Original article

Risk of recurrence 5 years or more after primary Lichtenstein

mesh and sutured inguinal hernia repair
T. Bisgaard1,2 , M. Bay-Nielsen1 , I. J. Christensen1 and H. Kehlet1,3
1
Danish Hernia Database, Department of Gastroenterology, Hvidovre University Hospital, Hvidovre, 2 Department of Surgical Gastroenterology,
Glostrup University Hospital, Glostrup and 3 Section for Surgical Pathophysiology, The Juliane Marie Centre, Rigshospitalet, Copenhagen, Denmark
Correspondence to: Dr T. Bisgaard, Danish Hernia Database, Department of Gastroenterology, Hvidovre University Hospital, Hvidovre 2650, Denmark
(e-mail: thuebisgaard@tdcadsl.dk)

Background: The risk of recurrence of inguinal hernia within 5 years of repair is lower after mesh than
sutured repair in men, but no large-scale studies have compared the risk of recurrence beyond 5 years.
Methods: The Danish Hernia Database prospectively collects data on almost all primary inguinal hernia
repairs in men (older than 18 years). This study used data recorded over 8 years, analysing reoperations
for recurrent hernia in the intervals 0–30 months, 30–60 months and 60–96 months after operation.
Results: The reoperation rate was significantly lower after Lichtenstein open mesh repairs than open
sutured repairs (Cox hazard ratio (HR) 0·45 (95 per cent confidence interval (c.i.) 0·39 to 0·51) for
0–30 months after surgery; HR 0·38 (95 per cent c.i. 0·29 to 0·49) for 30–60 months). In 13 674 primary
inguinal hernia repairs with an observation interval of 5 years or more, the risk of reoperation after
Lichtenstein repair was a quarter of that after sutured repair (HR 0·25 (95 per cent c.i. 0·16 to 0·40) for
60–96 months after surgery). After 5 years, the reoperation rate increased continuously after sutured
repair but not after mesh repair.
Conclusion: Lichtenstein mesh repair for inguinal hernia prevented recurrence beyond 5 years after the
primary operation, but sutured repair did not.

Paper accepted 6 June 2007

Published online 2 July 2007 in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.5756

Introduction with sutured open repair of primary inguinal hernia, with

It is well established that open inguinal hernia repair with
a mesh technique has a recurrence rate lower than that
after open sutured repair1 , although similar to that of
laparoscopic repair2 – 7 . Despite an increased use of mesh
repairs, either open or laparoscopic, the number of repairs
for recurrent inguinal hernia is decreasing only slowly8 ,
and the question has arisen whether mesh repair just
delays recurrence until the usual observation interval of
1–5 years has passed8 . Observations in incisional hernia
showed an initial reduction in the recurrence rate after
mesh repair but a subsequent linear rise of the cumulative
rate of operations after both sutured and mesh repair9,10 .
These findings suggested that the late recurrence may
have resulted from scar remodelling rather than surgical
technique8 . However, the question remains for inguinal
hernias, as there has been no large series with long-term
follow-up of more than 5 years.
The aim of this nationwide study was to assess
reoperation rates in men after Lichtenstein mesh compared
an observation interval of 5–8 years.
Methods
The study included data from 47 975 inguinal hernia repairs
in men (over 18 years) recorded in the Danish Hernia
Database, who had undergone an elective primary inguinal
hernia repair in Denmark between 1 January 1998 and
31 December 2005. More than 98 per cent of all inguinal
hernias in Denmark are reported to the Danish Hernia
Database11 . Owing to the unique national civil register with
personal numbers, a complete follow-up on reoperations
is ensured. Details about data collection and management
have been described previously11 .
Patients had Lichtenstein mesh repair or one of the
following non-mesh repairs: annulorrhaphy, Bassini repair,
Shouldice repair or McVay repair. The rate of reoperation
was used as a proxy for recurrence. Reoperation for
recurrence was defined as a hernia repair in the same

