inguinal herniorrhaphy remains one of the most common general surgical operations , with approximately 15% performed for recurrence and there is little available evidence on the optimal management of recurrent inguinal hernia .
the repair of the resulting recurrent hernia is a daunting task because of already weakened tissues and obscured and distorted anatomy and therefore failure rate of these repairs using an open anterior approach may reach as high as 36% . in 1988 , nyhus stated that the evolution of the posterior preperitoneal approach for recurrent inguinal hernia repair made it the procedure of choice for the management of all recurrent groin hernias . in previous published data ,
the author reported that posterior preperitoneal approach gives results far superior to those of the commonly used anterior approach .
the laparoscopic transabdominal preperitoneal ( tapp ) inguinal hernia repair is an evolving technique associated with the well - known advantages of a minimally invasive approach .
a recent study stated that for the treatment of recurrent inguinal hernias , the first choice should be given to the laparoscopic method , especially for young , physically active , non - obese patients .
some researchers advised that greater efforts should be undertaken to make laparoscopic repair easier , safer , and less expensive . the present work aimed at comparing three approaches in repair of recurrent inguinal hernia : anterior inguinal approach , open properitoneal repair and transabdominal pro - peritoneal repair regarding complications and early recurrence .
patients in this study were divided randomly into three main groups : a , b , and c. group a patients were subjected to open posterior preperitoneal approach , those of group b were subjected to transinguinal anterior tension - free repair and group c patients were subjected to tapp .
all of our patients were gentlemen with total number was 180 patients ; 60 for each group , their ages ranged between 42 and 65 years .
the study started from january 2007 to april 2011 and included all patients having unilateral recurrent inguinal scrotal and irreducible hernias . patients with primary inguinal hernia , patients with marked obesity ( bmi > 35 ) and asa grade 3 and beyond were excluded .
calculation of the sample size included the number of participants to be recruited for the study using the mathematical equation .
the authors used two equations to calculate the minimum number required to reliably answer the research question .
randomization was performed prior to the study using a computer - generated table of random numbers for group assignment .
operations were performed in port - fouad general hospital , port - fouad , port - said , egypt and in the university hospital , department of surgery , faculty of medicine , suez canal university , egypt . 

the open preperitoneal approach to the inguinal region was performed under general or regional anesthesia , as originally described by nyhus . through a lower abdominal transverse incision ,
a 15 15 cm polypropylene mesh with a slit was inserted in the preperitoneal space and fixed with non - absorbable sutures to pubic tubercle and cooper 's ligament .
the mesh was passed behind the cord and manipulated to lay flat against the posterior inguinal floor overlapping the entire myopectineal orifice.the anterior tension - free repair , as defined by lichtenstein et al .
large pore - sized ( 1.6 mm ) , monofilament heavy - weight polypropylene meshes were used ( prolene ; ethicon , egypt ) .
really our patients were oriented to the type of repair and the other observers were unaware to operative techniques of the study groups.the laparoscopic transabdominal preperitoneal repair ( tapp ) : 
  the open preperitoneal approach to the inguinal region was performed under general or regional anesthesia , as originally described by nyhus . through a lower abdominal transverse incision ,
a 15 15 cm polypropylene mesh with a slit was inserted in the preperitoneal space and fixed with non - absorbable sutures to pubic tubercle and cooper 's ligament .
the mesh was passed behind the cord and manipulated to lay flat against the posterior inguinal floor overlapping the entire myopectineal orifice . the anterior tension - free repair , as defined by lichtenstein et al . ,
large pore - sized ( 1.6 mm ) , monofilament heavy - weight polypropylene meshes were used ( prolene ; ethicon , egypt ) .
really our patients were oriented to the type of repair and the other observers were unaware to operative techniques of the study groups .
the properitoneal space was dissected from lateral to medial at the level of the retroinguinal ( bogros ' ) space , with parietalization of the spermatic cord posteriorly and outwards .
the dissection was continued medially toward the retropubic space , extending behind the symphysis pubis and iliopubic tract , exposing the pectineal ligament .
the peritoneum forming the hernia sac was pulled in , separating it from the cord structures . a 15  10 cm sheet of polypropylene mesh
was placed so as to cover the hesselbach 's triangle , the indirect space , and the femoral ring areas .
the mesh was fixed using an endoscopic multifire hernia stapler ( ethicon , johnson and johnson ) , beginning at the pubic tubercle and proceeding laterally . the peritoneum is tightly closed using 3/0 running vicryl suture .
the fascia at the two 10/12 mm port site is closed using 2 - 0 prolene sutures .
the primary end point of the study was the recurrence of the hernia , defined as a clinically detectable characteristic swelling in the groin and diagnosed by two authors .
the secondary end points were time off from work , defined as the number of days between the day of surgery and the first day a patient returned to work , postoperative pain , scrotal swelling , and wound infections . regarding the postoperative pain , we considered the visual analog scale pain score , prosthesis awareness and return to normal physical activity .
chronic pain was defined as pain lasting more than 3 months and was studied in relation to age , body mass index and operative procedure .
this system is a 3-scale system ; with maximum score as 7 points and minimum as 2 points . 

