Case Report
Bilateral Inguinal Hernia Recurrence after 24 Years
Ved Bhushan ST*, Ajay Kale and Murugesh
Department of Surgery, KLE Centenary Charitable Hospital, India
*Corresponding author: Ved Bhushan ST, Department of Surgery, KLE Centenary Charitable Hospital, Yellur Road Belagavi- 590001, Karnataka, India
Published: 29 Apr, 2017
Cite this article as: Ved Bhushan ST, Kale A, Murugesh.
Bilateral Inguinal Hernia Recurrence
after 24 Years. Clin Surg. 2017; 2:
1451.
Abstract
Inguinal hernia repair is one of the commonest operations performed in the world over. The success
of the hernia repair is judged mainly by the recurrence rate after following the operation. Different
techniques have different recurrence rates. Open hernia repairs have recurrence rate between 10%
to 30%. Lichtenstein’s tension free open hernia repair heralded a new era the reported recurrence
after this repair in around 0% to 1.7%.
Keywords: Hernia recurrence; Inguinal hernias, Hernioplasty hernias
Introduction
Inguinal hernia repair is one of the commonly performed operations all over the world. Inguinal
hernia repair is measured by its long term recurrence free duration. Recurrence rate varies from the
procedure to procedure in open tissue repair. In pre-mesh era, the recurrence rate about 15% for the
primary repair [1], and about 35% for the recurrent hernia repair [2].
It is known that maximum recurrence of inguinal hernia repair occurs within 1-2 years hence
most of the surgeons and institutions follow up their patient’s up to 2-5 years. It is also noted
that most of the patients do not come for any follow up after a period of 2-3 years. Hence, if any
recurrence occurs later this will be unnoticed or not registered. We report a case of recurrence in
bilateral inguinal hernia after 24 years following open repair (Modified Bassini’s Repair).
Case Presentation
A 75-years-old man came to Surgical OPD with the history of swelling in both groin since 1
year. The patient noticed a small swelling over the left groin first later on the right side. It was small
initially and attained the present size about 4 cm to 5 cm. Both swellings appeared while straining
and spontaneously reduced while lying down.
Past surgical history
The patient had bilateral inguinal Hernia repair 24 years back in the district Civil Hospital.
Past medical history
The patient was a chronic smoker for 35 years and suffering from COPD for which he is on
regular treatment with bronchodilators and steroid inhaler, but no history of diabetes mellitus or
hypertension.
On examination the patient is an elderly man moderately built and nourished. His vital signs
were BP 110/70 mm of Hg, pulse 76/min and respiratory rate 18/min. Careful examination of the
respiratory system revealed reduced air entry bilaterally, basal ronchi with crepetitions. Other
systems were normal.
Local examination revealed right side inguinal hernia measuring 6 cm × 7 cm and on the left
side it was 4 cm × 5 cm, both were reducible and the previous scar was present.
The patient underwent bilateral inguinal hernioplasty in March 2016 under spinal anaesthesia.
Right side was operated first as it was larger in size later the left side. Hernia kit with prolene mesh
11 cm × 7 cm was used for meshplasty. He was shifted to ICU for post operative monitoring as
the patient condition was stormy and had to be administered intravenous antibiotics, steroids and
bronchodilators in the first 24 h to 48 h. When patient’s general condition was stabilized as well
as COPD was controlled, he was shifted from ICU and the treatment was changed over to oral
administration.
The patient was discharged in good condition on the 7th post-operative day. He is on regular
follow up since 12 months, surgical wounds on both the groin have healed and patient is doing well (Figure 1).
Figure 1
Discussion
Inguinal hernia repair is one of the most common surgical
operations performed in all parts of the world. In USA, approximately
700,000 inguinal hernia operations are done yearly. In England,
approximately 60,000 inguinal hernia operations are done annually
[3]. Recurrence of inguinal hernia repair differs from open hernia
repair to laparoscopic hernia repair. Even in open hernia repairs
different techniques have different recurrence rates.
Primary inguinal hernia repair recurrence rate is around 4.8% in
shouldice technique compared to other techniques such as Bassini’s,
cooper ligament repair etc., and the recurrence rate of 7.7% is
reported [4].
There is an anatomo-clinical classification of recurrent inguinal
hernias.
• Type R1: first recurrence ‘high’ oblique external, reducible
hernia with small (< 2 cm) defect in non-obese patients, after pure
tissue or mesh repair.
