World J Surg (2023) 47:2425–2435 https://doi.org/10.1007/s00268-023-07080-8 ORIGINAL SCIENTIFIC REPORT Elective Recurrent Inguinal Hernia Repair: Value of an Abdominal Wall Surgery Unit V. Rodrigues-Gonçalves1 • M. Martı́nez-López1 • M. Verdaguer-Tremolosa1 • P. Martı́nez-López1 • M. López-Cano1 Accepted: 15 May 2023 / Published online: 2 June 2023 Ó The Author(s) 2023 Abstract Background The aim of this study was to analyze the impact of an abdominal wall surgery unit on postoperative complications (within 90 days postoperatively), hernia recurrence and chronic postoperative inguinal pain after elective recurrent inguinal hernia repair. Methods We conducted a retrospective cohort study of all adult patients who underwent elective recurrent inguinal hernia repair between January 2010 and October 2021. Short- and long-term outcomes were compared between the group of patients operated on in the abdominal wall surgery unit and the group of patients operated on by other units not specialized in abdominal wall surgery. A logistic regression model was performed for hernia recurrence. Results A total of 250 patients underwent elective surgery for recurrent inguinal hernia during the study period. The patients in the abdominal wall surgery group were younger (P B 0.001) and had fewer comorbidities (P B 0.001). There were no differences between the groups in terms of complications. The patients in the abdominal wall surgery group presented fewer recurrences (15% vs. 3%; P = 0.001). Surgery performed by the abdominal wall surgery unit was related to fewer recurrences in the multivariate analysis (HR = 0.123; 95% CI = 0.21–0.725; P = 0.021). Conclusions Specialization in abdominal wall surgery seems to have a positive impact in terms of recurrence in recurrent inguinal hernia repair. The influence of comorbidities or type of surgery (i.e., outpatient surgery) require further study. Introduction been suggested that operations in these patients be per- formed by experienced surgeons [5]. However, surgical Inguinal hernia repair is one of the most frequent proce- specialization in abdominal wall surgery continues to be an dures performed by a general surgeon [1]. Despite being a area poorly studied in the literature, even more so in the common intervention, recurrence rates up to 15% have case of recurrent inguinal hernia. Although clinical been reported [2]. The risk of hernia relapse in recurrent guidelines recommend treating these patients in specialized inguinal hernias is greater than the risk of relapse after centers [6], little is known about the impact of specializa- repair of the primary hernia [3, 4]. For this reason, it has tion on short- and long-term postoperative outcomes in this difficult setting. The objective of our study is to determine the impact of & V. Rodrigues-Gonçalves the surgeon’s specialization and experience in abdominal victor.rodrigues@vallhebron.cat wall surgery on the postoperative complications (within 1 General Surgery Department, Abdominal Wall Surgery Unit, 90 days postoperatively), hernia recurrence and chronic Hospital Universitari Vall dHebron, Universitat Autònoma postoperative inguinal pain of elective recurrent inguinal de Barcelona, Paseo Vall d‘Hebron 119-129, hernia repair. 08035 Barcelona, Spain 123 2426 World J Surg (2023) 47:2425–2435 Methods and patients The exclusion criteria were patients \ 18 years, patients who underwent emergency recurrent inguinal hernia repair, Study design and setting and patients with recurrent inguinal hernia who did not undergo surgery. A retrospective cohort study was performed at Vall Patients were followed up by their surgeons at regular dHebron University Hospital between January 2010 and intervals. A follow-up visit was routinely performed October 2021. All adult patients who underwent surgery 4 weeks after hospital discharge. More face-to-face visits for recurrent inguinal hernia were identified from a were scheduled before or after the routine visit depending prospectively maintained database of our General Surgery on the presence of postoperative complications. Department. Patients with elective repair for recurrent For the purpose of this study, telephone interviews were inguinal hernia were selected for analysis, and the data conducted at the time of the study to assess the presence