analog scale pain score ( 1 - 10 ) : mild ( 1 - 4 ) = 1 point , moderate ( 5 - 7 ) = 2 points , severe ( 8 - 10 ) = 3 points.prosthesis awareness : yes = 1 point , no = 0
point.physical activity : pain only on exertion = 1 pain limits some daily activity = 2 , disabling pain = 3 . 
 
analog scale pain score ( 1 - 10 ) : mild ( 1 - 4 ) = 1 point , moderate ( 5 - 7 ) = 2 points , severe ( 8 - 10 ) = 3 points .
physical activity : pain only on exertion = 1 pain limits some daily activity = 2 , disabling pain = 3 .
ethical approval for this study was granted by the ethical review committee under supervision of the general director of port- fouad general hospital , port - fouad , port - said , egypt .
the statistical tests were run on a compatible personal computer using the statistical package for social scientists ( spss ) for windows 15 .
chi - square distribution was used for studying the frequencies of recurrence , pain , hospital stay , and postoperative complications .
the mean values of the groups were compared by one - way analysis of variance ( anova ) and paired comparisons of the groups were done using the paired student t - test .
patients in this study were divided randomly into three main groups : a , b , and c. group a patients were subjected to open posterior preperitoneal approach , those of group b were subjected to transinguinal anterior tension - free repair and group c patients were subjected to tapp .
all of our patients were gentlemen with total number was 180 patients ; 60 for each group , their ages ranged between 42 and 65 years .
the study started from january 2007 to april 2011 and included all patients having unilateral recurrent inguinal scrotal and irreducible hernias . patients with primary inguinal hernia , patients with marked obesity ( bmi > 35 ) and asa grade 3 and beyond were excluded .
calculation of the sample size included the number of participants to be recruited for the study using the mathematical equation .
the authors used two equations to calculate the minimum number required to reliably answer the research question .
randomization was performed prior to the study using a computer - generated table of random numbers for group assignment .
operations were performed in port - fouad general hospital , port - fouad , port - said , egypt and in the university hospital , department of surgery , faculty of medicine , suez canal university , egypt .

 the open preperitoneal approach to the inguinal region was performed under general or regional anesthesia , as originally described by nyhus . through a lower abdominal transverse incision ,
a 15 15 cm polypropylene mesh with a slit was inserted in the preperitoneal space and fixed with non - absorbable sutures to pubic tubercle and cooper 's ligament .
the mesh was passed behind the cord and manipulated to lay flat against the posterior inguinal floor overlapping the entire myopectineal orifice.the anterior tension - free repair , as defined by lichtenstein et al .
large pore - sized ( 1.6 mm ) , monofilament heavy - weight polypropylene meshes were used ( prolene ; ethicon , egypt ) .
really our patients were oriented to the type of repair and the other observers were unaware to operative techniques of the study groups.the laparoscopic transabdominal preperitoneal repair ( tapp ) : 
  the open preperitoneal approach to the inguinal region was performed under general or regional anesthesia , as originally described by nyhus . through a lower abdominal transverse incision , the anterior rectus sheath was incised and the rectus muscle reflected medially .
a 15 15 cm polypropylene mesh with a slit was inserted in the preperitoneal space and fixed with non - absorbable sutures to pubic tubercle and cooper 's ligament .
the mesh was passed behind the cord and manipulated to lay flat against the posterior inguinal floor overlapping the entire myopectineal orifice . the anterior tension - free repair , as defined by lichtenstein et al . ,
large pore - sized ( 1.6 mm ) , monofilament heavy - weight polypropylene meshes were used ( prolene ; ethicon , egypt ) .
really our patients were oriented to the type of repair and the other observers were unaware to operative techniques of the study groups .
the properitoneal space was dissected from lateral to medial at the level of the retroinguinal ( bogros ' ) space , with parietalization of the spermatic cord posteriorly and outwards .
