The Challenges and Benefits of an Open Anterior Repair of Recurrent Inguinal Hernias: A Cohort Study

ABSTRACT

Introduction

Recurrent inguinal hernia repair presents unique clinical challenges. While minimally invasive surgery (MIS) is often preferred, open anterior mesh repair is a valid approach particularly when requiring mesh, suture, or tack removal. This study evaluates the outcomes of a small incision open anterior mesh repair, including foreign body (FB) removal, in an Australian cohort.

Methods

Retrospective analysis of patients who underwent open anterior mesh repair for a clinically detectable recurrent inguinal hernia at a tertiary centre. Demographics, hernia history, intraoperative findings, anaesthetic technique, complications, and follow‐up symptoms were analysed.

Results

From 2001 to 2024, 173 patients were included (97.7% male, median age of 66). Swelling (54.9%) was the most common symptoms. 82.7% had a prior open repair, same‐day procedures occurred in 40% and 13.3% were treated under local anaesthesia with sedation. FB removal was done in 15.6% of patients. The overall complication rate was 10.4%, wound or spermatic cord haematoma (5.2%) was the most common. At median follow‐up of 35.7 months, (range 9.7–163 months), 92.3% were pain‐free. Minor discomfort occurred in 7.6%, no patient reported moderate or severe pain and re‐recurrence is 5.2%. No major complications occurred during FB removal. Subgroup analysis showed no significant difference in outcomes based on the prior repair approach, FB removal, or nerve management.

Conclusion

Open anterior mesh repair for recurrent inguinal hernia is safe and effective, even after prior anterior repairs, and enables safe removal of FBs. Maintaining proficiency in open techniques is important given the increasing use of MIS in primary hernia repair.

1. Introduction

Abdominal hernias are a significant global health problem, affecting millions annually and placing a substantial burden on healthcare systems [1]. In Australia, they are among the most common surgical conditions, often requiring intervention to relieve symptoms, prevent complications, and improve quality of life [2]. Recurrent inguinal hernias, defined as the protrusion of intra‐abdominal contents through the inguinal canal following a prior repair, remain a clinical challenge. Contributing factors include patient‐related variables such as smoking, age, hernia type (direct vs. indirect), as well as technical aspects such as poor mesh fixation and mesh‐related complications including folding, inflammation, or infection [3, 4].

Estimating the true incidence of recurrence is difficult due to variations in reporting and coding. Scandinavian registries report recurrence rates of 10%–15%, with 11%–17% of repairs undertaken for recurrence [5, 6]. Comparable trends are noted in the US and Australia, although recurrence is often underreported due to asymptomatic or unrecorded patients [7], complicating efforts to benchmark or develop evidence‐based strategies.

Despite surgical advances including minimally invasive surgery (MIS) techniques, improved meshes, and anterior preperitoneal approaches, recurrence remains common and optimal management is still debated [8]. Guidelines advise using a posterior approach after anterior repair and vice versa, but this is not universally adopted [8, 9]. Although HerniaSurge guidelines have improved consistency in practice, they are contested and highlight the need for specialist involvement in complex presentations [10].

Patients may present with swelling, pain, or both, and evaluating whether symptoms correlate with a true recurrence can be difficult. Dynamic imaging may assist, and alternative diagnoses like adductor longus tendinopathy should be considered when pain predominates. Treatment is further complicated by heterogeneity in the literature. A 2021 systematic review noted significant variability in outcome reporting, limiting widespread applicability [11].

Key considerations include the previous repair method (mesh vs. non‐mesh, open vs. MIS), surgical expertise, and the patient's willingness for reoperation. MIS use has steadily increased in Australia, as shown by Medicare expenditure trends [12]. Some studies suggest that MIS repair reduces early postoperative pain and recovery time, although this depends on the comparator context. Notably, small incision open mesh repair of inguinal hernias results in excellent outcomes even after a prior anterior repair [13]. This approach also enables removal of mesh, sutures, or tacks contributing to symptoms, a task more challenging via MIS particularly after anterior repairs [14]. Despite trends favouring MIS in some countries, evidence is inconclusive regarding superiority in terms of recurrence or long‐term pain outcomes [15].

