Inguinal hernia repair is one of the most commonly performed general surgery procedures [1, 2]. Despite its prevalence, there is no consensus regarding the optimal approach to inguinal hernia repair [2]. With an estimated recurrence rate of 0.2% to 17%, there is no doubt that recurrent inguinal hernias have a significant impact on the global healthcare system and that a durable, primary repair is ideal [3, 4]. A thorough preoperative patient evaluation, inspection of all potential locations of a groin hernia, and meticulous surgical technique all contribute to primary repair success. Nevertheless, recurrent hernias do occur and a general knowledge of the causes for a failed primary repair and surgical approach to recurrent hernias is essential. In this chapter, we will discuss the risk factors associated with inguinal hernia recurrence and the operative approach to recurrent inguinal hernia repair.

There are several patient and operative characteristics that increase the risk of inguinal hernia recurrence. Patient factors include malnutrition, immunosuppression, obesity, diabetes mellitus, and smoking, all of which negatively impact the wound healing process [5]. Significant time should be spent during the preoperative evaluation at minimizing or resolving these patient factors. One method that has been successful in improving preoperative optimization at our institution is engaging patients in addressing their high-risk factors. Previous studies have shown that inguinal hernia recurrence is the most important long-term outcome and measure of success from a patient’s perspective [6, 7]. Therefore, instilling a sense of self-responsibility in patients to their surgical outcome often leads to increased motivation to achieve preoperative goals.

Despite the fact that a majority of first-time and recurrent groin hernias are asymptomatic at presentation, the long-term teaching has been to repair these hernias due to the perceived risk of associated bowel obstruction and/or strangulation [11, 12]. Further studies are needed to determine the ideal approach to asymptomatic recurrent groin hernias. Nevertheless, we do recommend surgical repair of all symptomatic recurrent inguinal hernias to prevent worsening of patient symptoms and to avoid the associated risk of emergency surgery should these hernias progress to bowel involvement.

The European Hernia Society’s (EHS) recommendation for repair of recurrent inguinal hernias is to “modify technique in relation to previous technique” [1]. Although this may seem oversimplified, approaching a recurrent inguinal hernia in a different surgical plane than the original operation leads to the best chance of repair success. The reason for this is twofold. First, surgery in a previously operated field is distorted with scar tissue. Scar tissue complicates the dissection in the inguinal canal and increases the risk for adverse outcomes such as testicular ischemia in a male patient or missing the recurrent hernia sac [3]. Second, the tissue in a healed wound is always weaker than virgin tissue. This increases the risk for recurrence with each subsequent inguinal hernia repair [3]. Therefore, review of prior operative reports requires scrutiny in an effort to avoid previous operative fields during recurrent inguinal hernia repair whenever possible.

In concert with the EHS, our recommendation for approaching recurrent inguinal hernias can be broadly categorized based on the prior failed surgical approach. Patients with a prior anterior repair (i.e., tissue repair or Lichtenstein repair) should have a posterior approach for repair of their inguinal hernia recurrence. Similarly, patients with a failed posterior approach (i.e., laparoscopic repair or Kugel repair) require an anterior repair for inguinal hernia recurrence. Finally, patients who underwent initial inguinal hernia repair in a bilaminar fashion with mesh in both the anterior and posterior compartments (i.e., Prolene Hernia System repair or plug-and-patch repair) should undergo repair of their inguinal hernia recurrence with an approach that the operating surgeon has most experience with.