Recurrent inguinal hernia after anterior repair: go posterior

Design

Systematic review and random-effects meta-analysis

Population

35 studies, 4,902 patients with recurrent inguinal hernia; 6 comparative studies after prior anterior repair

Primary outcome

Recurrence, chronic pain, surgical site infection, seroma

Effect

Recurrence OR 0.70 (0.39 to 1.27); SSI OR 0.24 (0.07 to 0.79)

This systematic review included 35 studies and 4,902 patients, almost all men, with recurrent inguinal hernia. Six studies compared posterior with repeat anterior repair after a failed anterior repair.

Recurrence did not differ (OR 0.70, 95% CI 0.39 to 1.27, I² 7.5%). Posterior repair was associated with lower odds of surgical site infection (OR 0.24, 0.07 to 0.79, I² 0%). Chronic pain favoured posterior repair but did not reach significance in the main analysis (OR 0.47, 0.22 to 1.00); in randomised trials alone the difference was significant (OR 0.36, 0.16 to 0.81). Across 17 single-arm studies of posterior repair after anterior repair, recurrence was about 2% and chronic pain about 3%.

This supports the European Hernia Society's advice to repair through the unoperated plane. For a man whose hernia has recurred after an open mesh repair, a laparoscopic or open preperitoneal repair is the approach to offer, or to refer for if the skills are not available locally. The evidence for the reverse direction, anterior repair after a failed posterior one, rests on a single study.

• Offer a posterior repair, laparoscopic or open preperitoneal, for hernia recurring after an anterior repair.
• Refer to a surgeon with posterior-plane experience if you do not offer it yourself.
• Check the previous operation note to confirm which plane was used.
• Counsel patients that recurrence rates are similar, but wound infection and chronic pain appear lower.
• Decide case by case after a failed posterior repair; evidence for the reverse switch is thin.

Why it matters

Operating through scar from the first repair costs patients wound infections and, probably, chronic pain.

Don't overread it

Recurrence was not lower with posterior repair; the advantage is in wound infection and, less certainly, pain.

The statistics, in plain English

The wound infection result, OR 0.24, rests on only 14 events, so the true effect could be smaller than it looks. The chronic pain result touches 1.0 in the main analysis and becomes significant only when restricted to randomised trials, which makes it supportive rather than conclusive.

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