The Royal Australasian College of Surgeons (RACS) recommends that 70%–80% of inguinal hernia repairs be performed as same‐day procedures, regardless of the approach [16]. Although this has been shown to be safe and cost‐effective for open repairs [17], only 25% of adult inguinal hernia repairs in Australia are currently done as day‐only cases [18].

The widespread use of mesh since the 1990s complicates reoperations. It is important to distinguish between true recurrence and chronic groin pain, which are often conflated. Some patients are misdiagnosed based on imaging alone, which may not correlate with symptoms. Algorithms for post‐hernia repair pain emphasise aetiology‐driven management, including recurrence repair, neurectomy, or mesh removal [8, 19]. However, identifying the precise source of pain can be difficult and requires careful evaluation. Adding mesh does not always resolve symptoms. In select patients with infection or chronic pain, mesh or suture removal may be required but this can be technically challenging, particularly when there is dense scar tissue [14]. In this setting, open repair offers a technical advantage, especially in patients with a prior anterior repair, by providing direct access to the groin for safe foreign body (FB) removal. Although MIS mesh explanation has been described as feasible and safe in experienced hands, it can be a complex undertaking [14, 20].

We hypothesise that a small incision open anterior mesh repair for recurrent inguinal hernia offers favourable outcomes, low complication rates, and rapid recovery, irrespective of the prior surgical approach. FB removal can be performed safely even after a previous MIS repair. This study aims to evaluate presenting symptoms, intraoperative findings, and both short‐ and long‐term outcomes in patients undergoing open mesh repair of recurrent inguinal hernias.

2. Methods

A cohort study including patients ≥ 18 years of age who underwent repair of a clinically relevant recurrent inguinal hernia repair at either Royal North Shore Hospital or North Shore Private Hospital between 2001 and 2024 was conducted. All operations were performed or supervised by the senior author (TJH). Data were analysed retrospectively from prospectively stored information. Ethics approval was obtained from the local Human Research Ethics Committee (2019/ETH00061).

Data collected and analysed included: patient age, gender, ASA grade, ECOG status, prior inguinal hernias and management history, main presenting symptoms, operation duration, anaesthesia type, intraoperative findings (management of FB and presence and preservation of sensory nerves), post‐operative complications, and symptoms at the last follow‐up. Ongoing groin pain or hernia re‐recurrence was noted at the last follow‐up. Postoperative pain was assessed using Cunningham's criteria and classified as either mild, moderate, or severe. At long‐term follow up, a semi‐structured telephone interview focused on two patient‐reported outcomes: the presence of a bulge and the presence of pain or discomfort at the hernia site. Any further abdominal surgery at the hernia repair site was also noted. Patients who reported symptoms were reviewed in the clinic to exclude a recurrent hernia and to assess other patients reported outcome measures, namely pain outcomes as defined by Cunningham's criteria and other assessments [21]. Hernia recurrence was assessed based on observations from direct clinical examination, intra‐operative findings during repeat operations, or by radiological confirmation.

Inguinal hernia repair was performed under either general anaesthesia (GA) or local anaesthesia (LA) with intravenous sedation based on patient preference and their ASA (American Society of Anaesthesiologists) status. A single dose of intravenous cephalosporin was given at the induction of anaesthesia, and thromboprophylaxis was reserved for inpatients. Patients taking pre‐operative aspirin or other non‐steroidal anti‐inflammatory agents remained on these perioperatively. All other anticoagulation medications were ceased pre‐operatively for 48 h and then recommenced on the first post‐operative day.

