Meta-analysis

Meta-analysis of randomized controlled trials comparing

laparoscopic with open mesh repair of recurrent inguinal hernia
A. Karthikesalingam1 , S. R. Markar2 , P. J. E. Holt1 and R. K. Praseedom2
1
Department of Outcomes Research, St George’s Vascular Institute, London, and 2 Department of Surgery, Cambridge University Hospitals NHS
Foundation Trust, Cambridge, UK
Correspondence to: Mr A. Karthikesalingam, St George’s Vascular Institute, Fourth Floor, St James Wing, St George’s Healthcare NHS Trust, Blackshaw
Road, London SW17 0QT, UK (e-mail: alankarthi@googlemail.com)

Background: Although there is plentiful evidence regarding the use of laparoscopic surgery for primary
inguinal hernia, there is a paucity of literature concerning its role after recurrence. There has been no
quantitative review of the evidence, despite suggestions that pooled analysis of existing data is required.
Methods: Medline, Embase, trial registries, conference proceedings and reference lists were searched
for controlled trials of laparoscopic versus conventional open surgery for mesh repair of recurrent hernia.
The primary outcomes were recurrence and chronic pain. Secondary outcomes were operating time,
visual analogue pain score, superficial wound infection, haematoma or seroma formation, time to return
to normal activities and serious complications requiring operation. Pooled odds ratios were calculated
for categorical outcomes and weighted mean differences for continuous outcomes.
Results: Four trials were included in the analysis. There was no effect on recurrence or chronic pain.
Laparoscopic surgery was associated with significantly less postoperative pain, a quicker return to normal
activities and fewer wound infections, at the cost of a longer operating time. There was no difference in
haematoma formation or the need for additional operations.
Conclusion: Careful patient selection and surgeons’ experience are important in the selection of
technique for recurrent inguinal hernia repair.

Paper accepted 8 October 2009

Published online in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.6902

Introduction in primary disease, few controlled studies have compared

Hernia repair is one of the commonest procedures
performed by general surgeons; indeed, it has been stated
that ‘the history of hernia repair is the history of surgery’1 .
Inguinal hernias affect 0·14 per cent of the population
and account for 70 000 operations per year in the UK2 .
The advent of laparoscopy has revolutionized abdominal
surgery and a large body of evidence has been amassed to
compare laparoscopic and open techniques in the repair
of primary inguinal hernias3 . Advantages of laparoscopic
procedures may include a reduction in postoperative
pain and hospital stay, and the ability to undertake a
simultaneous repair of symptomatic incipient contralateral
herniation. However, open repair can be performed under
local anaesthesia and is preferred by many surgeons.
The repair of recurrent inguinal hernia is a more
complex undertaking, accounting for up to 15 per cent
of all hernia surgery4 . Although there is plentiful evidence
outcome of laparoscopic surgery with that of open tension-
free mesh repair for recurrent inguinal hernia. There
has hitherto been no meta-analysis of results, despite
suggestions that a pooled analysis of these individually
small trials is required5 to eliminate any type II error.
Methods
An electronic search was performed using the Embase
and Medline databases from 1966 to 2009. The search
terms ‘hernia’, ‘recurrent’, ‘laparoscopic’, ‘TAPP’, ‘TEP’,
‘Lichtenstein’ and MeSH headings ‘Laparoscopy’ (MeSH),
‘Hernia, Inguinal’ (MeSH) were used in combination
with the Boolean operators AND or OR. Two authors
independently performed electronic searches in July 2009.
The electronic search was supplemented by a handsearch
of published abstracts from meetings of the Surgical
Research Society, the Society of Academic and Research