the dissection was continued medially toward the retropubic space , extending behind the symphysis pubis and iliopubic tract , exposing the pectineal ligament .
the peritoneum forming the hernia sac was pulled in , separating it from the cord structures .
a 15  10 cm sheet of polypropylene mesh was placed so as to cover the hesselbach 's triangle , the indirect space , and the femoral ring areas .
the mesh was fixed using an endoscopic multifire hernia stapler ( ethicon , johnson and johnson ) , beginning at the pubic tubercle and proceeding laterally . the peritoneum is tightly closed using 3/0 running vicryl suture . the trocars are removed under direct vision , and the peritoneum is deflated .
the fascia at the two 10/12 mm port site is closed using 2 - 0 prolene sutures .
the primary end point of the study was the recurrence of the hernia , defined as a clinically detectable characteristic swelling in the groin and diagnosed by two authors .
the secondary end points were time off from work , defined as the number of days between the day of surgery and the first day a patient returned to work , postoperative pain , scrotal swelling , and wound infections . regarding the postoperative pain , we considered the visual analog scale pain score , prosthesis awareness and return to normal physical activity .
chronic pain was defined as pain lasting more than 3 months and was studied in relation to age , body mass index and operative procedure .
this system is a 3-scale system ; with maximum score as 7 points and minimum as 2 points . 

analog scale pain score ( 1 - 10 ) : mild ( 1 - 4 ) = 1 point , moderate ( 5 - 7 ) = 2 points , severe ( 8 - 10 ) = 3 points.prosthesis awareness : yes = 1 point , no = 0 point.physical activity : pain only on exertion = 1 pain limits some daily activity = 2 , disabling pain = 3
. 
  analog scale pain score ( 1 - 10 ) : mild ( 1 - 4 ) = 1 point , moderate ( 5 - 7 ) = 2 points , severe ( 8 - 10 ) = 3 points .
physical activity : pain only on exertion = 1 pain limits some daily activity = 2 , disabling pain = 3 .
written consents were obtained from all patients before the study . the steps of operative interferences
was granted by the ethical review committee under supervision of the general director of port- fouad general hospital , port - fouad , port - said , egypt .
the statistical tests were run on a compatible personal computer using the statistical package for social scientists ( spss ) for windows 15 .
chi - square distribution was used for studying the frequencies of recurrence , pain , hospital stay , and postoperative complications .
the mean values of the groups were compared by one - way analysis of variance ( anova ) and paired comparisons of the groups were done using the paired student t - test .
there was no statistical difference between the three groups regarding patients ' age and body mass index [ table 1 ] .
showing subdivision of the three groups regarding age and body mass index age ranged between 42 and 65 years with a mean age as 53.5 years .
follow - up assessment was at the 1st week after discharge then at 1st month and through regular visit of 6 months duration or by a telephone call thereafter .
follow up included patients ' complaint , if any , clinical examination and ultrasonography if needed .
the maximum follow - up period was 60 months and the minimum was 22 months with a mean value as 41  26.87 months .
a complete follow - up was obtained in 56/60 ( 93.3% ) of patients in group a , 54/60 ( 90% ) of patients in group b , and 58/60 ( 96.2% ) in group c. the mean operative time in group a was 71.6 min  25.47 ( 40 - 120 ) . in group b , the mean value was 94.7 min  28.5 ( 60 - 150 ) . in group c , the operative time was calculated just after the induction of anesthesia and including the time required for the setup of the laparoscopy .
the mean operative time in group c was 122.5 min  31 ( 80 - 170 ) .
the mean hospital stay was 1- 3 days ( 2.1  0.8 ) in group a , 2 - 6 days ( 3.7  1.5 ) in group b and 1 - 2 days ( 1.3  0.5 ) in group c. in the other hand , the mean time to return work was 8.2  1.15 ( 7 - 10 ) days in group a while in group b was 11.2  2.3 ( 7 - 15 ) and in group c was 7.6 1.4 ( 6 - 9 ) days . therefore , the mean time off from work in group a was 10.3  1.95 days and in group b was 14.9  3.8 while in group c was 8.9  1.9 [ p < 0.05 ] .
chronic postoperative pain was observed in 8 patients in group a ( 13.33% ) , in 18 patients in group b ( 30% ) , and 6 patients in group c ( 10% ) .
table 2 shows the detailed descriptions of pain in the three groups as well as the final pain score per patient [ p < 0.003 ] .