2.1. Operative Technique

An anterior modified Lichtenstein repair was performed using the following standardised steps: (a) pre‐emptive skin and subcutaneous infiltration with 8–10 mLs of 0.75% Ropivacaine (Astra‐Zeneca, Cambridge, UK); (b) 3–5 cm groin incision; (c) identification and preservation of residual nerves; (d) pre‐emptive intraoperative perineural infiltration with 1–2 mLs 0.75% Ropivacaine (Astra‐Zeneca); (e) dissection of scar tissue and removal of previously placed mesh, suture material or titanium tacks as required; (f) fixation of polypropylene or Parietex Progrip polyester mesh inferiorly to the inguinal ligament and superiorly to the conjoined area with several interrupted 2/0 prolene sutures. Foreign body removal was tailored to safety and symptom origin, with complete excision feasible usually only after prior anterior repairs. In all patients, a fine‐bore catheter was laid beneath the external oblique overlying the mesh and then passed externally through the skin 2–3 cm above the incision, providing a constant flow of anaesthetic agent into the wound at 2 mL/h for 48 h postoperatively. All patients were educated in how to self‐remove the analgesic catheter, and use of this device itself did not prolong the hospital stay or complicate discharge planning.

Detailed information brochures were provided postoperatively to all patients, with specific self‐care instructions about removal of the analgesic catheter at home on the second postoperative day. Discharge criteria included the ability to mobilise freely, the ability to void, and being pain free. An analgesic pack containing paracetamol, a nonsteroidal anti‐inflammatory agent, and a stronger non‐constipating oral medication was provided on discharge with a recommendation to take regular pain relief for 4–5 days. Patients were encouraged to return to normal activities as soon as possible and were reviewed in the clinic 4 weeks postoperatively and thereafter for any ongoing pain or wound complications.

Categorical data were presented with a count and percentage and analysed using a Chi square test or Fisher's Exact test. Continuous data were presented as a median and range and analysed using a Mann–Whitney U test.

3. Results

The demographic, clinical, and operative characteristics of 173 consecutive patients who underwent open repair of a recurrent inguinal hernia are outlined in Table 1. Most patients were male (98%), and the median age of the cohort was 66 years (27–92 years). The most common presentation was swelling only (54.9%), with 45.1% of patients presenting with swelling and pain. Regarding the previous hernia surgical history, most patients (86.7%) had only one prior hernia repair on the side of the recurrence, although 11% had two prior hernia repairs, and 2.3% had three prior hernia repairs. Most patients had their immediately preceding hernia repair on the recurrence side done as an open procedure (83%), while only 17% of patients had a previous laparoscopic repair as the immediately preceding operation.

TABLE 1.

Demographic, clinical, and operative characteristics of patients undergoing open repair of recurrent inguinal hernia (n = 173).

Characteristic	Value
Gender, n (%)
Male	169 (97.7)
Female	4 (2.3)
Median Age (range)	66.0 (27–92)
ASA, n (%)
1	73 (42.2)
2	76 (43.9)
3	23 (13.3)
4	1 (0.6)
ECOG, n (%)
0	107 (61.9)
1	57 (32.9)
2	9 (5.2)
Side for presentation, n (%)
Right	106 (61.3)
Left	67 (38.7)
Reason for presentation, n (%)
Swelling only	95 (54.9)
Pain and swelling	78 (38.7)
Prior operations on the side of recurrence, n (%)
1	150 (86.7)
2	19 (11.0)
3	4 (2.3)
Method of repair of the most recent prior hernia on the side of recurrence, n (%)
Open	143 (82.7)
Laparoscopic	30 (17.3)
Date of recurrent inguinal hernia repair
2001 to 2009	42 (24.3)
2010 to 2024	131 (75.7)
Median operative time in minutes (range)	50 (35–240)
Anaesthetic used, n (%)
General	149 (86.1)
Local	23 (13.3)
Local converted to general	1 (0.6)
Post‐operative length of stay, n (%)
< 4 h	69 (39.9)
Overnight	73 (42.2)
≥ two nights	31 (17.9)
Nerves encountered intraoperatively, n (%)
Nerves not identified	72 (41.6)
Nerves identified and preserved	94 (54.3)
Nerves identified and transected	7 (4.1)
Perioperative complication on follow up, n (%) a , b
No complication	152 (89.4)
One or more perioperative complication	18 (10.6)
Haematoma	9 (5.3)
Seroma	6 (3.5)
Surgical site infection	3 (1.8)
Urinary retention	2 (1.2)
DVT	1 (0.6)
Median follow up length in months (range)	35.7 (9.7–163.0)
Issues on final follow up visit
No complaints	156 (92.3)
Persistent post‐operative pain	13 (7.6)
Re‐recurrence	5 (2.9)