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Published by John Wiley & Sons Ltd
Laparoscopic versus open mesh repair of recurrent inguinal hernia
Surgery, the Association of Surgeons of Great Britain and
Ireland, the European Hernia Society, the Asia Pacific
Hernia Society and the American Hernia Society from
1980 to 2009. The reference lists of articles obtained
were also searched to identify further relevant citations.
Finally, the search included the Current Controlled
Trials Register (http://www.controlled-trials.com) and the
Cochrane Database of Controlled Trials.
Abstracts of the citations identified by the search were
then scrutinized by two of the authors (A.K. and S.R.M.)
to determine eligibility for inclusion in the meta-analysis.
Studies were included if they were controlled trials in which
patients underwent either laparoscopic or tension-free
open mesh repair of recurrent inguinal hernia. Previous
studies have shown there to be no significant difference in
outcomes between giant prosthesis for reinforcement of the
visceral sac (GPRVS) and Lichtenstein or transabdominal
preperitoneal (TAPP) and totally extraperitoneal (TEP)
operations when performed for recurrent or bilateral
hernias6,7 . These techniques were therefore pooled into
composite ‘tension-free open mesh repair’ and ‘tension-
free laparoscopic mesh repair’ groups for analysis.
The primary outcome measures for the meta-analysis
were postoperative hernia recurrence and the development
of chronic pain. Chronic pain was defined as ‘severe
chronic pain’8 after at least 1 year9,10 . Secondary outcome
measures were operating time, mean linear pain score
on a visual analogue scale (VAS) during the first 7 days
after surgery8,9 , superficial wound infection, haematoma or
seroma formation, time to return to normal activities, and
the incidence of complications requiring further surgery.
This final composite outcome measure was defined as
the need for additional operations during or after the
hernia repair to treat complications. Superficial wound
infections were defined as those treated without further
surgery and were identified by clinical examination without
microbiological confirmation5,8 – 10 . Haematoma or seroma
formation was identified by clinical examination alone
before discharge from hospital, without the requirement
for radiological confirmation8,10 . The time to return to
normal activity was defined as the time taken for patients
to return to work after surgery; all patients were encouraged
to return to work as soon as possible, irrespective of their
job or the operative technique employed5,8 – 10 .
Statistical analysis
Data from eligible trials were entered into a computer-
ized spreadsheet for analysis. The quality of each trial
was assessed using the Jadad scoring system11 . Statistical
analysis was performed using StatsDirect 2.5.7 (StatsDi-
rect, Altrincham, UK). Weighted mean difference was
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Published by John Wiley & Sons Ltd
5
calculated for the effect size of laparoscopic surgery on
continuous variables such as operating time, postoperative
pain VAS and time to return to normal activity. Pooled odds
ratios were calculated for the effect of laparoscopic surgery
on discrete variables such as postoperative wound infec-
tion, haematoma or seroma, recurrence and development
of chronic pain.
All pooled outcome measures were determined using
random-effects models as described by DerSimonian and
Laird12 . Heterogeneity among the trials was assessed by
means of the I 2 inconsistency test and Cochran’s Q statistic,
a null hypothesis test in which P < 0·050 is taken to indicate
the presence of significant heterogeneity. The Egger test
was used to assess the funnel plot for significant asymmetry,
indicating possible publication or other biases.
Results
The initial search identified 728 publications (Fig. 1). After
screening, six prospective trials were identified5,8 – 10,13,14 .
One study compared laparoscopic and open surgery in the
repair of a composite group of bilateral and recurrent
inguinal hernias13 . It was not possible to obtain data
for the recurrent hernia group in isolation by contacting
the study authors and so this trial was excluded from
pooled meta-analysis. One study did not randomize trial
participants between operative techniques14 . Sensitivity
analysis by removing this trial revealed its significant effect
on pooled operating times (Fig. 2). Therefore, this trial
was also excluded from the final meta-analysis. One study
randomized two cohorts separately to TAPP or TEP
laparoscopic surgery5 , and both were pooled separately
for analysis. Surgical techniques in the ‘tension-free open
mesh repair’ group included both GPRVS and Lichtenstein
operations. The ‘tension-free laparoscopic mesh repair’
group included both TAPP and TEP operations (Table 1).
Primary outcome measures
Recurrence
All four trials reported hernia recurrence5,8 – 10 after repair
of recurrent inguinal hernia and there was no significant
difference between laparoscopic and open groups (pooled
odds ratio 0·84 (95 per cent confidence interval (c.i.) 0·33
to 2·17); P = 0·724) (Fig. 3). There was no significant
statistical heterogeneity (Cochran’s Q = 6·27, P = 0·180;
I 2 = 0·36 (95 per cent c.i. 0·00 to 0·76)) or bias (Egger
test = −0·51, P = 0·701).
Chronic pain
There was no significant effect of laparoscopic surgery
on development of chronic pain (more than 1 year after
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6 A. Karthikesalingam, S. R. Markar, P. J. E. Holt and R. K. Praseedom