of were collected through a retrospective review of medical chronic postoperative pain (CIPIP) and recurrence. and surgical records. This study was conducted in accor- dance with the Declaration of Helsinki, and the Strength- Preoperative variables ening the Reporting of Observational Studies in Epidemiology (STROBE) [7] and Reporting of Studies Patient demographic data (age, sex, and body mass index) Conducted Using Observational Routinely Collected as well as clinical variables, including American Society of Health Data (RECORD) [8] requirements for observational Anesthesiologists (ASA) classification, the Charlson score studies were applied. [13], and the presence of comorbidities (chronic obstruc- Patients were classified according to the surgical unit tive pulmonary disease (COPD), cardiovascular disease, that performed the surgical repair into patients operated on diabetes, chronic nephropathy, anticoagulant therapy, in the abdominal wall surgery unit (AWS group) and neurocognitive disorders, and smoking status), were col- patients operated on by surgeons not specialized in lected. Variables related to the hernia included the side of abdominal wall surgery (NAWS group). the hernia, content, and type of hernia according to the In our hospital, there are two surgery departments with EHS classification [6]. Regarding the primary hernia completely independent management models, one for repair, the type of approach (anterior or posterior) and the digestive surgery and another for hepatobiliary and pan- type of repair (tissue or mesh) were collected. creatic surgery and liver transplantation. The digestive surgery department is organized into specialized units with Operative variables exclusive dedication to abdominal wall, colorectal, gas- troesophageal, endocrine, and bariatric surgery. Due to the The procedures documented in the operative records were presence of two independent surgical departments, some reviewed to classify the repair approaches for recurrent repairs were performed by surgeons outside the abdominal hernias into anterior and posterior. An open transinguinal wall surgery unit. repair using mesh was considered an open anterior The abdominal wall surgery unit comprises three senior approach. A posterior approach involved open or laparo- surgeons who specialize in abdominal wall surgery, two scopic posterior access to the preperitoneal space without fellows, and one resident and performs approximately 500 entering the inguinal canal from the front and exposure of inguinal hernia repairs per year, including majority of all myopectineal orifices to allow hernia repair with outpatient inguinal hernia surgeries at our hospital. A placement of a prosthesis. surgeon is defined as an abdominal wall specialist with the Recurrent hernia repairs were classified according to following criteria: high surgical volume and a minimum of whether they were based on guideline recommendations. 5 years of surgical dedication to abdominal wall surgery Repairs based on clinical guidelines included cases in [9, 10]. Our abdominal wall surgery unit meets the required which the primary hernia had been operated on using an criteria to be a hernia center published by different orga- anterior tissue or mesh approach and the recurrence was nizations [11, 12]. The rest of the surgeries were performed repaired with a posterior approach (open preperitoneal or by the NAWS group comprising six surgeons specializing laparoscopic) and cases in which the primary hernia had in other areas. been treated with a posterior approach and the recurrence was repaired with an anterior approach using mesh. The Patients cases in which the primary hernia and recurrence were operated on using the same type of approach (anterior or The inclusion criteria were age C 18 years and elective posterior) were considered repairs not based on clinical repair of recurrent inguinal hernia. guidelines. 