Recurrence after inguinal hernia repair is one of the most important measurable outcomes. It is largely determined by technique and can only accurately be reported with complete long-term follow-up. Recurrences are more frequent after treatment of primary rather than recurrent hernias, while they are less frequent after prosthetic reinforcement, as compared to conventional open surgery without mesh.6,7 Approximately 770,000 inguinal herniorrhaphies are performed in the United States8,9 and 100,000 in the United Kingdom10 each year. This corresponds to approximately 20,000 and 100,000 recurrent hernias, respectively.11
Operating on recurrent hernias is technically challenging12. Re-recurrence rates from national hernia registers in Sweden13 and Denmark14 has shown an incidence of recurrence of 16-18% following primary repair, but a recurrence rate of even over 30% has been reported.15
During the last two decades, mesh repairs have become widely accepted because they result in a tension-free repair with a low recurrence rate.16. Large consecutive series of patients having tension-free mesh repair have a very good results. Laparoscopic hernia repair has short term advantages in post operative pain but requires high degree of technical skill, a consequent long learning curve, a risk of serious complications and increased cost. Laparoscopic repair has not been widely adopted for routine repair of inguinal hernias17,18. Tension-free repairs have gained popularity not only for primary or recurrent hernias but also for complicated inguinal hernia repairs as well.19
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The open tension-free mesh operation is technically more straightforward than laparoscopic repair - it is easy to teach and learn - and good results are readily obtainable with a low recurrence rate and low morbidity. It is also cost-effective and is the operation favoured by the vast majority of surgeons for the repair of primary inguinal hernia.20
Recurrences after mesh repair of hernias occur early and are related to technical factors such as inadequate dissection, insufficient prosthesis size and fixation, and surgeon's inexperience.21,22
PATIENTS AND METHODS:
An analysis of 62 patients having recurrent inguinal hernia was done from 5th January 2005 to 4th January 2009 in the Department of Surgery at Liaquat University Hospital Jamshoro/Hyderabad, Sindh, Pakistan. The adult male patients of all age group with recurrent inguinal hernias was included in the study while patients with other types of hernia like femoral, epigastric, paraumblical, female patients were considered in exclusion criteria. All the data was entered in a specified proforma designed for this purpose. The detailed history and general physical and local examination was done in all the patients with special regard to the recurrent inguinal hernia. The digital rectal examination was done in patients above the age of 50 years to exclude enlargement of prostate and any rectal growth. All the patients underwent base line investigations like Blood CP, Blood Urea/Sugar, Urine DR and X-Ray chest. Where available, details about primary repair were collected including grade of surgeon, surgical technique used in primary repair, the side of inguinal hernia recurrence and clinical and operative details of the re-operation. Finally patients who had re-operation following primary repair were evaluated in more detail, in particularly to identify the predisposing factors of recurrence. Diagnosed cases of recurrent inguinal hernia were selected for data entry of analysis, to assess the frequency. All patients operated by lichenstien tension free hernioplasty by single surgeon. Data was fed in computer with software SPSS (SPSS Version 11) for windows and results are plotted in the form of frequencies of different variables.
Following results were obtained from one year study period (5th July 2006 to 4th July 2008) in the Department of Surgery at Liaquat University Hospital Jamshoro/Hyderabad, Sindh, Pakistan. Table 1 shows that the highest incidence was seen among 41-50 years i.e. 27 patients (43.5%). During the course of this study, 51 patients i.e. (82.2%) were found to be ambulatory workers i.e. farmers, Manual labors. On the other hand, two patient (3.2.%) was an Athlete Table 2.