Copyright  2007 British Journal of Surgery Society Ltd British Journal of Surgery 2007; 94: 1038–1040
Published by John Wiley & Sons Ltd
Recurrence after inguinal hernia repair
groin as the initial repair, performed after 1 January
1998. Reoperations because of haematoma, infectious
complication or neuralgia were ruled out, as these
complications are not routinely recorded in the database.
To find the long-term results on recurrence, the two
largest groups in the database (open mesh and sutured
repair) were considered, excluding laparoscopic repairs
as only 5–8 per cent of patients in Denmark have these.
Reoperations for recurrence in the intervals 0–30 months
(interval 1), 30–60 months (interval 2) and 60–96 months
(interval 3) after operation were analysed.
Statistical analysis
Estimates of the probability of recurrence were obtained
using the life-table method. The time to recurrence for
sutured and Lichtenstein mesh repairs was compared using
the Cox proportional hazards model. Operation types were
the time-dependent co-variates. Cut-off points were at 30
and 60 months. The analysis of intergroup differences used
the likelihood ratio and Mann–Whitney non-parametric
tests when appropriate. P < 0·050 was considered signifi-
cant. The analysis was performed using SAS version 9.1
(SAS Institute, Cary, North Carolina, USA).
Results
A total of 47 975 primary inguinal hernias with a
Lichtenstein mesh or sutured open repair were recorded.
Table 1 gives patient ages and hernia types for sutured
and mesh repairs. Late recurrences after open non-mesh
repairs were more often performed for an indirect hernia
(76·0 per cent) compared to 54·0 percent of those receiving
a mesh repair (Table 1).
Figure 1 shows the cumulative probability of recurrence
for each type of operation (life-table curves). Reoperation
Table 1 Demographic data and hernia type
Sutured repair Mesh repair
(n = 4932) (n = 43 043)
Median (range) age (years) 51 (18–97) 58 (18–99)†
Hernia type*
Direct 1184 (24.0) 19 800 (46.0)
Indirect 3748 (76.0) 23 243 (54.0)
Technique
Annulorrhaphy 2555
Bassini 1027
McVay 707
Shouldice 643
*Values in parentheses are percentages. †P < 0·001 versus sutured repair
(Mann–Whitney U test).
Copyright  2007 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
1039
10 Interval 1 Interval 2 Interval 3
8
Recurrence (%)
6 Sutured repair
Mesh repair
4
2
0 6 12 18 24 30 36 42 48 54 60 66 72 78 84 90 96
No. at risk
Time after surgery (months)
Sutured repair 4932 4650 4338 3989 3416 2801 2047 1202 127
Mesh repair 43043 36639 29802 22711 16385 10873 5976 2347 190
Fig. 1 Life-table curves illustrating the risk of recurrence after
sutured and Lichtenstein mesh repairs for primary inguinal
hernia in men. The risk of reoperation was significantly lower
after a mesh repair than a sutured repair for each interval
(0–30 months, hazard ratio (HR) 0·45; 30–60 months, HR 0·38;
60–96 months, HR 0·25) (P < 0·001, Cox regression)
rates were significantly lower after Lichtenstein mesh
repairs than sutured repairs (Cox hazard ratio (HR) 0·45
(95 per cent confidence interval (c.i.) 0·39 to 0·51) for
interval 1 and 0·38 (95 per cent c.i. 0·29 to 0·49) for
interval 2). In 13 674 primary inguinal hernia repairs with
an observation interval of 5 years or more, the HR for
interval 3 was 0·25 (95 per cent c.i. 0·16 to 0·40); in other
words, more than 5 years after a Lichtenstein repair, the
risk of reoperation was only one-quarter of that after a
sutured repair. The reoperation rate continued to increase
after sutured repair, whereas it remained constant after
Lichtenstein repair (Fig. 1). The cumulative reoperation
rate was significantly lower after mesh than sutured repairs
within 5–8 years from the initial operation (P < 0·001).
There was no significant intergroup difference in the risk
of reoperation between the different non-mesh techniques
(P = 0·280).
The recurrences after 5 years (n = 74) were almost all
inguinal, with only two (6·3 per cent) femoral recurrences
in the mesh group (32 recurrences) and none after a sutured
repair (42 recurrences).
Discussion
This study of reoperation rates after open inguinal hernia
repair clearly demonstrates that the low early rate after
Lichtenstein mesh repair compared with sutured repair1 – 3
is maintained beyond 5 years, with very few reoperations,
in contrast to a further steady increase after sutured repair.
This is the first large-scale long-term follow-up study
beyond 5 years after the primary operation comparing
reoperation rates after sutured and Lichtenstein mesh
www.bjs.co.uk British Journal of Surgery 2007; 94: 1038–1040
1040
repairs. Measuring reoperations is an acceptable proxy for
recurrences; although as many as 30–50 per cent of recur-
rences are asymptomatic or do not lead to reoperations,
this study was investigating recurrences serious enough to
require reoperation, and so the results are valid.
These findings contrast with observations after incisional
hernia repair9 , where both mesh and suture groups showed
a steady increase in reoperation rate, despite an initial
reduction after mesh repair. Those results suggested that
incisional hernia reoperations may represent a biological
problem of scar healing10 , which may not be the case after
an inguinal mesh hernia repair. Despite the positive long-
term results after a mesh repair, the overall percentage of
operations for recurrent inguinal hernia has shown only
a slow decrease based on nationwide or large regional
data8,12 – 14 , which is explained by a constant inflow and
development of recurrences which reflects previous use of
suture techniques.
The recurrences after 5 years were almost all true
inguinal recurrences after both techniques, in contrast
to the presence of femoral ‘recurrences’ in the early
observation interval15 , which may have been femoral
hernias that had been overlooked at the primary operation.
The present study found more late recurrences after
open non-mesh repairs including annulorrhaphy, which
were performed for an indirect hernia in about 75 per cent
of these patients, compared with about 50 per cent in the
mesh repair group. However, this skew in distribution of
hernia type between the sutured and mesh repair groups
cannot explain the difference in long-term outcome, as
direct hernias may be more prone to recurrence than indi-
rect hernias after a sutured repair16 . The fact that there is no
difference in chronic pain after open mesh and non-mesh
repair3,17 suggests that a mesh repair should be used even
in younger adult patients with an indirect hernia. These
large-scale nationwide results lend further support to the
established value of a mesh repair for an inguinal hernia.
Acknowledgements
The Danish Hernia Database was funded by Danish
Regions.
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Copyright  2007 British Journal of Surgery Society Ltd
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