123 World J Surg (2023) 47:2425–2435 2427 The type of surgical approach was selected at the sur- Results geons discretion. The type of anesthesia was determined by the anesthesiologist. Some patients underwent outpa- Demographics tient surgery according to the preoperative assessment by the anesthesiologist. Given that these patients had fewer Of a total of 250 patients who underwent elective repair of comorbidities, a subgroup analysis was performed recurrent inguinal hernia from January 2010 to October excluding these patients to create more homogeneous 2021, 214 (86%) had first-episode recurrence, and 36 groups. (14%) had multiple recurrences of inguinal hernia. All repairs were unilateral recurrences. A total of 196 patients Postoperative variables (78%) were operated on by surgeons from the abdominal wall surgery unit, and 54 (22%) were operated on in other The postoperative variables collected were complications general surgery units. Most patients with recurrence in the (within 90 days postoperatively), CPIPs and hernia recur- AWS group underwent outpatient surgery (n = 138; 67%), rence. Postoperative complications were defined as any while only ten patients (10%) in the NAWS group under- condition that could influence the outcomes or prolong the went surgery in this setting. Patients in the NAWS group length of hospital stay. The severity of postoperative were older (P B 0.001) and had more comorbidities (P complications was graded using the Clavien–Dindo clas- B 0.001) (Table 1). sification [14]. Hernia recurrence was determined by review of opera- Hernia characteristics tive notes reporting any reoperations for hernia recurrence, physical evaluation by the surgeon, or by telephone inter- Comparing the characteristics of the primary hernia, view based on a patient-reported outcome measure ques- abdominal wall unit surgeons had more recurrences after tionnaire: the Ventral Hernia Recurrence Inventory (VHRI) posterior repairs (open preperitoneal and laparoscopic) [15]. The VHRI is a validated tool used to assess the (P = 0.005) and after a previous mesh repair (P B 0.001). presence of recurrence in both ventral [16] and inguinal Regarding the repair of recurrent hernia, abdominal wall hernias [15]. CPIP was defined as persistent pain lasting surgeons performed a greater number of repairs based on more than 3 months after surgery [17]. CPIP was assessed clinical guidelines (P B 0.001) and more frequently per- using the last question of the VHRI questionnaire: ‘‘Do you formed repairs by the preperitoneal approach (P B 0.001), have pain or other physical symptoms at the site?’’ made in either open or laparoscopic (P B 0.001) (Table 1). the telephone interview. If presenting any positive response in the VHRI, patients were strongly recommended to Postoperative outcomes schedule a face-to-face visit for a physical evaluation. The last face-to-face postoperative visit was considered the last The overall rate of 90-day postoperative complications was follow-up date in the patients who did not respond to fol- 20% (n = 51). The most common postoperative compli- low-up telephone interviews. cations included hematoma (n = 29; 12%), seroma (n = 16; 6%) and wound infection (n = 3; 1%). Patients in Statistical analysis the NAWS group had a higher rate of wound hematoma (P = 0.006) and ischemic orchitis (P = 0.046). There were Continuous variables are reported as medians and no significant differences between the groups in terms of interquartile ranges (IQRs) and were analyzed using Stu- seroma formation (P = 1) or wound infection (P = 0.119). dents t test or the Mann–Whitney U test as needed. Cat- egorical variables are reported as counts and percentages Hernia recurrence and were compared using the chi-square test or Fishers exact test as needed. A logistic regression model was The median follow-up was 58 months (IQR: 14.75–97). performed for hernia recurrence. The inclusion of variables The flowchart of the patients included in the study with the in the model was based on their significance in the uni- long-term results is shown in Fig. 1. The recurrence rate of variate analysis (P \ 0.05) and on clinical consensus. the entire series was 5% (n = 13). Patients operated on by Recurrence results are reported as hazard ratios with 95% surgeons not specialized in abdominal wall surgery had a confidence intervals. The Kaplan–Meier method was used significantly higher rate of recurrence than those operated to estimate the cumulative recurrence rate, and significance on by abdominal wall surgeons (NAWS 15%vs. AWS 3%; was tested with the log-rank test. P \ 0.05 was accepted as P = 0.001). a significant statistical value. For statistical analysis, SPSS (IBM SPSS