Recurrent Hernias

An estimated 25% of all hernia recurrences present within a year of the hernia repair. Another
25% will become evident by the fifth postoperative year. The remaining 50% of recurrences
occur more than 5 years after the surgical repair.[37]

The treatment for recurrent hernias is surgical correction. Generally, this can be done
electively, except in cases of acute incarceration or suspected strangulation. Typically,
recurrent hernias are best repaired with regional anesthesia so that the patient can cooperate
during the procedure to identify additional defects or those that may be encased in the scar
tissue.

An understanding of the causes of failed hernia repairs is essential for successful second
repairs. Before mesh repairs, the most common recurrent hernias were those located just
above the pubic tubercle (Gilbert-type 5). Since the widespread use of anterior onlay mesh
repairs and plugs, recurrences occur more commonly around the internal ring, and lateral to it
(Gilbert-types 2 and 3, and interstitial). Where plugs alone are used for primary repairs,
recurrences present both medially and laterally to the plug. Failures after sutured onlay graft
repairs usually relate to using a graft that is too small or short-changing the tails of the graft
around the spermatic cord. When the onlay graft is used in a sutureless manner, recurrences
frequently appear at the pubic tubercle by lifting the graft at its medial angle.

Case 2. A 68-year-old patient presented with a recurrent left inguinal hernia. Three years
before he had a mesh repair of a type 4 hernia. The earlier repair utilized a polypropylene
underlay graft placed beneath a 2-layer Shouldice repair. The patient's current presentation
was a recurrent type 2 extra tunica inguinal hernia. It presented lateral to the deep epigastric
vessels, yet it was not contained within the internal spermatic fascia.
Recognizing that the recurrent hernia had formed because of the added strength in the medial
canal, it was deemed necessary to reinforce the medial triangle. To accomplish this, a
polypropylene bilayer single piece connected device was used. It was inserted through the
defect in the lateral triangle. The medial portion of the underlay component was actually
placed beneath the existing polypropylene mesh graft while laterally it protected the posterior
surface of the lateral triangle and the femoral triangle. The onlay graft extended almost to the
anterior superior spine also protecting the lateral triangle with an anterior repair. The patient's
recovery was uneventful and his hernia repair has remained intact.

Recurrent hernias vary in size, shape and degree of challenge. Factors that determine results
include the operative approach, type of anesthesia used, and the surgeon's experience and
skill in dealing with recurrent hernias. Other factors that contribute to the outcome of
recurrent herniorrhaphies are the patient's weight and medical comorbidities.

The diagnosis of a recurrent hernia is usually simple, although in some patients, especially
with obese individuals, diagnosis may present a greater challenge. The causes of recurrent
inguinal hernias, especially those that appear in the first postoperative year, are usually due to
errors of observation, judgment, or surgical technique. Less frequently, repairs fail due to
metabolic problems of the tissues in the groin, or from infection that destroys the repair.
A major cause of recurrent indirect hernias, and to a lesser degree direct hernias, is the failure
of the surgeon to appreciate the presence of a double hernia when only one is obvious.
Whether the surgeon finds a hernia and overlooks another, or whether the surgeon overlooks
the only hernia present, is moot. When a recurrent indirect hernia is found within the internal
spermatic fascia following any repair other than a Halsted procedure, it is likely that the
patent processus or frank indirect sac was missed. This does not mean that the indirect
component had been clinically significant before the first operation; rather, the basis for a
recurrence, a patent processus vaginalis projecting through the internal ring, was present and
probably overlooked. The reason for its development is widening of the internal ring
following the initial operation. If a Halsted repair had been done, a recurrent indirect hernia is
not uncommon, because the external wall formed by the external oblique, and the step-down
protection created by separating the internal and external rings, had been sacrificed.

Incomplete dissection of the peritoneal sac from the threshold of the internal ring is a
frequent source of indirect recurrence. (Sidebar: Management of the Peritoneal Sac of an
Indirect Hernia) The true neck of the sac must be freed and invaginated behind the threshold
of the internal ring, if completeness of the repair is expected[14] (Figure 35). When an
appropriately high dissection of the sac is done, the vas deferens is usually the most posterior
structure of the cord, and the last to come off the peritoneal sac. The investing fibers of the
transversalis fascia must also be dissected free from the neck of the sac to properly free it at
the internal ring. For the indirect hernia to be repaired, from either the anterior or posterior
approach, the threshold of the internal ring must be cleared of the peritoneal sac.
Figure 35. The true neck of the sac is at the level of the deep epigastric vessels.

Leaving an amputated sac open may also cause recurrence of an indirect hernia. When the sac
has been divided or amputated, its proximal pedicle should be ligated and reduced deep to the
threshold of the internal ring.[34] Improper closure of the internal ring in what appeared to be a
simple indirect hernia often results in failure. In the Marcy procedure, when the internal ring
is repaired, it often creates an abnormal fixed point in the vulnerable posterior wall.
Continued pressure exerted medial and lateral to that simple ring closure is sufficient to cause
a weakened posterior wall to herniate.

The Shouldice technique recognizes the need to spread the forces of intra-abdominal pressure
more equally throughout the entire posterior wall and requires that the entire posterior wall be
equally reinforced whenever it has been opened. Damage to the posterior wall may occur
while repairing a hernia or when attempting to reinforce it against a subsequent direct hernia.
If the patient has only an indirect hernia and the posterior wall is intact, it is preferable do
nothing to the posterior wall, rather than to try to shore it up with a suturing technique as in a
modified Bassini repair. Application of prosthetic mesh in a tension-free method is acceptable
and, in fact, preferable, although suturing techniques alone can be destructive as they impart
suture line tension.

Sidebar: Management of the Peritoneal Sac of an Indirect Hernia

The classic herniorrhaphists describe the need for a high dissection and high ligation of the
peritoneal sac in the iliac fossa. The threshold of the internal ring must be freed of peritoneal
sac. This can be accomplished with a full dissection and invagination of the sac, or in cases of
complete hernia, the sac within the tunica can be divided and the proximal portion ligated and
invaginated on the abdominal side of the internal inguinal ring.

Division and ligation if the sac is associated with some degree of local peritonitis and can
contribute to increased postoperative discomfort. The critical issue is to dissect the sac high
enough to free it from surrounding tissues of the spermatic cord and to free it from the
investing fibers of the transversalis fascia. The true neck of the sac reaches to the level of the
deep epigastric vessels. Leaving the sac open has been shown to result in a high rate of
recurrent indirect inguinal hernias.