Potentially relevant studies identified

and screened for retrieval
n = 728

Studies excluded n = 722

Studies not comparing open and
laparoscopic repair of recurrent
inguinal hernia

RCTs retrieved for more detailed

evaluation
n=6
RCTs excluded n = 1
Compared laparoscopic and open
techniques in a mixed population
of both recurrent and bilateral
hernia. Raw data for recurrent
hernia only not available
Potentially appropriate RCTs to be
included in the meta-analysis
n=5

RCTs excluded from meta-analysis n = 0

RCTs included in meta-analysis

RCTs withdrawn, by outcome n = 1
n=5
Trial not randomized. Sensitivity
analysis revealed that inclusion of this
trial significantly changed pooled
analysis of operating times. This non-
randomized trial was removed to
improve the quality of the final meta-
RCTs with usable information, by
analysis
outcome
n=4

Fig. 1 QUOROM diagram for review. RCT, randomized controlled trial

Table 1 Characteristics of trials included in final meta-analysis

Beets et al.8 1999 Dedemadi et al.5 2006 Eklund et al.9 2007 Kouhia et al.10 2009

No. of patients 79 82 147 96

Study design RCT RCT Multicentre RCT RCT
Jadad score 2 2 3 2
Pain scoring VAS and VRS Pain score at rest VAS —
system
Intraoperative General General General 117 General 50
anaesthesia Spinal 21 Spinal 46
Epidural 9
Postoperative Paracetamol 1 g TDS (as Paracetamol Paracetamol 325 mg + Opioid + other unspecified
anaesthesia needed) dextropropoxyphene analgesic
32·5 mg
Operative Open: GPRVS 37 Open: Lichtenstein 32 Open: Lichtenstein 74 Open: Lichtenstein 47
technique Lap: TAPP 42 Lap: TAPP 24, TEP 26 Lap: TAPP 73 Lap: TEP 49
Mean(s.d.) length 34 (6–50) months† 1087(588) days 5 years 5·3(3·6) years
of follow-up*

*Values are mean(s.d.) unless indicated otherwise; †mean (range). RCT, randomized controlled trial; VAS, visual analogue scale; VRS, verbal rating scale;
TDS, three times daily; GPRVS, giant prosthesis for reinforcement of the visceral sac; Lap, laparoscopic; TAPP, transabdominal preperitoneal; TEP,
totally extraperitoneal.

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Laparoscopic versus open mesh repair of recurrent inguinal hernia 7

Beets et al.8 (Fig. 4). There was no significant statistical heterogeneity

(Cochran’s Q = 4·52, P = 0·104; I 2 = 0·56 (95 per cent
Feliu et al.14
c.i. 0·00 to 0·86)). Too few trials provided data to allow
Dedemadi et al.5 − TAPP calculation of statistical bias.
Dedemadi et al.5 − TEP

Eklund et al.9 Secondary outcome measures

10
Kouhia et al.
Postoperative pain scores
Pooled effect size Two trials contained data regarding postoperative pain
−2 −1 0 1 2 scores measured on a VAS in the first 7 days after
Favours open surgery surgery8,9 . Laparoscopic surgery was associated with a
a Including Feliu et al.14 trial significant reduction in pain VAS (weighted mean differ-
ence −0·58 (95 per cent c.i. −0·84 to −0·31); P < 0·001)
Beets et al.8 (Fig. 5). There was no evidence of significant heterogeneity
Dedemadi et al.5 − TAPP
(Cochran’s Q = 0·52, P = 0·471). There were too few data
to allow calculation of the I 2 value for heterogeneity or to
Dedemadi et al.5 − TEP apply the Egger test to evaluate statistical bias.
Eklund et al.9
Superficial wound infection
Kouhia et al.10 All four trials reported superficial wound infection treated
Pooled effect size by antibiotics5,8 – 10 . Laparoscopic surgery was associated
with significantly fewer superficial wound infections than
−0·5 0 0·5 1·0 1·5 2·0
Favours open surgery
open surgery in pooled analysis (pooled odds ratio 0·29
b Excluding Feliu et al.14 trial (95 per cent c.i. 0·08 to 0·96); P = 0·043) (Fig. 6). There
was no statistical evidence of heterogeneity (Cochran
Fig. 2Sensitivity analysis illustrating the influential effect of the Q = 0·96, P = 0·916; I 2 = 0·00 (95 per cent c.i. 0·00 to
non-randomized trial by Feliu and colleagues14 . a Initial forest 0·64)) or bias (Egger test = −0·14, P = 0·936).
plot of weighted mean difference in operating times between
laparoscopic and open surgery before this trial was removed. b
Operating time
Forest plot showing final analysis of weighted mean difference in
All included trials reported length of operation5,8 – 10 .
operating times between laparoscopic and open tension-free
mesh repair of recurrent inguinal hernia incorporating only Laparoscopic surgery took significantly longer than
randomized controlled trials. Weighted mean differences are the open procedure (weighted mean difference 0·68
shown with 95 per cent confidence intervals (95 per cent c.i. 0·23 to 1·13) min; P = 0·003) (Fig. 2b).
However, there was evidence of significant statistical
surgery), which was reported by three trials8 – 10 (pooled heterogeneity (Cochran’s Q = 20·07, P < 0·001; I 2 =
odds ratio 0·91 (95 per cent c.i. 0·14 to 5·88); P = 0·921) 0·80 (95 per cent c.i. 0·37 to 0·90)) and significant