the authors found that 6/8 patients in group a were in the age group < 50 years and the other two were > 50 year while regarding the body mass index , all 8 patients were < 30 . in group b ,
bmi < 25 kg / m and the remaining 6 were in the age group > 50 and bmi < 30 kg / m2 .
however , 5/6 patients in group c were in the age group < 50 years while regarding the body mass index , all 6 patients were < 30 .
all patients who were aware of the presence of prosthesis and pain on exertion belonged to the smaller age group < 50 and the less bmi < 25 kg / m . showing the detailed descriptions of pain in both groups as well as
the final pain score per patient regarding the early postoperative complications , 6 patients ( 10% ) in group a developed mild scrotal swelling due to tissue edema not for hematoma formation and wound seroma formation while in group b , the figure was higher as 12 patients ( 20% ) experienced mild to moderate scrotal swelling and seroma . in group c ,
wound infection was seen in three patients ( 5% ) in groups a and b necessitating only dressing in the outpatient clinic under cover of systemic antibiotics with no need to remove the mesh but those patients developed re - recurrence thereafter . in group c ,
four patients ( 6.7% ) showed superficial port site infection necessitating only dressing in the outpatient clinic .
testicular atrophy was not seen and only two recurrences ( 3.3% ) in group a all over the period of follow up .
five cases of testicular atrophy ( 8.3% ) and four cases of hernia recurrence ( 6.25% ) were seen in group b. however , in group c three patients came with recurrence with no testicular atrophy reported [ p  0.05 ] .
moreover , the overall postoperative complication rates were 18.3% and 40% in group a and group b , respectively with significant distribution { p < 0.01 } [ table 3 ] . showing the detailed descriptions of results in the three groups with corresponding p - values
the ideal method for repair of inguinal hernia would cause minimal discomfort to the patient , both during the surgical procedure and in the postoperative course
. it would be technically simple to perform and easy to learn , would have a low rate of complications and recurrence , and would require only a short period of convalescence .
however , the most effective method in any given patient is not clearly defined and consequently surgery for recurrent inguinal hernia after mesh repair is usually a difficult operation due to the disadvantage of re - operating through dense fibrotic scar tissue around the mesh with the risk of testicular damage and a large number of local hematoma . to avoid the disadvantage of re - operating through scar tissue and dense fibrotic scar tissue around the mesh ,
the open posterior preperitoneal mesh repair was popularized by nyhus as a good alternative for recurrent inguinal hernias . in previous study ,
saber and co - workers 1 reported that open preperitoneal hernia repair offers many advantages over the transinguinal repair for recurrent hernia .
laparoscopic transabdominal preperitoneal ( tapp ) procedure generally is accepted for the repair of primary and recurrent hernias that follow conventional transinguinal repair . in the present study , we found that the time of hospital stay and sick leaves and accordingly the time off from work all were reduced in patients with open posterior preperitoneal approach and tapp compared with the anterior approach and the difference was statistically significant .
many studies of same interest reported less hospital stay and rapid return to physical activity .
chronic postoperative pain is strongly related to two main patient - related factors ; age and body mass index or three surgery  related factors such as surgery for recurrence with anterior approach , operations performed in specialist hernia centers , and finally the experience of the surgeon .
the total laparoscopic preperitoneal ( tapp ) and then the open preperitoneal approach in the present study significantly reduced the final chronic pain score per patient in comparison with the anterior transinguinal approach and our data came in concordance with studies of same interest . , there are many studies traced patient age in relation to occurrence chronic pain and found that the risk of chronic pain decreased with increasing age .
the bmi is another studied factor for chronic pain occurrence where many investigators found good correlation between less bmi values and chronic pain and our data in the present study supported these finding .
the postoperative complications of hernia repair were estimated regarding the rate and traced regarding the type in similar previous studies as early and delayed forms .
early complication , defined as that occurring within 1 month of surgery , are wound seroma , sepsis , scrotal edema and hematoma formation while the long - term complications , assessed at 3 months are testicular atrophy and recurrence . in published literatures ,
the overall postoperative complication rates were 18 - 38% and may reach as high as 49.7% in some series and in our study , the overall complication rate was 19.7% in both groups a and c and 34.36% in group b due to more tissue dissection and manipulation .
wound hematoma and superficial wound infections are the most common problems in previous series and serious complications , such as major hemorrhage , pubic osteitis and testicular atrophy , occur in less than one percent of patients undergoing herniorrhaphy .
minor complications such as seroma formation , wound sepsis , and scrotal hematoma were seen in the three groups in the present study but with more incidence in group b. this observation met with data reported by other investigators .
