Editing Inguinal hernia (section)

=== '''Recurrence''' ===

* Anatomy
** Usually involves the floor of the inguinal canal near the pubic tubercle, where tension is greatest
** Can also be recurrent indirect hernias
* Risk factors
** Technical issues
*** Inadequate dissection and reduction of the indirect sac
*** Failure to identify a direct or indirect hernia in either open or laparoscopic repair
*** Repair under tension
*** Incorrect mesh placement
*** Inadequate overlap of mesh in the inferomedial side of inguinal canal near the pubic tubercle (medial recurrence)
*** Failure to close a patulous internal ring
*** Surgeon's overall caseload and experience
*** Procedure under LA
** Factors contributing to healing
*** Malnutrition
*** Immunosuppression
*** Diabetes
*** Infection
*** Obesity
*** Smoking - double recurrence rate
** Genetics
*** Collagen synthesis disorders
** Notably no clear increased recurrence with post-op haematoma or emergency case
** Main reasons for failure of non-mesh repair:
*** Medially - tension
*** Medially or laterally with unzippering of suture line if not anchored properly
* Workup
** Cameron's says MRI with Valsalva is best for studying planes looking for recurrence
* Treatment
** Reinforce lifestyle advice and counsel patient that risk of another recurrence is higher
** Operate again through a different tissue plane
** Keep in mind that risk of strangulation through a recurrent hernia is generally considered to be low