Majority of the patient's i.e. 43 (69.3%) were chronic smokers. 38 patients (61.2%) had history of chronic constipation. Furthermore, 30 (48.3%) of subjects had chronic cough. 30.6% of patients had recurrence who were obese and some 12 (19.3%) patients had associated prostatic disease. 4 patients (6.45%) who had cardiac disease had also recurrent inguinal hernia on which surgery was only performed after getting anesthetic and cardiac fitness None of the patient had ascites, previous sepsis and intra abdominal mass in this study
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Majority of patients had reported a lump in the inguinoscrotal region i.e. 50 (100%), however, few of them had dragging type of pain in the inguinal region or abdomen i.e.16 (32.0%) Table 3
In 47 cases (75.8%) the recurrence was on right side, whilst 15 (24.1%) had on the left side. First time recurrence was seen in 54 patients (87.0%) and, second time recurrence was seen in 7 patients (11.2%); moreover, third time recurrence was seen only in 1 subject. All of these patients had an initial open surgery without mesh beside one.
Recurrent inguinal hernia was noted within one year in 1 patient. By five years in 8 (12.9%) patients and in 19 (30.6%) patients after 8 years. 32 (51.6%) patients had developed recurrence after ten years. However, in 2 (3.2%) patients, the recurrence of a hernia was noted after 18 years.
All of these patients had an initial open surgery without mesh, except one. In this series, Bassini's repair was carried out in 47 (75.8%) cases while 11 (17.7%) patients had no previous medical records. Darning repair was done in 3 patients (4.8%) and open surgery with mesh was done in only one patient with 53 (85.4%) being indirect and remaining 9 patients (14.5%) had direct type of inguinal hernia.
All of these patients had an initial open surgery without mesh, except one. In this series, Bassini's repair was carried out in 47 (75.8%) cases while 11 (17.7%) patients had no previous medical records. Darning repair was done in 3 patients (4.8%) and open surgery with mesh was done in only one patient
Due to lack of availability of previous records 11 (17.7%) patients had no data available for previous surgeries; while, 47 (75.8%) patients had previous bassini's repair performed and 03 (4.8%) had darning repair; All these patients had an initial open surgery without mesh. only 1 patient was subjected to recurrence after mesh repair.
In this series, highest recurrence rate was seen in hernia repairs done by the postgraduate trainees i.e. 45 (72.5%), compared to 11 (17.7%) and 6 (9.6%) cases done by registrars and consultants respectively. This study included 62 patients with recurrent inguinal hernias all of them were repaired by Lichtenstein tension-free mesh repair.
Three postoperative complications were observed i.e. retention of urine (40.3%); mainly because almost all of the patients were operated under spinal anesthesia; scrotal hematoma (6.4%); and wound infection (3.2%). There were no major intraoperative complications.
Spinal anaesthesia was used in 59 patients (95.1%) and general anaesthesia in 3 patients (4.8%).
The average hospital stay in the post operative period was 3-8 days in respect of 58 patients whereas 3 patients remained admitted for 9-12 days. 1 Patients who had infection took longer period of 13-17 days to return to his usual work as compared to other counterparts.
TABLE 1 - AGE DISTRIBUTION PATIENTS WITH RECURRENT INGUINAL HERNIA
NO: OF PATIENTS
21 - 30
31 - 40
41 - 50
51 - 60
61 - 70
71 - 80
TABLE- 2 OCCUPATIONS OF PATIENTS
NO: OF PATIENTS
TABLE - 3
CLINICAL PRESENTATION OF PATIENTS WITH RECURRENT INGUINAL HERNIA
NO. OF PATIENTS
The incidence of recurrent hernias is not known with certainty largely because of the need for careful and prolonged follow-up.23 There are discordant results reported in the literature (0-30%)24, with the rates in a series of patients operated went on varying between 10 and 15%.25 Recurrences are more frequent after treatment of primary rather than recurrent hernias, while they are less frequent after prosthetic reinforcement, as compared to conventional open surgery without mesh. After the introduction of tension-free surgical repair with use of prosthetic mesh, recurrence and patient comfort improved substantially as compared with use of traditional, tension-producing techniques.7 There is no consensus on the management of recurrent hernias, which lead to significant loss of activity and monetary loss. One hundred and forty thousand hernias are operated every year in France and 700,000 in the USA.26 This corresponds to approximately 20,000 and 100,000 recurrent hernias, respectively. From the patient's perspective, the prevention of recurrence is the most important factor in relation to an early return to work.27
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Although excellent results have been reported regarding inguinal hernia surgery, the fact remains that hernia repair is not always successful. The increasing use of mesh for the repair has not solved this problem. The National Hernia Register of Sweden has shown that the rate of operations for recurrence has not fallen below 16-17%, despite the use of mesh repairs.28 Moreover, if we include patients with asymptomatic recurrence or those who simply do not want to be operated on again, the real recurrence rate could be much higher.