Statistics 23) was used. 123 2428 World J Surg (2023) 47:2425–2435 Table 1 Patient characteristics of study population Variables Total (n = 250) NAWS group AWS group P values (n = 54) (n = 196) Age (yr)[median (IQR)] 66.5 (54 – 77) 75 (67 – 81) 63 (51 – 74) \ 0.001 Sex [n, (%)] 0.473 Male 225 (90) 50 (93) 175 (89) Female 25 (10) 4 (7) 21 (11) BMI (kg/m2) [median (IQR)] 25.4 (23.8 – 24.5 (23.4 – 26.3) 25.7 (24—27.8) 0.031 27.5) ASA score \ 0.001 I/II [n, (%)] 180 (72) 24 (44) 156 (80) III/IV [n, (%)] 70 (28) 30 (56) 40 (20) Charlson score [median (IQR)] 3 (1 -5) 5 (4—7) 3 (1 – 5) \ 0.001 Comorbidity [n, (%)] 149 (60) 46 (85) 103 (53) \ 0.001 Cardiovascular disease [n, (%)] 86 (34) 28 (52) 58 (30) 0.002 Chronic obstructive pulmonary disease [n, (%)] 46 (18) 20 (37) 26 (13) \ 0.001 Chronic nephropathy [n, (%)] 18 (7) 8 (15) 10 (5) 0.031 Neurocognitive disorders [n, (%)] 17 (7) 10 (19) 7 (4) 0.001 Diabetes [n, (%)] 28 (11) 10 (19) 18 (9) 0.054 Active smoking [n, (%)] 36 (14) 10 (19) 26 (13) 0.330 Anticoagulant treatment [n, (%)] 30 (12) 17 (31) 13 (7) \ 0.001 Comorbidity more than one [n, (%)] 75 (30) 29 (54) 46 (23) \ 0.001 Hernia type [n, (%)] 0.305 Lateral 101 (41) 28 (52) 73 (37.5) Medial 87 (35) 14 (26) 73 (37.5) Femoral 20 (8) 4 (7) 16 (8) Combined 36 (14) 6 (11) 30 (15) Others 6 (2) 2 (4) 4 (2) Hernia side [n, (%)] 0.771 Right 134 (54) 28 (52) 106 (54) Left 116 (46) 26 (48) 90 (46) Inguinoescrotal hernia [n, (%)] 21 (8) 5 (9) 16 (8) 0.784 Multirecurrent hernia [n, (%)] 36 (14) 7 (13) 29 (15) 0.734 Hernia sac contents [n, (%)] 0.167 Omentum 22 (9) 2 (4) 20 (10) Small bowel 3 (1.2) 1 (2) 2 (1) Colon 16 (6) 1 (2) 15 (8) Bladder 8 (3.2) 1 (2) 7 (3.5) Other 1 (0.4) 0 (0) 1 (0.5) Not reported 192 (77) 49 (90) 143 (73) Empty 8 (3.2) 0 (0) 8 (4) Guideline-based repair [n, 185 (74) 8 (15) \ 0.001 (%)] 177 (90) Type of primary hernia repair approach [n, (%)] 0.005 Anterior 212 (85) 52 (96) 160 (82) Posterior 38 (15) 2 (4) 36 (18) Type of primary hernia repair [n, (%)] \ 0.001 Tissue repair 100 (40) 35 (65) 65 (33) Mesh repair 150 (60) 19 (35) 131 (67) Emergency presentation of primary hernia [n, (%)] 15 (6) 5 (9) 10 (5) 0.327 123 World J Surg (2023) 47:2425–2435 2429 Table 1 continued Variables Total (n = 250) NAWS group AWS group P values (n = 54) (n = 196) Type of anesthesia [n, (%)] \ 0.001 Spinal 143 (57) 38 (70) 105 (54) Local alone 4 (2) 0 (0) 4 (2) General 103 (41) 16 (30) 87 (44) Type of hernia repair approach \ 0.001 [n (%)] Anterior 68 (27) 47 (87) 21 (11) Posterior 182 (73) 7 (13) 175 (89) Type of procedure [n (%)] \ 0.001 Lichtenstein 56 (22) 36 (67) 20 (10) Other anterior technique 12 (5) 11 (20) 1 (0.5) Open preperitoneal mesh 160 (64) 6 (11) 154 (78.5) Laparoscopic 22 (9) 1 (2) 21 (11) Postoperative complication [n (%)] 53 (21) 14 (26) 39 (20) 0.337 Clavien–Dindo classification of postoperative complications [n, 0.050 (%)] None 197 (79) 40 (74) 157 (80) I 48 (19) 11 (20) 37 (19) II 3 (1) 1 (2) 2 (1) III A 1 (0.5) 1 (2) 0 (0) III B 1 (0.5) 1 (2) 0 (0) Wound hematoma [n, (%)] 29 (12) 12 (22) 17 (9) 0.006 Wound infection [n, (%)] 3 (1) 2 (4) 1 (0.5) 0.119 Wound seroma [n, (%)] 16 (6) 3 (6) 13 (7) 1.000 Ischemic orchitis [n, (%)] 2 (1) 2 (4) 0 (0) 0.046 Hernia Re-recurrence [n, (%)] 13 (5) 8 (15) 5 (3) 0.001 Chronic postoperative inguinal pain [n, (%)] 34 (14) 4 (7) 30 (15) 0.519 NAWS: not specialized in abdominal wall surgery AWS: abdominal wall surgery Only procedures performed by the AWS unit were Subgroup analysis associated with fewer recurrences in multivariate analysis (HR = 0.123; 95% CI = 0.21–0.725; P = 0.021) (Table 2). Patients were compared according to the type of surgeon, In the cumulative recurrence curves, significant differ- excluding those who underwent outpatient surgery. There ences were observed in favor of the AWS group compared were no significant differences between the groups in terms with the NAWS group (P B 0.001, log rank) (Fig. 2). of age (P = 0.922) or ASA classification (P = 0.322). Regarding the presence of comorbidities, patients in Chronic postoperative inguinal pain NAWS group presented a higher percentage of COPD (P = 0.027) compared to patients in the AWS group. There The rate of CPIP in the entire series was 14% (n = 34). were no significant differences between the groups in terms There were no significant