Beets et al.8 7·20 (0·84, 333·31)

Dedemadi et al. − TAPP

5 0·49 (0·04, 3·40)

Dedemadi et al.5 − TEP 0·45 (0·04, 3·11)

Eklund et al.9 1·02 (0·38, 2·69)

Kouhia et al.10 0·14 (0·00, 2·49)

Combined (random) 0·84 (0·33, 2·17)

0·01 0·10·2 0·51 2 5 10 100 1000

Odds ratio
Favours open surgery

Fig. 3Forest plot for pooled odds ratio of further hernia recurrence after laparoscopic or open tension-free mesh repair of recurrent
inguinal hernia. Odds ratios are shown with 95 per cent confidence intervals

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8 A. Karthikesalingam, S. R. Markar, P. J. E. Holt and R. K. Praseedom
Beets et al.8
Eklund et al.9
Kouhia et al.10
Combined (random)
0·01
Fig. 4Forest plot for pooled odds ratio of the development of chronic pain after laparoscopic or open tension-free mesh repair of
recurrent inguinal hernia. Odds ratios are shown with 95 per cent confidence intervals
Beets et al.8
Eklund et al.9
Pooled effect size
−1·00 −0·75 −0·50 −0·25 0 0·25
Favours laparoscopic surgery
Fig. 5Forest plot for weighted mean difference in pain score
measured on a visual analogue scale during the first 7 days after
laparoscopic or open tension-free mesh repair of recurrent
inguinal hernia. Weighted mean differences are shown with
95 per cent confidence intervals
statistical bias (Egger test = 9·09, P = 0·006). This
effect was unmasked by a sensitivity analysis after
removal of data from an excluded non-randomized
trial that had an influential role in pooled analysis14
(Fig. 2).
Return to daily activity
Return to normal working activity was reported by all four
trials5,8 – 10 . Laparoscopic surgery significantly shortened
the time taken to return to working activities (weighted
mean difference −0·82 (95 per cent c.i. −1·27 to −0·36)
days; P < 0·001) (Fig. 7). However, this outcome mea-
sure was associated with significant statistical heterogeneity
(Cochran’s Q = 20·00, P < 0·001; I 2 = 0·80 (95 per cent
c.i. 0·37 to 0·90)). There was no evidence of significant
statistical bias (Egger test = 5·88, P = 0·443)
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1·80 (0·09, 109·10)
5·21 (0·19, infinity)
0·26 (0·06, 0·94)
0·91 (0·14, 5·88)
0·10·2 0·5 1 2 5 10 100 1000
Odds ratio
Favours open surgery
Wound seroma or haematoma
All four trials reported the development of postoperative
seroma or haematoma5,8 – 10 . There was no significant effect
of laparoscopic or open surgery on seroma or haematoma
formation (pooled odds ratio 0·65 (95 per cent c.i. 0·22 to
1·92); P = 0·440) (Fig. 8). Although there was no statistical
evidence of bias (Egger test = −8·53, P = 0·225), this
outcome measure was associated with significant statistical
heterogeneity (Cochran’s Q = 18·38, P = 0·001; I 2 = 0·78
(95 per cent c.i. 0·27 to 0·89)).
Complications requiring further surgery
Three trials reported intraperitoneal complications requir-
ing additional surgery8 – 10 . These comprised reopera-
tion to repair a peritoneal tear in the open group8
and bleeding from the epigastric artery requiring addi-
tional intraoperative9 or postoperative10 operations in both
groups. There were no injuries to major vascular structures
or to an intraperitoneal viscus. There was no significant
difference in complications requiring additional surgery
between the groups (pooled odds ratio 1·48 (95 per cent c.i.
0·36 to 6·10); P = 0·585) (Fig. 9). There was no significant
statistical heterogeneity (Cochran’s Q = 1·65, P = 0·438;
I 2 = 0·00 (95 per cent c.i. 0·00 to 0·73)) and there were
insufficient data to carry out the Egger test for bias.
Discussion
This meta-analysis demonstrated that laparoscopic
tension-free mesh repair of recurrent inguinal hernia did
not offer a significant benefit over open tension-free mesh
repair in the major outcome measures of preventing future
recurrence and chronic pain. Laparoscopic surgery offered
benefits in secondary outcome measures by reducing short-
term postoperative pain, shortening the time to return to
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Laparoscopic versus open mesh repair of recurrent inguinal hernia 9