^a Follow‐up data were available for 170 patients (98.3%). The median follow‐up was 35.7 months (IQR: 9.7 to 163.0 months).

^b Some patients had more than one complication.

The median operation time for this cohort was 50 min (35–240 min), and most patients received a GA (86%). A total of 23 patients (13%) had their operation done under LA with sedation. No temporal variation in perioperative outcomes or complication rates was observed between patients not having an analgesic catheter (pre‐2005) and those with an analgesic catheter (post‐2005). A total of 40% of patients were treated as outpatients (< 4‐h hospital stay), with the remaining patients staying for either one night (42.2%) or for ≥ 2 nights postoperatively (17.9%).

Post operative complications occurred in 10.4% of patients (Table 1). Importantly, no patients experienced testicular compromise (arterial injury causing infarction or venous congestion leading to engorgement and/or testicular atrophy) despite the challenges of re‐operative surgery. Follow‐up data were available for 170 patients (98%). The median follow‐up was 35.7 months (IQR: 9.7 to 163.0 months). At last follow‐up, 156 patients (92.3%) were pain‐free, 13 patients (7.6%) reported minor ongoing discomfort; no patient reported moderate or severe chronic pain. Nine recurrences were identified, corresponding to a recurrence rate of 5.2% (Table 1).

3.1. Impact of the Previous Hernia Repair Approach

In patients with a first‐time recurrent inguinal hernia (n = 150), those who had a prior laparoscopic repair were more likely to have sensory nerves identified and preserved intraoperatively compared to those who had a prior open repair, X ² (2) = 9.50, two‐sided p = 0.009 (Table 2). They were also more likely to be younger (< 65 years old), X ² (1) = 4.83, two‐sided p = 0.027. However, the previous approach to the primary inguinal hernia repair did not significantly affect pain at presentation, post‐operative pain levels, complications, or symptom outcomes after the recurrent hernia repair (Table 2).

TABLE 2.

Differences between patients who had one prior open versus those who had one prior laparoscopic operation on the side of their recurrence.

	Prior open operation (n = 125)	Prior laparoscopic operation (n = 25)	p
Age, n (%)			0.027a
< 65	50 (40.0)	16 (64.0)
≥ 65	75 (60.0)	9 (36.0)
Reason for presentation, n (%)			0.510a
Pain and swelling	59 (47.2)	10 (40.0)
Swelling without pain	66 (52.8)	15 (60.0)
Mesh or other FB removed, n (%)			0.123b
No FB removed	110 (88.0)	19 (76.0)
Mesh, sutures, or tacks removed	15 (12.0)	6 (24.0)
Intraoperative management of nerves, n (%)
None identified	55 (44.0)	3 (12.0)	0.009a
Identified and preserved	64 (51.2)	21 (84.0)
Identified and divided	6 (4.8)	1 (4.0)
Complications on follow‐up, n (%)			0.279b
No	114 (91.2)	21 (84.0)
Yes	11 (8.8)	4 (16.0)
Persistent post‐operative pain, n (%)			0.692b
No	115 (92.0)	24 (96.0)
Yes	10 (8.0)	1 (4.0)
Re‐recurrence, n (%)			0.330b
No	120 (96.0)	23 (92.0)
Yes	5 (4.0)	2 (8.0)

Note: Key for p‐values: a = Pearson's Chi‐squared test, b = Fisher's exact test.

