Inguinal herniorrhaphy is among the most frequently performed general surgical procedures, with approximately 15% of cases being related to recurrent hernias. However, there is limited available evidence regarding the optimal management of recurrent inguinal hernias [1, 2]. Repairing these recurrent hernias presents a formidable challenge due to the pre-existing weakened tissues and the complex, obscured, and distorted anatomy. Consequently, the failure rate for repairs conducted using an open anterior approach can be as high as 36%. This underscores the need for improved strategies and techniques for managing recurrent inguinal hernias to enhance patient outcomes and reduce the risk of recurrence [3]. Nyhus, a renowned figure in the field of hernia surgery, has emphasized the evolution of the posterior preperitoneal approach for repairing recurrent inguinal hernias. He regarded this approach as the procedure of choice for managing all recurrent groin hernias [4]. Previous data published by the author highlighted that the posterior preperitoneal approach consistently produces results that are significantly superior to those achieved through the commonly used anterior approach. This recognition underscores the importance of adopting innovative and effective techniques in the surgical management of recurrent inguinal hernias to improve patient outcomes. The laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is a developing surgical technique known for its association with the well-established advantages of minimally invasive surgery [5, 6]. This approach offers the potential for reduced postoperative pain, quicker recovery, shorter hospital stays, and a lower rate of postoperative complications and recurrences [7]. It is an evolving and increasingly popular option in the field of hernia repair due to its minimally invasive nature and its potential to enhance patient outcomes. In a recent study, it was suggested that when it comes to treating recurrent inguinal hernias, the laparoscopic method should be the preferred choice, particularly for young, physically active, and non-obese patients. This recommendation aligns with the notion that laparoscopic repair offers distinct advantages in terms of reduced postoperative discomfort, faster recovery, shorter hospital stays, and lower complication rates [8].

Furthermore, there is a call for greater efforts to be made to enhance the accessibility and affordability of laparoscopic repair. This includes making the procedure easier to perform and ensuring that it is as safe and cost-effective as possible. These endeavors aim to expand the benefits of laparoscopic repair to a broader range of patients, ultimately improving the overall management of recurrent inguinal hernias.

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. In this study, patients were randomly allocated to one of three primary groups: Group A, Group B, and Group C. Patients in Group A underwent the open posterior preperitoneal approach, while those in Group B received transinguinal anterior tension-free repair [9]. Group C patients underwent the laparoscopic transabdominal preperitoneal (TAPP) procedure. This random allocation allowed for a comparative analysis of these different surgical approaches in the context of recurrent inguinal hernia repair. In this study, certain patient groups were excluded from the analysis. Specifically, patients with primary inguinal hernia, individuals with significant obesity (those with a Body Mass Index, or BMI, exceeding 35), and patients classified as ASA grade 3 or higher were not included in the study. These exclusions were likely made to focus the research on a specific population or to ensure that the study group was representative of a particular patient profile [10].

The open preperitoneal approach to the inguinal region was carried out under either general or regional anesthesia, following the original description by Nyhus. This surgical procedure involved making a transverse incision in the lower abdominal region. The anterior rectus sheath was then incised, and the rectus muscle was gently moved medially. Through blunt dissection, the preperitoneal space was accessed, revealing the myopectineal orifice. The spermatic cord was carefully explored, and any hernias were reduced. A polypropylene mesh, measuring \(15 \times 15 cm^{2}\) and featuring a slit, was introduced into the preperitoneal space [11]. This mesh was secured in place using non-absorbable sutures, attaching it to the pubic tubercle and Cooper’s ligament. The mesh was positioned behind the spermatic cord and adjusted to lie flat against the posterior inguinal floor, effectively covering and overlapping the entire myopectineal orifice. The anterior tension-free repair, following the definition by Lichtenstein and colleagues, involved the use of a \(6 \times 11 cm^{2}\) polypropylene mesh. Specifically, large pore-sized meshes with a diameter of 1.6 mm and made from monofilament heavy-weight polypropylene material were employed in this procedure [12]. In the TAPP procedure, the hernia defect was meticulously examined. The properitoneal space was dissected, starting from the lateral side and progressing medially at the retroinguinal space, which is also known as the Bogros’ space. During this dissection, the spermatic cord was carefully positioned posteriorly and away from the surgical field. The dissection continued medially toward the retropubic space, extending behind the symphysis pubis and the iliopubic tract. This meticulous dissection exposed the pectineal ligament.

Furthermore, the peritoneum, which formed the hernia sac, was gently pulled inward, effectively separating it from the cord structures. This step allowed for the safe and precise management of the hernia sac during the procedure.

The study participants’ ages ranged from 40 to 70 years, with an average age of 53.5 years. Follow-up assessments were conducted at specific intervals, including one week after discharge, at the one-month mark, and through regular visits every six months thereafter. This structured follow-up schedule allowed for the monitoring of patient progress and the evaluation of long-term outcomes [13]. The study reported varying operative times, hospital stays, and return-to-work durations among three distinct groups. In Group A, the mean operative time was 70.6 minutes, while in Group B, it averaged 92.7 minutes, with Group C including the setup of laparoscopy, resulting in a mean operative time of 120.5 minutes. Hospital stays showed differences, with Group A having a range of 1 to 3 days and an average of 2.1 days, Group B’s hospital stays ranging from 2 to 6 days with a mean of 3.5 days, and Group C experiencing 1-2 days in the hospital, averaging 1.2 days [14]. The time to return to work also differed; Group A averaged 8.4 days, Group B took 10.2 days, and Group C averaged 7.4 days. Consequently, the mean time off from work was notably longer in Group B, averaging 14.9 days, while Group A averaged 10.3 days, and Group C had the shortest time off at 8.9 days. Statistical analysis revealed a significant difference in the mean time off from work between the three groups, highlighting the variation in postoperative recovery times among them [15]. Subdivision of three groups regarding age and and body mass index is shown in Table 1.