long term complications such as testicular atrophy and recurrence were traced by many researchers who reported 0% incidence for testicular atrophy and 0% or very low incidence ( 1.5% ) for recurrence in their studies . while others found 4.38% hernia recurrence after posterior preperitoneal repair 10% in the open anterior approach while other data ranged between 2% and 14% . in a multicenter study
, there was no significant difference in the recurrence rate between laparoscopic and open methods of hernia repair was revealed .
however , while the laparoscopic technique has a significantly lower re - recurrence rate than the open technique , there is no statistical difference in the re - recurrence rate between the two techniques during short - term follow - up evaluation .
accordingly , we found that recurrence rate was statistically insignificant in the three groups and this finding met with other data in published literatures .
an indirect comparison between tapp and open ( ohr ) techniques by considering randomized , controlled trials in a network meta - analysis , the following outcomes were considered : operative time , postoperative complications , hospital stay , postoperative pain , time to return to work and recurrences .
testicular dysfunction , atrophy and necrosis as a result of ischemic orchitis is a well - known complication after anterior inguinal hernia repair with 1% occurrence following primary herniorrhaphy and 5% in recurrent cases but in open preperitoneal repair , the procedure is safe as it effectively eliminates testicular complications .
a significant decrease in testicular volume and less improvement in blood flow is seen after open repair where there is significant reduction in serum testosterone , follicle stimulating ( fsh ) , and leutinizing ( lh ) hormones level .
testicular ischemia and necrosis are thought to be due to acute thrombosis of the pampiniform venous plexus rather than arterial injury , as there is collateral arterial flow to the testis from the inferior epigastric , vesical , prostatic , and scrotal arteries .
testicular atrophy is thought to be more common after open procedures particularly recurrent inguinal hernias due to greater manipulation of the spermatic cord beyond the pubic tubercle and during dissection of the distal hernia sac . according to these finding , we found that no testicular atrophy was seen in patients of both groups a and c but seen in two patients of group b ( 4.25% ) due to operating within the fibrotic field with tissue reaction around the mesh .
in recurrent inguinal hernia , the laparoscopic and open posterior approaches are equally effective in term of operative outcome .
it is inexpensive , has a low recurrence rate , and allows the surgeon to cover all potential defects with one piece of mesh .
however , while laparoscopic hernia repair requires a lengthy learning curve and is difficult to learn and perform , it has advantages of less post - operative pain , early recovery with minimal hospital stay , low post - operative complications , and recurrence .
 introduction : the repair of the recurrent hernia is a daunting task because of already weakened tissues and distorted anatomy . 
 open posterior preperitoneal approach gives results far superior to those of the anterior approach . 
 laparoscopic transabdominal preperitoneal ( tapp ) inguinal hernia repair is an evolving technique associated with advantages of a minimally invasive approach . 
 the present work aimed at comparing these three approaches for repair of recurrent inguinal hernia regarding complications and early recurrence.materials and methods : a total of 180 patients were divided randomly into three equal groups : a , b , and c. group a patients were subjected to open posterior preperitoneal approach , those of group b were subjected to transinguinal anterior tension - free repair and group c patients were subjected to tapp . 
 the primary end point was recurrence and the secondary end points were time off from work , postoperative pain , scrotal swelling , and wound infections.results:the mean hospital stay , the mean time to return to work and the mean time off from work were less in group c then a and b. chronic postoperative pain was observed in eight patients in group a ( 13.33% ) , in 18 patients in group b ( 30% ) and six patients in group c ( 10% ) . 
 the overall complication rate was 19.7% in both groups a and c and 34.36% in group b.conclusion:in recurrent inguinal hernia , the laparoscopic and open posterior approaches are equally effective in term of operative outcome . 
 the open preperitoneal hernia repair is inexpensive , has a low recurrence rate . 
 postoperative recovery is short and postoperative pain is minimal . 
 this approach gives results far superior to those of the commonly used anterior approach . 
 however , while laparoscopic hernia repair requires a lengthy learning curve and is difficult to learn and perform , it has advantages of less post - operative pain , early recovery with minimal hospital stay , low post - operative complications and recurrence.trial registrationactrn12613001050741 
Trial Registration
INTRODUCTION
MATERIALS AND METHODS
Materials
Sample Size and Randomization
Surgical Teams and Study Sites
Operative Techniques
End Points
Ethical Consideration
Statistical Analysis
RESULTS
DISCUSSION
CONCLUSION