3.2. Intraoperative Management of Nerves

Sensory nerves were encountered and preserved in slightly over half the patients (54.3%). In the remaining patients, sensory nerves were either identified and divided as part of the procedure or were not encountered in the scar tissue. The identification and preservation of sensory nerves was associated with reduced pain post‐operatively compared to the pre‐operative presentation; however, this did not reach statistical significance (Fisher–Freeman–Halton exact test, two‐sided p = 0.097) as seen in Table 3.

TABLE 3.

Differences between intraoperative management of inguinal nerves during open anterior repair of a recurrent inguinal hernia.

	None Identified, n = 72	Identified and preserved, n = 94	Identified and divided, n = 7	p
Short‐term postoperative complications, n (%)				0.599a
No	66 (91.7)	83 (88.3)	6 (85.7)
Yes	6 (8.3)	11 (11.7)	1 (14.3)
Persistent post‐operative pain				0.097a
No	67 (93.1)	89 (94.7)	5 (6.4)
Yes	5 (6.9)	5 (5.3)	2 (28.6)
Re‐recurrence				0.999a
No	68 (94.4)	89 (94.7)	7 (100.0)
Yes	4 (5.6)	5 (5.3)	0 (0.0)

Note: Key for p‐values: a = Fisher–Freeman–Halton exact test.

3.3. Mesh, Sutures, or Tacks Removed Intraoperatively

Mesh or other FB (sutures or tacks) were removed in 15.6% of patients. The presence or absence of pain at presentation did not significantly impact the frequency of FB removal, and FB removal had no significant impact on the type or rate of follow‐up symptoms or patient‐reported pain (Table 4).

TABLE 4.

Difference between intraoperative removal or preservation of mesh or other FB during open anterior repair of a recurrent inguinal hernia.

	No FB removed (n = 146)	Mesh or FB removed (n = 27)	p
Reason for presentation, n (%)			0.234a
Pain and swelling	63 (43.2)	15 (55.6)
Swelling without pain	83 (56.8)	12 (44.4)
Short‐term postoperative complications, n (%)			0.489b
No	132 (90.4)	23 (85.2)
Yes	14 (9.6)	4 (14.8)
Persistent post‐operative pain, n (%)			0.999b
No	136 (93.2)	25 (92.6)
Yes	10 (6.8)	2 (7.4)
Re‐recurrence, n (%)			0.633b
No	139 (95.2)	25 (92.6)
Yes	7 (4.8)	2 (7.4)

Note: Key for p‐values: a = Pearson's Chi‐squared test, b = Fisher's exact test.

4. Discussion

Managing patients with suspected recurrent inguinal hernias can be challenging. Symptoms may arise from a true recurrence, a radiologically detected but clinically silent hernia, or from a FB reaction to previously implanted mesh or sutures [22, 23].

This study examined outcomes following a small incision open anterior mesh repair in patients with clinically relevant recurrent inguinal hernias, including those with prior anterior repairs. The findings support the safety and efficacy of this approach, with 40% of patients treated as day‐only cases. This compares to 24.6% nationally in Australia, 46.5% in New Zealand, and 67.8% in the UK [18]. Accepting that recurrent inguinal hernia repair can be technically challenging, this does not align with the Royal Australasian College of Surgeons' recommendation that 70%–80% of all inguinal hernia repairs be conducted as same‐day procedures due to cost and patient satisfaction benefits [16]. The relatively low rate of same‐day discharge in our patients compared with the RACS recommendations suggests that recurrent inguinal hernia repairs, particularly those involving mesh removal or when there is chronic pre‐repair pain, often necessitate overnight monitoring due to surgical complexity or patient comorbidities.

FB removal (mesh, tacks, or sutures) was technically straightforward and associated with minimal morbidity. This contrasts with MIS where explantation is technically demanding and carries risks of vascular or visceral injury [14, 20, 24, 25]. Although MIS approaches for FB removal are feasible and may offer short recovery, they may be associated with high complication and recurrence rates in re‐operative fields or when mesh is not replaced [24, 26, 27, 28, 29, 30, 31]. Altered tissue planes after previous surgery may complicate a posterior dissection, highlighting the need for careful patient selection and surgical expertise [32, 33]. In this context, the open anterior approach provided safe access for explantation without major complications.