In the context of early postoperative complications, Group A had 10% of patients experiencing mild scrotal swelling, which was attributed to tissue edema and not hematoma formation or wound seroma. In contrast, Group B had a higher incidence, with 20% of patients encountering mild to moderate scrotal swelling and seroma formation. Group C, on the other hand, exhibited a lower incidence, with only 6.7% of patients showing mild scrotal swelling. These findings suggest varying rates of early postoperative complications related to scrotal swelling and seroma formation among the three groups, with Group B experiencing the highest occurrence. Wound infections emerged as a complication in this study, with 5% of patients in both Group A and Group B affected. In these cases, treatment involved dressing changes in an outpatient clinic, combined with systemic antibiotics. Importantly, the mesh did not require removal in these instances, although patients from both groups later experienced re-recurrence of their condition [16]. In contrast, Group C had a lower rate of complications, with 6.7% of patients experiencing superficial port site infections. Again, outpatient clinic visits and dressing changes were sufficient for addressing these infections. Notably, there were no instances of testicular atrophy observed throughout the study. Moreover, in Group A, only two patients (3.3%) experienced recurrences over the follow-up period, demonstrating the relatively lower incidence of recurrence in this group.

The ideal method for inguinal hernia repair would prioritize the patient’s comfort, both during the surgical procedure and in the postoperative phase. It should be straightforward to perform and relatively easy to learn, while maintaining a low rate of complications and recurrence. Additionally, the recovery period for the patient should be relatively short. However, it’s worth noting that there is no universally accepted "best" method for every patient, and the choice of surgical technique may vary based on individual factors [17].

Furthermore, surgery for recurrent inguinal hernia following a mesh repair can pose significant challenges. Re-operating in this context often involves navigating through dense fibrotic scar tissue that has formed around the mesh. This presents the risk of potential testicular damage and can lead to an increased incidence of local hematomas [18]. Therefore, the surgical management of recurrent inguinal hernias can be particularly complex and demanding. In order to circumvent the challenges associated with re-operating through scar tissue and dense fibrotic regions surrounding mesh, the open posterior preperitoneal mesh repair technique, as popularized by Nyhus, has emerged as a promising alternative for the treatment of recurrent inguinal hernias. Prior research, such as that conducted by Saber and colleagues, has highlighted the many advantages of open preperitoneal hernia repair, particularly for cases of recurrence. This approach has demonstrated notably better outcomes compared to the commonly employed anterior approach. Moreover, the laparoscopic transabdominal preperitoneal (TAPP) procedure has gained widespread acceptance for the repair of both primary and recurrent hernias, especially following conventional transinguinal repairs. These surgical techniques offer effective solutions for addressing recurrent inguinal hernias while minimizing the difficulties associated with scar tissue and mesh-related complications [19]. The findings of our current study revealed a significant reduction in hospital stay, sick leave, and, consequently, the time taken off from work among patients who underwent the open posterior preperitoneal approach and the laparoscopic transabdominal preperitoneal (TAPP) procedure when compared to those who underwent the anterior approach. This reduction in recovery time was statistically significant. These results align with previous research in the same field, which has consistently reported shorter hospital stays and quicker return to regular physical activities for patients undergoing similar surgical approaches. This suggests that the open posterior preperitoneal approach and TAPP may offer distinct advantages in terms of postoperative recovery and patient resumption of normal daily activities. In a multicenter study, no significant difference was observed in the recurrence rate between laparoscopic and open methods of hernia repair [20]. However, it’s worth noting that while the laparoscopic technique demonstrated a significantly lower re-recurrence rate than the open technique, this difference did not reach statistical significance in short-term follow-up evaluations. Similarly, in our study, we found that the recurrence rate was statistically insignificant across the three groups, which is consistent with findings from other published studies.

Furthermore, an indirect comparison between the laparoscopic transabdominal preperitoneal (TAPP) and open (OHR) techniques, conducted through randomized controlled trials in a network meta-analysis, considered various outcomes including operative time, postoperative complications, hospital stay, postoperative pain, time to return to work, and recurrences. This study indicated that TAPP offered improved clinical outcomes in comparison to the open approach, further emphasizing the potential advantages of laparoscopic techniques in hernia repair [21].

In cases of recurrent inguinal hernia, both the laparoscopic and open posterior approaches have demonstrated comparable effectiveness in terms of operative outcomes. The open preperitoneal hernia repair method offers several advantages, including cost-effectiveness, a low recurrence rate, and the ability to cover all potential defects with a single piece of mesh. Additionally, patients tend to experience a shorter postoperative recovery period and minimal postoperative pain with this approach, leading to notably better results compared to the commonly used anterior approach.

Conversely, laparoscopic hernia repair presents its own set of advantages, despite the longer learning curve and the inherent difficulty in mastering this technique. The benefits of laparoscopic repair include reduced post-operative pain, earlier recovery with shorter hospital stays, and lower rates of post-operative complications and recurrence. In essence, both approaches offer distinct advantages, making them valuable options in the management of recurrent inguinal hernias, and the choice between them may depend on individual patient characteristics and surgeon expertise.

This research paper received no external funding.

The authors declare no conflicts of interest.

All authors contributed equally to this paper. They have all read and approved the final version.

Informed consent was obtained from all participates in the study as needed.

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