differences between the patients of the presence of chronic nephropathy (P = 0.546), active operated on by general surgeons and those operated on by smoking (P = 0.982), and neurocognitive disorders surgeons from the abdominal wall surgery unit (P = 0.089). Patients operated on by abdominal wall sur- (P = 0.519). geons had more interventions after mesh repair (P B 0.001) and a higher number of guideline-based repairs (P B 0.001). Of note, a higher number of recurrences was 123 2430 World J Surg (2023) 47:2425–2435 Recurrent inguinal hernia repair N= 250 Patients not available to Patients contacted for answer telephone telephone interview interview n=176 n=75 Negative telephone Positive telephone interviews interviews Deceased Unlocalized n= 39 n= 137 n= 42 n= 32 Telephone Patients with recurrence Patients with recurrence appointment for detected during routine clinical visit detected during routine postoperative follow-up n= 39 postoperative follow-up previous to telephone previous to telephone contact contact n= 5 n= 2 Physical Declined visit examination n= 28 n= 11 Patients with CPIP Patients with recurrence detected during routine detected during routine postoperative follow-up Patients with recurrence postoperative follow-up Patients with Patients with previous to telephone detected during routine previous to telephone recurrence CPIP postoperative follow-up contact contact n= 5 n= 8 n= 1 n= 0 n= 0 Patients with CPIP detected during routine postoperative follow-up n= 26 Fig. 1 Flowchart of study cohort and long-term outcomes observed in the group of patients operated on by surgeons recommend management by expert surgeons [6], this from other surgery units (P = 0.001). aspect has been poorly studied in the literature. Recurrent inguinal hernia repair still represents an important challenge for general surgeons as it is a techni- Discussion cally demanding procedure and is associated with a high rate of postoperative morbidity and repeated recurrence [3]. The present study shows that the specialization of the The present study shows that the main factor in reducing surgeon in abdominal wall surgery is one of the main recurrences in the elective repair of recurrent inguinal factors in reducing recurrence after repair of recurrent hernia is the surgeons specialization in abdominal wall inguinal hernias. surgery. A previous study showed a lower risk of chronic The role of specialization in general and digestive sur- pain in patients operated on for recurrent inguinal hernia by gery has been previously evaluated in several areas, such as high-volume surgeons [5]. Some authors have reported that colorectal [18] and bariatric surgery [19]. These studies the incidence of recurrence appears to depend to a great have shown better results in patients operated on in high- extent on the skill of the surgeon in both open and volume centers and by specialized surgeons [20]. In laparoscopic approaches [23]. However, the criteria for abdominal wall surgery, lower recurrence rates have been defining the proficiency of the hernia surgeon in most of reported in incisional hernia repairs in patients operated on these studies were based on annual case volume with by specialized surgeons [12]. Regarding inguinal hernia arbitrary cutoff points. In our study, patients were operated surgery, previous studies have shown a reduction in on by surgeons from a unit specialized in abdominal wall recurrence rates with high-volume surgeons in primary surgery that met the proposed requirements to certify her- hernia repairs [21]. In addition, better outcomes have been nia centers in other European countries[9, 10], and signif- reported at specialized inguinal hernia repair centers icantly better results were obtained in terms of recurrence compared with general hospitals in Canada [22]. In compared with surgeons from other specialties. The high recurrent inguinal hernia, although clinical guidelines volume and systematic repetition of techniques in a 123 World J Surg (2023) 47:2425–2435 2431 Table 2 Univariable and multivariable analysis of recurrence Recurrence Variables Univariable analysis Multivariable analysis HR (95% CI) P value HR (95% CI) P value Patient age (y) 0.008 0.046 \ 75 (n = 164) 1 1 C 75 (n = 74) 0.206 (0.64—0.662) 0.287 (0.084 – 0.978) Sex 0.581 Male (n = 214) 1 Female (n = 24) 1.784 (0.229 – 13.926) BMI 0.647 \ 30 (n = 214) 1 C 30 (n = 24) 1.612 (0.209 – 12–412) ASA score 0.219 I/II (n = 168) 1 III/IV (n = 70) 0.492 (0.159 – 1.523) Charlson score 0.139 \ 3 (n = 93) 1 C 3 (n = 145) 0.375 (0.102 – 1.373) Comorbidity 0.330 Yes (n = 144) 0.552 (0.167 – 1.834) No (n = 94) 1 Cardiovascular disease 0.175 Yes (n = 83) 0.463 (0.152 – 1.409) No (n = 155) 1 Chronic Obstructive Pulmonary disease 0.214 Yes (n = 45) 0.471 (0.144 – 1.543) No (n = 193) 1 Chronic nephropathy 0.590 Yes (n = 17) 21.872 (0.000 – 1,612,659.634) No (n = 221) 1 Diabetes 0.618 Yes (n = 28) 1.681 (0.218 – 12.939) No (n = 210) 1 Active smocking 0.361 Yes (n = 35) 26.258 (0.024 – 29,003.901) No (n = 203) 1 Anticoagulant treatment 0.463 Yes (n = 30) 0.463 (0.122 – 2.611) No (n = 208) 1 Comorbidity more than one 0.954 Yes (n = 74) 1.040 (0.281 – 3.842) No (n = 164) 1 Femoral hernia 0.738 Yes (n = 18) 1.422 (0.180 – 11.223) No (n = 220) 1 Inguinoescrotal hernia 0.905 Yes (n = 20) 0.883 (0.113 – 6.900) No (n = 218) 1 Multirecurrent hernia 0.329 123 2432 World J Surg (2023) 47:2425–2435 Table 2 continued Recurrence Variables Univariable analysis Multivariable analysis Yes (n = 35) 26.535 (0.037 – 19,118.891) No (n = 203) 1 Guideline-based repair 0.184 Yes (n = 176) 2.142 (0.696 – 6.587) No (n = 62) 1 Type of surgeon 0.007 0.021 NAWS (n = 54) 1 1 AWS (n = 184) 0.140 (0.045 – 0.437) 0.123 (0.021 – 0.725) Primary hernia repair approach 0.822 Anterior (n = 207) 1 Posterior (n = 31) 0.841 (0.186 – 3.810) Primary hernia repair 0.145 Tissue repair (n = 113) 0.414 (0.127 – 1.354) Mesh repair (n = 125) 1 Recurrent hernia repair approach 0.028 0.521 Anterior (n = 67) 1 1 Posterior (n = 171) 3.414 (1.146 – 10.176) 0.554 (0.091 – 3.367) Postoperative complication 0.294 Yes (n = 48) 0.532 (0.163 – 1.730) No (n = 190) 1 NAWS: not specialized in abdominal wall surgery AWS: abdominal wall surgery surgical protocol can improve and refine the skills of sur- difficult procedures, the rate of complications between the geons involved in a specific abdominal wall surgery unit. groups was similar, and even in the AWS group there was a The group of patients operated on by surgeons not lower rate of recurrence. This can also be explained by the specialized in abdominal wall surgery were older and fact that surgeons from the abdominal wall unit performed presented more comorbidities, including COPD, which is a a higher number of guideline-based repairs (90% vs. 15%) recognized risk factor for recurrence [6] that could have than surgeons from other surgical units. In the literature, influenced the results observed in this group. However, in compliance with guideline-based repairs of 38.5% was multivariate analysis, COPD was not a risk factor for reported, and nonguideline-based repairs were associated recurrence in our study. This differences between the with higher rates of intraoperative complications, seroma groups can be explained by the fact that in our surgery formation, and recurrences [24]. Although there was department, younger patients with fewer comorbidities greater adherence to the guidelines in the AWS group, underwent surgery on an outpatient basis, and the abdom- compliance was not complete. This is demonstrated in the inal wall surgery unit is responsible for performing most imbalance observed between patients originally operated inguinal hernia repairs in this regimen. Interestingly, when on via a posterior approach (18%), in whom only 11% both groups were compared excluding patients who underwent an anterior approach. This is because the choice underwent outpatient surgery, no differences were of technique ultimately depended on the surgeons criteria observed in terms of age and most comorbidities; however, and patient-specific factors. In our study, there was a high the differences in postoperative results were maintained in percentage of patients who underwent regional anesthesia terms of lower recurrence rates in the AWS group. that would not be in accordance with guideline recom- Regarding the characteristics of the hernia, a higher mendations [6]. This can be explained by the fact that the percentage of patients with recurrences after a previous decision on the type of anesthesia was at the discretion of posterior approach and mesh techniques were operated on the