Ambulatory bilateral groin hernia repair: open preperitoneal versus laparoscopic outcomes

Over the years, multiple surgical techniques have been developed for inguinal hernia repair, each offering specific advantages and limitations. The ideal technique should be reproducible, cost-effective, and associated with low recurrence and chronic pain rates, minimal complications, and a fast, safe recovery [1].

The HerniaSurge group published the first international guidelines for the management of bilateral groin hernia (BGH), recommending minimally invasive surgery (MIS)—either transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) —as the preferred approach for primary BGH, with prosthetic mesh placement in the preperitoneal space [2]. However, the guidelines and other authors [3, 4] also emphasize that the choice of approach may depend on the surgeon’s expertise in either open or endoscopic techniques. In such cases, an open anterior approach, such as Lichtenstein repair, is proposed as an alternative. This recommendation is partly based on the fact that Lichtenstein remains the most widely used technique worldwide for groin hernia repair among surgeons from different hernia societies [5].

Unlike anterior mesh placement, preperitoneal mesh positioning has been proposed to benefit from certain biomechanical advantages. By covering the myopectineal orifice of Fruchaud and being supported by intra-abdominal pressure (‘upstream principle’), it may allow broader reinforcement with potentially less need for fixation [6, 7] This setting reduces the need for traumatic fixation methods, which are more frequently required in anterior mesh repairs and may increase the risk of nerve entrapment and chronic postoperative inguinal pain (CPIP) [6, 8‐10]. Additionally, preperitoneal mesh placement provides simultaneous coverage of the femoral canal, thereby reducing the risk of occult femoral hernias—an advantage particularly relevant in female patients, who show a higher rate of femoral recurrences after anterior repairs [2].

Previous studies comparing open preperitoneal approaches (OPA) to MIS have shown similar outcomes regarding chronic pain, complications, and recurrence rates [11, 12]. However, most of this evidence comes from studies including unilateral cases or mixed techniques. To date, there is a lack of specific comparative data focused exclusively on pure OPA versus MIS for the repair of BGH.

This study aims to compare OPA and MIS (TAPP and TEP) in the surgical treatment of BGH in an ambulatory setting. We present the results of a single-centre experience with long-term follow-up, focusing on clinical outcomes such as operative time, complications, recurrence, and CPIP. Our prespecified hypothesis was that OPA would achieve outcomes comparable to MIS in selected patients.

This retrospective study included all patients with a BGH who underwent elective surgery using OPA or MIS in ambulatory surgery at the Abdominal Wall Surgery Unit of the Vall d'Hebron University Hospital in Barcelona (Spain) between January 2010 and September 2018, defining ambulatory surgery as surgery that does not require an overnight hospital stay [13]. The Abdominal Wall Surgery Unit is an accredited unit by the Spanish Association of Surgeons (Asociación Española de Cirujanos, AEC) [14].

The study was approved by the hospital ethics committee (PR(AG)505/2021) and informed consent for the intervention was obtained for all patients. Patients meeting the inclusion criteria for outpatient surgery were included: age over 18 years, primary and/or recurrent, inguinal or femoral bilateral hernia, American Society of Anaesthesiologists (ASA) grade I-III, non-obese patients [i.e. Body Mass Index (BMI) < 30], good exercise tolerance, well-controlled diabetes, well-controlled chronic obstructive pulmonary disease (COPD) or other comorbidities (i.e. hypertension, well-controlled ischaemic heart disease). Excluded from the data collected were the emergency repairs and the patients with poorly controlled comorbidities (non-ischemic or poorly controlled ischemic heart disease, stroke), use of anticoagulants and those classified like scrotal hernias. Additionally, patients who did not complete in-person visits or long-term follow-up through the telephone call were excluded from this study.

All patients were operated by the same surgeon who has an optimal prior learning curve of more than 100 repairs with the different procedures [2]. In our institution, open preperitoneal repair is systematically preferred over anterior open approaches for elective inguinal and femoral hernias, with the anterior approach reserved only for cases where the posterior plane has been previously altered.

This observational study has been designed and reported following the guidelines established by the STROBE [15] and RECORD [16] checklists to ensure the quality and transparency in the presentation of the results.

