A recurrent hernia occurs at the site of a previous hernia repair. If a hernia or swelling develops near to a scar from the previous repair or operation it is usually not a “new” hernia. Most such lumbs occur due to a recurrence of the hernia and are called “recurrent” hernias”. The risk of developing a recurrent hernia depends the site of the hernia, how the hernia was repaired and the expertise of the surgeon. Experienced surgeons have lower recurrence rates compared to non-specialist surgeons.
The risk of a hernia coming back after surgical repair varies from 1 in 200 (0.5%) to 1 in 7 (15%). The single most important factor is the site of the original hernia. Inguinal hernias have the lowest recurrence rates compared to incisional and femoral hernias which have the highest risk of recurrence. The risk of developing a recurrent hernia is also substantially higher if no mesh was used compared to a repair where a synthetic mesh was used.
The type of surgery that was used to perform the repair is also a factor. The risk of developing a recurrent hernia after an open tension free mesh repair is around 0.5 – 1% compared to a risk of 2-5 % for a laparoscopic or keyhole repair.
The experience of the surgeon performing the surgery is also an important factor and inexperienced surgeons appear to have poorer results compared to experienced surgeons.
It is therefore clear that there are a number of factors that lead to the development of a recurrent hernia. Some of these are avoidable and some not e.g. you cannot avoid an emergency operation for a strangulated hernia. You also do not get to pick the site of your hernia which has an important role in determining your risk for recurrence. However, you do get to pick your surgeon, which has an important influence on your risk of developing a recurrence.
Reasons why a hernia may come recur
- Type of operation that was performed e.g. a stitched repair (no mesh used) is now rarely performed as the risk of recurrence is at least 5 times higher compared to a mesh repair. This is the case for inguinal, femoral, incisional and umbilical hernia repairs
- Type of hernia e.g. incisional hernias have a much higher risk compared to an inguinal hernia repair
- Surgeon experience. More experienced and specialist surgeons have a lower recurrence rate
- Operations performed as an emergency have a higher risk of recurrence compared to elective or planned surgery
- Redo operations performed for a recurrent hernia probably have a higher risk of developing a recurrent hernia compared to first time surgeries. It is best to get it right the first time with an experienced surgeon
How should recurrent hernias be fixed?
The ideal approach to a redo or recurrent hernia repair depends on the nature of the previous repair. Most commonly, patients will have had an open mesh repair. In this circumstance, redo surgery through the old incision can be a very difficult undertaking as all the tissues, nerves and blood vessels are usually pulled into the hernia and scar tissue from the previous repair.
A laparoscopic or keyhole approach in this setting offers the chance to approach the hernia from behind the abdominal wall in “virgin territory” deep to the old operation site. Such an approach means less traumatic and difficult surgery with a faster recovery less prone to complications.
The reverse is also true. Recurrent inguinal hernias following a primary laparoscopic repair are best repaired by an open approach in order to stay away from the scarring at the old operation site.
The same holds true for femoral and umbilical hernias. A laparoscopic approach is not always possible for a recurrent incisional hernia and a clinical decision will be made on the best approach based on site and nature of the previous surgeries.
Should all recurrent hernias be fixed?
Consideration should certainly be given to repairing most recurrent hernias. This is especially so for hernias that are causing symptoms such as pain, impairing mobility or activity. If you have a small recurrent hernia which is not causing any problems. it may be reasonable to observe, particularly if you are not keen for surgery or you have medical problems that might make you not fit enough for surgery. If this is the case, you should discuss with your doctor.
What are the risks and complications of redo surgery for a recurrent hernia?
In general terms, the nature of risks are similar to those for the original operation. Surgery for recurrent hernias is technically more difficult and as a consequence, the risk of developing a complication is higher. Side-
For a few days after the operation, emptying the bladder may be more difficult than usual, and in men, the scrotum may swell for a few days. These symptoms will clear up over a week or so, without the need for specific treatment. There will be small scars from the keyhole incisions and a longer scar if open surgery is performed.
Complications are unexpected problems that can occur during or after the operation. Most people are not affected, but the main possible complications of any surgery are an unexpected reaction to the anaesthetic, or developing a blood clot, usually in a vein in the leg (deep vein thrombosis).
To help prevent this, most people are given compression stockings to wear during the operation.
Complications may require further treatment such as returning to theatre to stop bleeding, or antibiotics to deal with an infection. Other complications can occur after a hernia operation. There’s a small chance of continuing pain in the groin area, caused by the handling of a nerve during surgery, or by the pressure on the nerves by scar tissue that forms during healing. In men, painful swelling of the scrotum or testicles occasionally occurs. This may require further surgery.
Inguinal hernias recur in 1-
Can I undergo repair of a recurrent hernia at the Scottish Hernia Centre?
Yes. Richard Molloy undertakes both open and laparoscopic hernia surgery on a regular basis at the Scottish Hernia Centre, based at Ross Hall hospital Glasgow. He has a particular interest in re-
Ross Hall hospital is Glasgow and Scotland’s premier private hospital, providing state of the art facilities to mange even the most complex hernia problem.
Is surgery the only option to treat my hernia?
Once an abdominal hernia occurs it tends to increase in size. If your hernia is not painful, is not getting larger, and is not trapped, you may choose to wait to have surgery. If you choose to wait, it is important to contact your doctor if you feel the hernia is getting bigger or if you experience sudden pain in the hernia. There are benefits and risks with both waiting and surgery. You should discuss both options with your doctor.
If after discussion with your surgeon, you have decided to adopt a watch and wait approach, it is important to avoid strenuous physical activity such as heavy lifting or straining with constipation. Some patients may find that a truss makes them more comfortable.
It is important to contact you doctor immediately if your hernia is getting bigger, more painful, if you develop nausea, vomiting, constant pain or discomfort in the hernia, or if the bulge does not return to normal when lying down or when you try to gently push it back in place. Ultimately, surgery is the treatment in almost all cases.
There are risks to not repairing a hernia surgically. Left untreated, a hernia may become incarcerated, which means it can no longer be reduced or pushed back into place. With an incarcerated hernia the intestines become trapped outside the abdomen. This could lead to a blockage in the intestine. If it is severe enough it may cut off the blood supply to the intestine and part of the intestine might actually die.
When the blood supply is cut off, the hernia is termed “strangulated.” Because of the risk of tissue death (necrosis) and gangrene, and because the hernia can block food from moving through the bowel, a strangulated hernia is a medical emergency requiring immediate surgery. Repairing a hernia before it becomes incarcerated or strangulated is much safer than waiting until complications develop.