Laparoscopic hernia repair is a new alternative to conventional treatment for recurrent hernia. Reports in the literature point out three main advantages: reduction of postoperative pain and disability; mesh placement in preperitoneal space where the hernia is produced; and avoidance of the need to re-operate through scar tissue with the risk of testicular damage and the higher morbidity described for open recurrent hernia repair. Furthermore, unexpected contralateral hernias can be repaired simultaneously.29-31
Constance E.Ruhl32 and James E. Everhart found cumulative incidence of recurrent inguinal hernia amongst men increased with baseline age: 7.3% at age 24-39 years, 14.8% at age 40-59 years and 22.8% at age 60-74 years however, in my study most of the cases of recurrent inguinal hernia were between 41-50 years i.e. (43.5%) in a range of 21-80 years. Also second peak incidence was noted in ages between 61 - 70 years i.e. 19.3%.
Epidemiological studies33 have documented that recurrence highly seen in hard workers and Athletes i.e. 45 - 55%, however in comparasion to above, in this study, 51 out of 62 were ambulatory workers i.e.82.2%. Only two patients were athletes.
E.M. Balen34 has reported the most common risk factors for recurrent inguinal hernia were cirrhosis, diabetes, COPD and asthma; however, in this study, the majority of the patient's i.e. 43 (69.3%) were chronic smokers and 38 patients (61.2%) had chronic constipation; furthermore, 30 (48.3%) of subjects had chronic cough. 30.6% of patients had recurrence who were obese and some 12 (19.3%) of patients who had associated prostatic disease. Among 4 (6.45%) of the patients who had cardiac disease also had recurrent inguinal hernia surgery, which was only performed after getting anesthetic and cardiac fitness None of the patient had ascites, previous sepsis and intra abdominal mass.
Study conducted in Netherlands35 amongst patients with recurrent inguinal hernia has shown that 15 patients out of 336 (4%) had reported a lump in the repaired area and at physical examination 8 of the 15 patients (53%) were diagnosed to be having recurrence; However, in this study 62 patients (100%) had complain of lump in the groin and few were having associated dragging type of pain in the inguinal region i.e. (37.0).
K. Junge36 in his study of 293 patients has observed that 97 hernias (56.7%) were located on the right side, 74 (43.3%) on the left side. Peter Sandbichler37 in his study observed that out of the total hernias, 184 were unilateral and 16 were bilateral. In 112 cases (56%) the recurrence was medial, in 75 lateral (37.5%), and in 7 cases both (3.5%). Comparing to the above studies, this study also speaks of right side involvement in 47 patients i.e. 75.8% and in 15 patients i.e. 24.1% had left side involvement.
John E. Morrison38 has reviewed in his case series of 108 patients that 11 patients had recurrent hernias in which 6 were direct and 5 were indirect. However in my study 53 patients (85.4%) had direct and only 9 patients (14.5%) had indirect type of involvement.
S. K. Richards39 in his study of review of management of recurrent inguinal hernia had mentioned different surgical technique performed in primary hernia repair i.e Nylon darn 31%, Herniotomy 18%, Open mesh18%, Laparoscopic (TAPP) repair 8%, Bassini's and others 7%, Unknown 18% while in this study due to lack of availability of previous operative records 11 patients i.e. (17.7%) had no data available for previous mode of surgeries; although, 47 patients i.e. (75.8%) had previous bassini's repair performed, 03 (4.8%) had darning repair . All these patients had an initial open surgery without mesh. only 1 patient was subjected to recurrence after mesh repair.