International guidelines recommend alternating approaches, posterior after anterior repair and vice‐versa [8] but this may not reflect local expertise, resource availability, or patient‐specific factors. Our data suggest that an anterior repair, even after a previous anterior approach, can be safe and effective when performed by an experienced surgeon. The overall short‐term complication rate was 10.4%, with wound or spermatic cord haematoma being most common (5.2%). Rates of wound infection (1.7%) and persistent pain (6.9%) compared favourably with laparoscopic repair outcomes reported by Yang et al. [22]. Importantly, there were no testicular injuries, and these outcomes are notable given that 14% of patients were ASA 3–4, many were on antiplatelet therapy, and 15.6% required FB removal.

Surgeon experience plays an important role in outcomes and several studies have shown that if a laparoscopic approach is used, then the best results are achieved by surgeons performing over five posterior repairs annually [23, 30]. Others caution against complex posterior approaches in scarred planes without specific expertise [25, 32]. Successful outcomes for recurrent inguinal hernias appear to be more dependent on surgeon proficiency and patient selection than on the chosen technique.

The anterior approach offers the advantage of local anaesthesia, particularly valuable for elderly or high‐risk patients. In our series, 13.3% of cases were performed under local anaesthesia with only one conversion to general anaesthesia (0.6%), emphasising that this is a safe and efficient strategy [13, 17, 33]. Although laparoscopic repair under local anaesthesia has been described [34], it is more technically demanding and less common in practice.

In the senior author's opinion, the only contra‐indication for an anterior approach is if patients have had more than three prior anterior repairs. Only three patients presented this way over the study period, and all were referred elsewhere for a laparoscopic approach.

Recurrent hernia symptoms may be due to improper mesh sizing, fixation failure, or chronic pain syndromes [35, 36, 37]. Both polypropylene and Parietex ProGrip polyester mesh types achieved comparable recurrence and pain outcomes, suggesting that the operative technique rather than mesh composition was the main determinant of success. Patients undergoing FB removal in our cohort had good outcomes, with 93% reporting no persistent pain or recurrence at follow‐up. No vascular or vas deferens injuries occurred. These results demonstrate the feasibility and safety of FB explantation via an open approach. When considering the impact of dividing nerves, the finding of higher rates of pain in patients whose nerves were divided for technical reasons compared with the other groups should be interpreted with caution given the small sample size and are presented descriptively rather than as statistically robust comparisons.

As MIS and posterior approaches become more common in primary hernia repair, future recurrences will increasingly necessitate an anterior reoperation. This may be challenging given the declining familiarity with open anterior techniques among younger surgeons, especially in patients requiring FB removal. Maintaining proficiency with the anterior open approach is important to ensure that these patients can be managed effectively and safely. We propose that a small incision open anterior mesh repair offers several key advantages, including favourable symptom resolution, cost‐effectiveness, and capacity for targeted FB removal with minimal risk [35, 36, 37, 38]. Interestingly, alternative open preperitoneal repairs have also demonstrated favourable post‐operative outcomes [39].

Strengths of the present study include the detailed recording of the intraoperative findings (mesh status, nerve identification, FB handling) and structured follow‐up. Importantly, only patients with clinically relevant recurrent inguinal hernias were included in this study. Patients with radiologically detected hernias that were not clinically evident or those who had radiologically detected hernias but other causes for the presenting symptoms were not offered further surgery.

Limitations include the single‐centre design, a modest sample size (173 patients), and the broad range of length of follow‐up (median 35.7 months; range 9.7–163.0 months). The extended study period (2001–2024) and absence of standardised follow‐up protocols may limit long‐term pain assessment. Future research should include multicentre trials with consistent outcome reporting and longer follow‐up to define the role of open anterior repair more clearly in recurrent inguinal hernia management.

Disclosure

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.