Beets et al.8 0·09 (0·00, 1·29)

Dedemadi et al.5 − TAPP 0·43 (0·00, 52·00)

Dedemadi et al.5 − TEP 0·40 (0·00, 48·00)

Eklund et al.9 0·50 (0·01, 9·85)

10 0·25 (0·01, 2·63)

Kouhia et al.

Combined (random) 0·29 (0·08, 0·96)

0·001 0·01 0·10·2 0·5 1 2 5 10 100

Odds ratio
Favours laparoscopic surgery

Fig. 6Forest plot for pooled odds ratio of superficial wound infection after laparoscopic or open tension-free mesh repair of recurrent
inguinal hernia. Odds ratios are shown with 95 per cent confidence intervals

Beets et al.8 Beets et al.8 0·29 (0·00, 34·36)

Dedemadi et al.5 − TAPP

Eklund et al.9 5·91 (0·19, infinity)

Dedemadi et al. − TEP5

Kouhia et al.10 1·60 (0·17, 19·93)

Eklund et al.9
Combined (random) 1·48 (0·36, 6·10)
Kouhia et al.10
0·1 0·2 0·5 1 2 5 10 100
Pooled effect size Odds ratio
−2·0 −1·5 −1·0 −0·5 0 0·5 Favours laparoscopic surgery
Favours laparoscopic surgery
Fig. 9Forest plot for pooled odds ratio of the requirement for
Fig. 7 Forest plot for weighted mean difference in the time taken additional operations for complications during or after
to return to working activity after laparoscopic or open laparoscopic or open tension-free mesh repair of recurrent
tension-free mesh repair of recurrent inguinal hernia. Weighted inguinal hernia. Odds ratios are shown with 95 per cent
mean differences are shown with 95 per cent confidence intervals confidence intervals

Beets et al.8 1·89 (0·69, 5·27) Recurrence affects about 9 per cent of repairs of
Dedemadi et al. − TAPP
5 0·33 (0·07, 1·37) recurrent inguinal hernia15 and was the first major
outcome measure of this meta-analysis. It has been
Dedemadi et al.5 − TEP 0·22 (0·04, 0·99)
suggested previously that laparoscopic tension-free mesh
Eklund et al.9 0·25 (0·07, 0·76)
repair of recurrent inguinal hernia leads to lower rates
10 2·74 (0·85, 9·66)
Kouhia et al. of recurrence of around 2 per cent if performed by
Combined (random) 0·65 (0·22, 1·92) experienced surgeons16,17 . However, the present meta-
0·01 0·1 0·2 0·5 1 2 5 10 analysis of randomized controlled trials demonstrated
Odds ratio no significant difference between laparoscopic and open
Favours laparoscopic surgery techniques in the rate of recurrence. The reported
follow-up was sufficient for detection of recurrence in
Fig. 8Forest plot for pooled odds ratio of wound seroma or
all analysed trials (Table 1), all employed intention-to-
haematoma after laparoscopic or open tension-free mesh repair
of recurrent inguinal hernia. Odds ratios are shown with
treat methodology and the analysis of this important
95 per cent confidence intervals outcome measure may be considered robust in the absence
of statistical evidence of bias or heterogeneity. Patient-
related risk factors including changes in anatomy after
work after operation and reducing the incidence of super- index hernia repair18 , or surgeon-related factors including
ficial wound infections, but there was a significantly longer the greater likelihood of technical error17 , increase the
operating time in the laparoscopic group. likelihood of recurrence independently of the operative