Harjai MM40 had conducted a prospective study on the patients reporting to Command Hospital (Southern Command) Pune for inguinal hernia. A total of 196 patients were included in the study and operated upon for over a period of 24 months and had shown that recurrence rate in cases operated by junior surgeons is known to be higher than that of the consultants.41 Similarly, in this study, high recurrence rate was seen in surgeries being done by the postgraduate trainees i.e. 45 (72.5%), and the recurrence rate in cases operated by registrar were 17.7% i.e. 11 patients which is Known to be higher than that of the consultants i.e. 6 patients (9.6%) majority of recurrences seen in patients who were operated by junior surgeons.
SK Richards & JJ Earnshaw42 in their study have described that the majority (86%) of the surgeons 95% used open mesh repair as standard for primary inguinal hernia. Only 8% used laparoscopic repair routinely for primary hernias. Few consultants (only 28%) were able to quote formally audited hernia recurrence rates. A total of 90% of respondents still employed open mesh repair routinely for recurrent hernias; however, if mesh had been used for the primary repair, this figure fell to 55%. Some 7% of respondents recommended laparoscopic repair for recurrent hernia, but this increased to 17% if the primary repair was done with mesh. Similarly, in this descriptive study we had also preferred mesh repair is the method of choice for recurrent inguinal hernia surgery.
Jon S. Thompson43 had recently reported postoperative complications i.e. the rate of complications within 30 days of surgery was similar for those in the immediate- and delayed-repair groups. In the entire cohort of patients, three intraoperative complications were reported (8%), a wound hematoma which required returning the patient to the operating room; post-anaesthetic hypertension; and an ilioinguinal nerve injury. Postoperative complications were reported in 63 patients (17.9%). One life-threatening complication, deep venous thrombosis, occurred within 30 days. While, in this study most common post operative complication was retention of urine (40.3%) mainly because almost all of the patients were operated under spinal anesthesia; however, scrotal hematoma was seen in (6.4%); and wound infection in (3.2%).
Xavier Feliu44 had reported regarding anaesthesia for inguinal hernia surgery i.e. General anaesthesia was indicated in ASA I-II patients in the laparoscopic group. ASA III patients and subjects who refused this procedure underwent spinal anaesthesia. Open repair patients underwent spinal anesthesia except those who preferred general anaesthesia. In my study most of the operations in series of patients were done under spinal anaesthesia, only 3 patients who had presented with strangulated hernia were operated under general anaesthesia.
Ezio Gianetta45 described a 7-year experience with recurrent inguinal hernia repair and reported mean hospital stay after surgery was 1.5 days (range 3 hours - 14 days). Thirty-five patients were discharged on the day of surgery and 66 after a day after and there were no perioperative deaths. While, in this series the maximum duration of stay was 3-8 days.
Bringman S46 reported two postoperative deaths in his series, and none of them was related to the surgery. On the other hand, Eklund A47 reported no perioperative or postoperative deaths. Similarly in this study no perioperative or postoperative deaths occurred.
Barrier A48 evaluate the time interval between initial inguinal hernia repair and the appearance of recurrent hernia. In his study recurrence appeared within two years in 40 patients (42%), five years in 32 patients (34%), and 20 years in 18 patients (19%). However, in this study recurrence was noted within one year in 1 (1.6%) patient, five years in 8 (12.9%) patients and after 8 years in 19 (30.6%) patients and 32 (51.6%) patients had developed recurrence after ten years and in 2 (3.2%) patients, the recurrence was noted after 18 years.
Recurrent inguinal hernia is still frequently observed today, although the frequency has gone down due to use of mesh in primary hernia repair. The Lichtenstein tension-free repair has gained great acceptance worldwide, because it is easy to teach and learn, has a low recurrence rate and morbidity and is cost-effective. Hence, Lichtenstein tension-free repair is currently considered the procedure of choice for inguinal hernia surgery.