anesthesiologist. However, in the AWS group there was in the group of surgeons from the abdominal wall unit. a significantly greater use of general anesthesia. Although these recurrences can be considered more 123 World J Surg (2023) 47:2425–2435 2433 Fig. 2 Cumulative probability of recurrence Despite the fact that preperitoneal approaches, both prior to recurrence repair. Second, the indication to per- open and laparoscopic, have better results and offer clear form recurrent inguinal hernia repair is often determined by benefits in this setting[25], in our series surgeons not spe- the degree of pain and disability, which may have caused a cialized in abdominal wall surgery used conventional selection bias. anterior approaches more frequently to repair recurrences. The current study has some limitations: (1) this is a The preperitoneal approach avoids scarred and distorted single-center retrospective study that, due to its nature, tissues that can increase the risk of local complications, could not collect some important variables, such as the ischemic orchitis, and CPIP [26]. On the other hand, this classification of the primary hernia; (2) there are no clear approach allows complete exposure of the myopectineal criteria to define both a surgeon and an abdominal wall orifice and allows the placement of a large mesh, poten- surgery unit; however, our unit complies with the tially reducing the risk of a new recurrence. In our opinion, requirements proposed to certify hernia centers in other this reinforces the importance of specialized abdominal European countries [9, 10]; (3) the surgical approach was wall surgery units where adherence to surgical guidelines performed at the surgeons discretion, which may lead to and protocols may be more feasible. selection bias; (4) not all patients were personally exam- The incidence of CPIP in the present study was 14% ined as the follow-up was based on a telephone question- without significant differences between the groups, while naire, which could affect the number of total recurrences the incidence reported in the literature was as high as detected; however, the VHRI method is considered an 27.6% depending on the type of approach, the definition of adequate instrument to minimize the risk of missing a CPIP, and the measurement methods [23, 27, 28]. Although recurrent hernia [15]; (5) as not all patients could be con- without significant differences, the percentage of patients tacted for telephone follow-up, reported rates of recurrence with CPIP was higher than in the AWS group; this could be and CPIP could potentially underestimate the current rate; explained by the fact that in this group there were a greater and 6) the fact that the AWS group had fewer comorbid number of multirecurrent hernias and recurrences after conditions (i.e., COPD) may have influenced the results in mesh repairs, factors that increase the risk of CPIP after terms of recurrence, however, in the subgroup analysis the recurrent inguinal hernia repairs [5]. The fact that no dif- results in favor of the group of patients operated on by ferences were found between the groups according to the abdominal wall surgery specialist remained when exclud- surgeons specialization must be interpreted with caution ing those patients operated on in outpatient surgery. for several reasons. First, due to the retrospective design of In summary, in this specific type of hernia, the choice of the study, it was not possible to obtain inguinal pain data the best surgical approach should be guided by experience, 123 2434 World J Surg (2023) 47:2425–2435 knowledge and implementation of protocols and clinical 2. Nilsson E, Haapaniemi S, Gruber G et al (1998) Methods of guidelines with a tailored approach allowing a low risk of repair and risk for reoperation in Swedish hernia surgery from 1992 to 1996. Br J Surg 85(12):1686–1691 surgical complications and fewer repeated recurrent ingu- 3. Haapaniemi S, Gunnarsson U, Nordin P et al (2001) Reoperation inal hernias. The results of our study with a lower repeated after recurrent groin hernia repair. Ann Surg 234:122–126 recurrence rate support the idea that the elective repair of 4. Köckerling F, Koch A, Lorenz R et al (2016) Open repair of recurrent inguinal hernia should be performed in the con- primary versus recurrent