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10
technique employed for the repair of recurrent inguinal
hernia.
Chronic pain is a major cause of morbidity, affecting
up to 54 per cent of patients after hernia repair19 . It is
a particular concern after repair of recurrent inguinal
hernia19 – 21 . A laparoscopic approach to recurrent hernia
repair is favoured by some surgeons as it avoids open
dissection through scar tissue, with unfamiliar anatomy
and higher theoretical potential for injury to unidentified
nerves, lymphatics and blood vessels. However, this
theoretical advantage did not translate into a significant
difference in the major outcome measure of chronic pain or
a significant difference in the secondary outcome measure
of haematoma or seroma formation. This may be partly
attributable to patient-related risk factors common to both
operative techniques, such as young age and high body
mass index20 . The importance of preoperative risk factors
for the development of chronic pain may be reflected in the
insignificant heterogeneity observed across trials for this
primary outcome measure. However, there were too few
data to allow calculation of statistical bias, so a degree of
caution is required in interpreting results for this outcome
measure.
The secondary findings of reduced postoperative pain,
fewer superficial wound infections and earlier return
to work in the laparoscopic group are not surprising.
These findings mirror those noted in repair of primary
inguinal hernia3 and have been replicated in many
surgical specialties embracing laparoscopic techniques22,23 .
A frequently reported disadvantage of laparoscopic
surgery is the risk of serious complications requiring
additional operations. Major injuries to the bladder, bowel
and aorta have all been described during laparoscopic
hernia repair24,25 . However, in the present meta-analysis
there was no significant difference in the incidence of
complications requiring operative management during or
after recurrent inguinal hernia repair. Furthermore, no
major intraperitoneal injury was reported in any of the
studied trials.
Laparoscopic surgery was associated with a significant
increase in operating time. A sensitivity analysis to ascertain
the effect of a non-randomized trial14 on operating
time demonstrated that inclusion of this trial exerted
a significant independent effect on pooled operating
time analysis, masking the significant difference between
laparoscopic and open groups. The final pooled analysis,
incorporating only patients subjected to randomized
selection, demonstrated significantly longer operating
times in the laparoscopic group. This underlined the
hazards of selection bias in trial design, as well as the
benefits of patient selection for laparoscopic surgery.
Copyright  2010 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
A. Karthikesalingam, S. R. Markar, P. J. E. Holt and R. K. Praseedom
Statistical heterogeneity in operating times may reflect
the methodological heterogeneity of the trials analysed. In
addition to the variety of operations performed within
composite laparoscopic and open groups, variation in
the seniority of operating surgeons is known to affect
outcome in laparoscopic hernia surgery26 . None of the
trials reported single-operator series and so interoperator
variability is likely to have contributed to statistical
heterogeneity in this outcome measure, a factor that
would not compromise the statistical validity of the
analysis.
The National Institute for Health and Clinical
Excellence (NICE) has produced guidance on this topic2 .
It currently advocates the use of laparoscopic repair for
inguinal hernias that are either recurrent or bilateral.
Furthermore, NICE places significant emphasis on the
surgeon’s experience in laparoscopic repair and stipulates
that this is a key factor if laparoscopy is to be considered
the preferred technique for recurrent hernia. There was
no consensus on a preferred method of laparoscopic
repair (TAPP or TEP), and no trials specify a minimum
degree of laparoscopic experience to eliminate the learning
curve. In addition to emphasizing the importance of
operator experience, the guidelines of the European
Hernia Society state that the technique used in the
index hernia repair should be taken into account when
choosing the technique for repair of recurrence27 . Further
research should address the importance of the technique
used during index herniorrhaphy and its implications
for the choice of technique for recurrent hernia repair.
The potential advantage of a laparoscopic approach after
bilateral recurrence compared with unilateral recurrence
requires quantification and further study. Furthermore,
the Kugel–Ugahary open approach confers a theoretical
advantage of providing a better view of the avascular
preperitoneal space28 and level 1 evidence is required to
quantify its potential role in the management of recurrent
inguinal hernia.
Although laparoscopic repair of primary hernia is more
expensive to healthcare providers than open surgery,
reduced differences in operating time and more marked
reduction in convalescence are seen for bilateral hernias,
rendering laparoscopic surgery cost effective in this
context26 . The findings of this meta-analysis imply that
these economic conclusions may also apply to recurrent
hernia surgery.
Acknowledgements
The authors declare no conflict of interest.
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Laparoscopic versus open mesh repair of recurrent inguinal hernia
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