During the study period, 253 consecutive patients underwent bilateral inguinal hernia repair, accounting for a total of 506 hernias. Of these, 244 patients (488 hernias) met the inclusion criteria and completed initial follow-up. Among them, 182 patients (364 hernias) reached long-term follow-up through telephone interviews (Fig. 1).

Bild vergrößern

A total of 116 patients (64%) representing 232 hernia repairs underwent OPA, while 66 patients (36%) representing 132 hernia repairs underwent MIS, either TAPP or TEP technique, as detailed in Table 1.

In the context of international guidelines recommending a preperitoneal approach for BGH—typically via MIS—our study evaluates a pure OPA as a potential alternative. Our findings show that OPA achieves comparable outcomes to MIS in terms of recurrence and surgical site complications, with the added benefit of significantly shorter operative time. Notably, OPA was independently associated with a lower risk of early CPIP, suggesting a potential protective effect during the initial recovery phase. In contrast, higher BMI was the only variable significantly associated with persistent CPIP beyond 12 months.

Earlier studies suggested that laparoscopic repairs might reduce postoperative pain and infection rates [34]. However, a meta-analysis of available data found no significant differences between laparoscopic and open preperitoneal approaches regarding CPIP, recurrence, or local complications [11]. More recently, a comparison of robotic-assisted laparoscopic and open preperitoneal repairs likewise reported no significant differences in clinical outcomes, reinforcing the equivalence of these techniques [12].

Although we observed a lower incidence of CPIP between 3 and 12 months in the open preperitoneal group, some literature suggest that the absolute difference tends to decrease over time [20‐24]. Long-term registry data and a randomized trial with long-term follow-up report a gradual resolution of pain in most patients regardless of surgical technique, with convergence in prevalence rates and quality-of-life measures over time [35‐37]. Nevertheless, a lower incidence of early CPIP may represent a clinical advantage, potentially improving quality of life during the initial recovery phase and facilitating an earlier return to work and daily activities, although these outcomes were not specifically assessed in our study. Notably, in our study, early CPIP was not associated with pain at long-term follow-up, in contrast with previous studies that have identified it as a potential risk factor for long-term CPIP [24].

Importantly, most clinical guidelines base their recommendations in favour of MIS (TAPP or TEP) on comparisons with anterior open repairs, particularly the Lichtenstein technique [2]. However, there is a notable lack of data evaluating OPA in this context. Several studies and meta-analyses have shown that posterior mesh placement—whether via MIS or OPA—is associated with less acute and chronic pain, fewer surgical site occurrences, and better quality of life compared to anterior repairs, with similar recurrence rates [9, 11, 38‐41]. In addition, the preperitoneal position of the mesh provides coverage of both the inguinal and femoral orifices, potentially reducing the risk of unrecognized femoral hernias [2]. A recent registry-based study found comparable outcomes between open and MIS approaches for BGH, although the open group included both anterior and posterior repairs, limiting specific conclusions about the open posterior technique [42].

The advantages of posterior repair, including the lower incidence of early chronic postoperative pain observed in our study, may be explained by the dissection plane: both MIS and OPA avoid the inguinal canal and reduce nerve contact, unlike the anterior approach. Furthermore, while tacker fixation is common in MIS and may contribute to discomfort, OPA allows for more selective and potentially less traumatic fixation strategies, potentially lowering the risk of CPIP.

In our cohort, mesh fixation practices further illustrate these distinctions. MIS procedures (TAPP and TEP) showed heterogeneous fixation methods, including both absorbable and non-absorbable tackers, the latter being predominant and chosen at the surgeon’s discretion. This reflects ongoing debate in the literature regarding the superiority of any specific fixation method [43]. In contrast, OPA was uniformly associated with absorbable suture fixation, which may contribute to the lower incidence of early CPIP observed in our cohort.

Additionally, in our series, the longer operative time observed in the MIS group aligns with prior evidence identifying this as a drawback of laparoscopic hernia repair [39]. However, several factors may have contributed to the median operative time of nearly 120 min. These procedures were performed in the early phase of implementing laparoscopic techniques in the ambulatory setting, before the widespread use of barbed sutures for peritoneal closure for example. These factors likely prolonged operative time beyond what is currently achievable with more standardized workflows and contemporary instrumentation.