male unilateral inguinal hernias: peri- operative complications and 1-year follow-up. World J Surg text of a specialized abdominal wall surgery unit. 40:813–825 5. Sevonius D, Montgomery A, Smedberg S et al (2016) Chronic groin pain, discomfort and physical disability after recurrent Author contribution VR-G made substantial contributions to the groin hernia repair: impact of anterior and posterior mesh repair. conception and design of the study, acquisition of data, analysis, Hernia 20:43–53 interpretation of data and drafting the article. MM-L made substantial 6. HerniaSurge Group (2018) International guidelines for groin contributions to the acquisition of data, analysis and interpretation of hernia management. Hernia 22:1–165 data. MV-T made substantial contributions to acquisition of data, 7. Vandenbroucke JP, von Elm E, Altman DG et al (2007) analysis and interpretation of data. PM-L made substantial contribu- Strengthening the reporting of observational studies in epidemi- tions to acquisition of data. ML-C made substantial contributions ology (STROBE): explanation and elaboration. PLoS Med 4:e297 drafting the article and revising it critically for important intellectual 8. Benchimol EI, Smeeth L, Guttmann A, Working Committee content and for the final approval of the version to be submitted. RECORD et al (2015) The reporting of studies conducted using observational routenely-collected health data (RECORD) state- Funding Open Access Funding provided by Universitat Autonoma ment. PLoS Med 12:e1001885 de Barcelona. This work did not receive external funding from any 9. Maruthappu M, Gilbert BJ, El-Harasis MA et al (2015) The source other than the authors’ institution. influence of volume and experience on individual surgical per- formance: a systematic review. Ann Surg 261:642–647 Declarations 10. Pereira JA, Bravo-Salva A, Montcusı́ B et al (2019) Incisional hernia recurrence after open elective repair: expertise in Conflict of interest The authors have no conflicts of interest to abdominal wall surgery matters. BMC Surg 19(1):103 declare or financial ties to disclose. Manuel López-Cano has received 11. Köckerling F, Berger D, Jost JO (2014) What is a certified hernia honoraria for consultancy, lectures, support for travels and partici- center? The example of the German Hernia Society and German pation in review activities from BD-Bard, Medtronic and Gore. society of general and visceral surgery. Front Surg 1:26 12. Stabilini C, Cavallaro G, Bocchi P et al (2018) Defining the Ethical approval The ethics committees of hospital approved the characteristics of certified hernia centers in Italy: the Italian study. The study was conducted in accordance with the ethical prin- society of hernia and abdominal wall surgery workgroup con- ciples of the Declaration of Helsinki. sensus on systematic reviews of the best available evidences. Int J Surg 54:222–235 Consent to participate No signed informed consent was needed for 13. Charlson ME, Pompei P, Ales KL et al (1987) A new method of this study. classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis 40:373–383 14. Dindo D, Demartines N, Clavien PA (2004) Classification of Consent for publication Not applicable. surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213 Open Access This article is licensed under a Creative Commons 15. Tastaldi L, Barros PHF, Krpata DM et al (2020) Hernia recur- Attribution 4.0 International License, which permits use, sharing, rence inventory: inguinal hernia recurrence can be accurately adaptation, distribution and reproduction in any medium or format, as assessed using patient-reported outcomes. Hernia 24:127–135 long as you give appropriate credit to the original author(s) and the 16. Baucom RB, Ousley J, Feurer ID et al (2016) Patient reported source, provide a link to the Creative Commons licence, and indicate outcomes after incisional hernia repair-establishing the ventral if changes were made. The images or other third party material in this hernia recurrence inventory. Am J Sur 212:81–88 article are included in the article’s Creative Commons licence, unless 17. Hu QL, Chen DC (2018) Approach to the patient with chronic indicated otherwise in a credit line to the material. If material is not groin pain. 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