Paraumbilical Hernia

A recurrent inguinal hernia is reappearance of a groin hernia after previous surgical repair.

Recurrence may result from inadequate mesh size or overlap, missed femoral or indirect defects, mesh migration, technical failure, infection or progressive tissue weakness.

The previous operation determines the safest route for reoperation. The key principle is to repair through an anatomical plane that has not already been extensively dissected.

Patients usually report a new groin swelling near the previous repair, with or without discomfort.

Pain without a definite swelling should not automatically be attributed to recurrence. Chronic postoperative inguinal pain, mesh related pain, neuralgia and musculoskeletal pathology are important alternatives.

Examine standing and during Valsalva. Examine the femoral canal because a previously missed femoral hernia can mimic recurrent inguinal disease.

Diagnosis is often clinical.

Dynamic ultrasound: useful when the recurrence is small or examination is uncertain.

CT or MRI: useful after several previous repairs, complex mesh anatomy, chronic pain or suspected alternative pathology.

Obtain the previous operative report whenever possible. Knowing whether the earlier operation was anterior or posterior fundamentally changes the reoperative strategy.

Symptomatic recurrence generally warrants repair.

After a previous anterior repair, such as Lichtenstein:

Use a posterior preperitoneal repair, preferably TEP or TAPP where expertise is available.

This avoids scarred anterior tissue planes and reduces unnecessary dissection around inguinal nerves and cord structures.

After a previous posterior repair, such as TEP or TAPP:

Use an anterior open repair, usually Lichtenstein.

After both anterior and posterior approaches have failed, management becomes substantially more complex and should be performed by a surgeon with specific expertise in recurrent groin hernia surgery.

At operation, identify the actual cause of failure rather than simply placing additional mesh over an undefined bulge.

Inspect the femoral space, indirect ring and medial direct space.

Avoid unnecessary removal of previous mesh unless it is infected, displaced or directly responsible for significant symptoms. Mesh removal substantially increases the risk of nerve injury, vascular injury, testicular complications and chronic pain.

Recurrent hernia surgery carries greater risk of chronic groin pain, cord injury and another recurrence than primary repair.