Nonetheless, no differences were observed in early postoperative complications, including SSOs. However, the use of non-absorbable skin sutures was significantly associated with superficial wound infection. While previous meta-analyses and RCTs report no consistent difference between absorbable and non-absorbable sutures [44, 45], our data suggest a possible trend favoring absorbable sutures. Nevertheless, the low number of infections limits the ability to draw firm conclusions, and larger series would be needed to validate it.

Our study also highlights a systematic difference in the type of anaesthesia used between groups, with OPA performed under spinal anaesthesia and MIS under general anaesthesia. We reported these differences but did not attribute independent clinical relevance to them, as current evidence suggests that both techniques are safe and effective, each with specific trade-offs [46‐48]. Spinal anaesthesia has been associated with less immediate postoperative pain but higher risks of urinary retention and headache, whereas general anaesthesia allows shorter operating times and avoids some of the complications related to spinal techniques [46‐48].

In the univariate analysis, younger age and recurrent hernias were both associated with a higher risk of early CPIP, in line with previous studies indicating that younger and recurrent patients may report more pain after hernia repair [49, 50]. However, multivariate logistic regression identified the surgical approach as the only independent predictor of early CPIP (AUC 0.84). This suggests that other variables, such as age or recurrence status, likely confounded the association, especially given their higher prevalence in the MIS group. Therefore, while patient-related factors may contribute to pain perception, the observed differences in early CPIP between groups appear to be more closely linked to the surgical technique itself. Importantly, the observed difference in pain outcomes between groups did not persist at long-term follow-up (> 12 months postoperatively).

Recurrence rates were similar between groups, with a median follow-up of 116 months (9.6 years). The only factor independently associated with CPIP at long-term follow-up was higher BMI (OR = 1.2, 95% CI: 1.024–1.405; P = 0.024), aligning with prior literature suggesting that both low and high BMI can increase postoperative chronic pain [51‐53].

Overall, our results suggest that a purely OPA can offer comparable—or even superior—early postoperative pain outcomes compared to MIS, while maintaining equivalent safety and efficacy at long-term follow-up.

Nonetheless, there are inherent limitations that should be acknowledged. First, its retrospective design introduces potential selection and information biases, limiting causal inference. Because of the study design, we were also unable to systematically record preoperative inguinal pain, a known risk factor for CPIP, which limited our ability to adjust for it. Second, despite a high retention rate, some patients were lost to follow-up, particularly for subjective measures like pain. Third, surgical technique selection was not randomized but based on surgeon preference, introducing potential selection bias. Additionally, all procedures were performed by a single surgeon at a single centre, which may limit generalisability. The study population was also limited to patients selected for ambulatory surgery, excluding individuals with higher surgical risk or significant comorbidities, which may restrict the generalisability of the findings to broader patient populations. Furthermore, although structured telephone interviews were used to standardize long-term follow-up, this approach may have reduced sensitivity in detecting asymptomatic or subclinical recurrences compared with systematic in-person evaluations. Finally, relevant patient-reported outcomes—such as quality of life, satisfaction, and costs—were not systematically collected, which limits the ability to assess the full impact of each approach.

A key strength of the study is the long-term follow-up, with a median of over 9 years (range 6–14), which allows a robust evaluation of less frequent outcomes such as recurrence and CPIP. This duration of follow-up is rarely achieved in similar cohorts and adds weight to the reliability of our findings.

Our findings suggest that OPA for BGH repair offers similar surgical outcomes comparable to those of MIS. It was associated with lower rates of early CPIP (3–12 months postoperatively), with no significant long-term differences in recurrence or CPIP. Although multivariate analysis identified the surgical approach as the main factor associated with early CPIP, other variables such as age, recurrence status, or fixation methods may also play a role. Higher BMI was the only independent predictor of CPIP at long-term follow-up. The extended follow-up duration enhances the reliability of our findings and supports the consideration of OPA as a viable, effective, and resource-efficient technique for repairing BGH in the ambulatory setting.