• Type R2: first recurrence ‘low’, direct, reducible hernia
with small (< 2cm) defect in non-obese patients, after pure tissue or
mesh repair.
• Type R3: all the other recurrences- including femoral
recurrences; recurrent groin hernia with big defect (inguinal
eventration); multi-recurrent hernias; non-reducible, linked
with a controlateral primitive or recurrent hernia; and situations
compromised from aggravating factors (for example obesity) or
anyway not easily included in R1 or R2, after pure tissue or mesh
repair.
Etiology for recurrence after open inguinal hernia repair is
broadly classified as operation related factors, general factors and
local factors.
Operation related factors
i) Experience of the surgeon is an important factor. Studies
in specialized centres shouldice clinic has shown lower incidence of
recurrence as low as 0.2% to 2.7% with 100% following over 10 years
compared to non- specialized centres shouldice repair in shouldice
clinic [5].
ii) Tension: Tension in the sutured area. In open hernias if one
is not careful then the tissues are approximated with some tension be
it at conjoint tendon with inguinal ligament as in Bassini’s repair or
with coopers ligament in another technique. Tension is avoided by
using mesh and other synthetic material for open repair [6].
iii) Infection: Infection in the tissues is implicated for the
recurrence in about 50% of the cases. The suture material acts as a
foreign body concentrating the inflammatory process around leading
to break down of the tissues causing recurrence [7].
iv) Suture material: Surgical wound gains about 80% of
strength at the end of 6 months. It is logical that the surgical wound
must be support till such time by the sutures. Synthetic absorbable
sutures lose 50% to 80% of the strength in 14 days time and disintegrate
in few weeks. Biological material such as silk, cotton, linen lose about
40% of their strength within 6 weeks hence not suitable for hernia
repair. Shouldice clinics uses 34 gauge stainless steel wire as suture
and their result is 1% of recurrence in 250,000 hernias [8].
v) Prolene suture: Prolene is synthetic non absorbable suture.
It will not adhere to the tissues and holds the knot well. Prolene is
biologically inert and has minimal tissue reaction prolene does not
disintegrate and it maintains its tensile strength up to 2 years [9].
General factorsm
General conditions will effect in any operations including
hernia repair. There are many factors which adversely influence
wound healing and collagen production. Some of these factors are
malnutrition, hypoproteinemia, malignant cachexia, long term
steroid therapy and advanced liver disease and others. It is commonly
seen that smokers develop both hernias and recurrence of hernias
than non-smokers. In a study it is shown that smokers have higher
circulating serum elastolytic activity than non-smoker [10].
Patients who develop recurrent hernias produce insufficient
amounts of naturally occurring growth factors and immunomodulators
that stimulate angiogenesis and granulation production
which increases wound cellularity, fibroblast proliferation and
collagen production [11].
Local factors
Size of hernia: Large hernias recur more than smaller ones
because of over stretching and destruction of tissues which are
normally used for repair [12].
Mixed hernias: It has be reported that while doing the original
hernia repair some hernias are either missed or overlooked sac which
later cause recurrence [13].
Site of recurrence
The most common site for recurrence is the medial area between
the rectus sheath and the inguinal ligament. When buttress has not
been effectively constructed during the primary repair causes the
recurrence. Another reason is that this area has been sutured under
tension which will give way in later days.
Lichtenstein consideration regarding the distribution of hernia
sites in recurrence is as follows: 47% at the public tubercle, 40% at
the internal ring and 13% in the entire posterior wall [14]. There is
an interesting article about inguinal hernia recurrence in which the
author conclude that about 91.87% recurrences occur within 10 years
of the operation and for incisional hernia recurrence may occur even
at 50 years [15].
In our case this patient was operated in one of the teaching
hospital in the city and the author was a medical student in the same
hospital thirty five years ago. The common surgical procedure in those
days for inguinal hernia was “Modified Bassini’s Repair”. It must be
appreciated that the tissue repair such as modified Bassinis repair
when done properly will last many years till the tissue failure occurs
as in our case. We have done tension free open mesh hernioplasty
using non absorbable suture (prolene). The patient is on regular
follow up and surgical wounds healed. Thus we report this interesting
case of recurrence.
Acknowledgement
The authors would like to thank The Director, Dr. S.C. Dharwad, Director Clinical Services of KLE- Centenary Charitable Hospital, Belagavi for his kind permission and encouragement for the publication.
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