

Footnotes

Correspondence: Prof. Ezio Gianetta, I Clinica Chirurgica dell’Università, Largo R. Benzi, 8, 16132 Genova, Italy.

Accepted for publication April 1, 1999.

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