Surgery is the treatment of choice varying from a nylon darn, Shouldice layered,

Lichtenstein mesh to a laparoscopic repair. The optimal repair has been assessed by
randomised clinical trials and population based studies.1

A meta-analysis from the EU Hernia Trialists Collaboration compared mesh with

sutured techniques from 58 trials comprising in total 11 174 patients. Individual patient data
were available for 6901 patients. Recurrence was less common after mesh repair (odds ratio
0.43 (95% confidence interval 0.34 to 0.55)). A population based study examining risk of
recurrence five years or more after primary mesh (Lichtenstein repair) and sutured inguinal
hernia repair in 13 674 patients found that recurrence after mesh repair was a quarter of that
after sutured repair (hazard ratio 0.25 (0.16 to 0.40)).2

Open mesh repair is reproducible by non-specialist surgeons, and hence open repair is
the preferred repair technique for primary inguinal hernia by 96% of UK surgeons, 99% of
Japanese surgeons, 95% of Danish surgeons, and 86% of US surgeons. Systematic review
and meta-analysis of randomised clinical trials have found that, compared with open repair,
laparoscopic surgery for hernia is associated with longer operation times but less severe
postoperative pain, fewer complications, and a more rapid return to normal activities.
Laparoscopic surgery is associated with higher recurrence rates during the learning curve but
causes less chronic pain and numbness when assessed by questionnaire up to five years after
operation. The National Institute for Health and Clinical Excellence (NICE) recently
recommended laparoscopic surgery as a treatment option for inguinal hernia and said that
patients should be fully informed of the risks and benefits of open and laparoscopic surgery
to enable them to choose between procedures.1

1. Jenkins JT, O’Dwyer PJ. Clinical review: Inguinal hernias. BMJ. 2008; 336(7638): 269–
72.

2. Bisgaard T, Bay-Nielsen M, Christensen IJ, Kehlet H. Risk of recurrence 5 years or more

after primary Lichtenstein mesh and sutured inguinal hernia repair. Br J Surg 2007;94:1038-
40
 The proportion of bilateral inguinal hernias identified using diagnostic laparoscopy is
28.5 % [1]. For bilateral inguinal hernia, all guidelines of the international surgical societies
recommend laparoscopic/endoscopic repair in TAPP or TEP technique [2–5]. A Swiss
registry study compared 3457 unilateral with 3048 bilateral inguinal hernia repairs using total
extraperitoneal patch plasty (TEP) technique [6]. The authors identified an intraoperative
complication rate of 1.9 % for unilateral and 3.1 % for bilateral TEP (p = 0.002). Likewise,
the postoperative complications for unilateral TEP at 2.3 % and for bilateral TEP at 3.2 %
were significantly different (p = 0.026). Therefore, as before, in compliance with the
guidelines [2–5] bilateral inguinal hernia should preferably be repaired using an
endoscopic/laparoscopic technique.

1. Wauschkuhn CA, Schwarz J, Boekeler U, Bittner R (2010) Laparoscopic inguinal hernia

repair: gold standard in bilateral hernia repair? Results of more than 2800 patients in
comparison to literature. Surg Endosc 24:3026–3030
2. Simons MP, et al (2009) European Hernia Society guidelines on the treatment of inguinal
hernia in adult patients. Hernia 13:343–403
3. Bittner R, et al (2011) Guidelines for laparoscopic (TAPP) and endoscopic (TEP)
treatment of inguinal Hernia [International Endohernia Society (IEHS)]. Surg Endosc
25:2773–2843
4. Poelman MM, et al (2013) EAES Consensus Development Conference on endoscopic
repair of groin hernias. Surg Endosc 27:3505–3519
5. Sanders D, et al (2013) The Royal College of Surgeons of England; Commissioning Guide:
Groin hernia 1–17
6. Gass M, Rosella L, Banz V, Candinas D, Gu¨ller U (2012) Bilateral total extraperitoneal
inguinal hernia repair (TEP) has outcomes similar to those for unilateral TEP: population-
based analysis of prospective data of 6,505 patients. Surg Endosc 26:1364–1368