title: Inguinal herniorrhaphy in women European Hernia Society guidelines on the treatment of inguinal hernia in adult patients Less collagen production in smokers. Groin hernia repair in young males: mesh or sutured repair? Laparoscopic transperitoneal procedure for routine repair of groin hernia Factors associated with postoperative complications and hernia recurrence for patients undergoing inguinal hernia repair: a report from the VA Cooperative Hernia Study Group. Transdermal nicotine patch enhances type I collagen synthesis in abstinent smokers. Hernia surgery in a defined population: a prospective three year audit. Body Mass Index and Groin Hernia: A 34-Year Follow-up Study in Swedish Men Synchronous femoral hernias diagnosed during endoscopic inguinal hernia repair Reoperation After Recurrent Groin Hernia Repair Outcome of repair of bilateral groin hernias: a prospective evaluation of 1,487 patients. Simultaneous bilateral laparoscopic inguinal hernia repair: an analysis of 1336 consecutive cases at a single center. National register study of operating time and outcome in hernia repair. Repeated Groin Hernia Recurrences Proficiency of Surgeons in Inguinal Hernia Repair: Effect of Experience and Age Reoperation as surrogate endpoint in hernia surgery. A three year follow-up of 1565 herniorrhaphies. Serum MMP 2 and TIMP 2 in patients with inguinal hernias.
abstract: Inguinal hernias in women are relatively rare , and an outcome in this specific subgroup of hernias has not been documented in the literature . An analysis was performed using data from the prospect i ve recording of 3,696 female inguinal hernia repairs in the national Danish hernia data base , in the 5.5 year period from January 1 , 1998 to June 30 , 2003 , where observation time specific reoperation rates were used as a proxy for recurrence . In the 3,696 female inguinal herniorrhaphies recorded , the overall reoperation rate was 4.3 % , which is slightly higher compared to male inguinal herniorrhaphies  ( 3.1 % ) ( P=0.001 ) . The reoperation rate was independent of the type of surgical repair . In 41.5 % of the reoperations a femoral hernia was found , compared to 5.4 % in males . Female inguinal herniorrhaphy is followed by a higher reoperation rate than in males , and is unrelated to the type of repair . The frequent finding of a femoral hernia at reoperation suggests the need for the exploration of the femoral canal at the primary operation The European Hernia Society ( EHS ) is proud to present the EHS Guidelines for the Treatment of  Inguinal Hernia in Adult Patients . The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare . They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS . They are evidence -based and , when necessary , a consensus was reached among all members . The Guidelines have been review ed by a Steering Committee . Before finalisation , feedback from different national hernia societies was obtained . The  Appraisal of Guidelines for REsearch and Evaluation ( AGREE ) instrument was used by the Cochrane Association to vali date the Guidelines . The Guidelines can be used to adjust local protocol s , for training purpose s and quality control . They will be revised in 2012 in order to keep them up date d. In between revisions , it is the intention of the Working Group to provide every year , during the EHS annual congress , a short up date of new high-level evidence ( r and omised controlled trials [ RCTs ] and meta-analyses ) . Developing guidelines leads to questions that remain to be answered by specific research . Therefore , we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment . In addition , a short summary , specifically for the general practitioner , is given . In order to increase the practical use of the Guidelines by consultants and residents , more details on the most important surgical techniques , local infiltration anaesthesia and a patient information sheet is provided . The most important challenge now will be the implementation of the Guidelines in daily surgical practice . This remains an important task for the EHS . The establishment of an EHS school for teaching inguinal hernia repair surgical techniques , including tips and tricks from experts to overcome the learning curve ( especially in endoscopic repair ) , will be the next step . Working together on this project was a great learning experience , and it was worthwhile and fun . Cultural differences between members were easily overcome by educating each other , respecting different views and always coming back to the principles of evidence -based medicine . The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project BACKGROUND An association between smoking and impaired wound healing has been reported in retrospective studies . The smoking status of a surgical patient may be confounded by social and medical parameters . We have evaluated the effect of smoking in a test wound in volunteers , with special reference to a reliable scientific match between smokers and nonsmokers . METHODS In a prospect i ve open study with blinded assessment , 19 smoking ( 20 cigarettes/day ) and 18 nonsmoking healthy volunteers were matched with respect to baseline characteristics . The deposition of total protein and mature collagen ( expressed as hydroxyproline ) was assessed in an exp and ed polytetrafluoroethylene wound healing model implanted subcutaneously for 10 days . RESULTS The nonsmokers had a 1.8 times higher median amount of hydroxyproline than the smokers ( p < 0.01 ) . The deposition of hydroxyproline was negatively correlated with the consumption of tobacco both before ( r = -0.44 ; p < 0.01 ) and during the study ( r = -0.48 ; p < 0.005 ) . The impairment was specific for the production of collagenous proteins and not other proteins . CONCLUSIONS The synthesis of subcutaneous collagen in smokers is specifically impeded , indicating an impaired wound-healing process . Because mature collagen is the main determinator of strength of an operative wound , the results support the view that patients should be advised to stop smoking before an operation Background Large-scale data for the optimal inguinal hernia repair in younger men with an indirect hernia is not available . We analysed nationwide data for risk of reoperation in younger men after a primary repair using a Lichtenstein operation or a conventional non-mesh hernia repair .  Methods Prospect i ve recording of all inguinal hernia repairs  from 1 January 1998 to 31 December 2005 in the national Danish Hernia Data base , using reoperation rate as a proxy for recurrence . We included only men between the age of 18 and 30 years with a primary repair of a primary indirect inguinal hernia . Results A primary sutured repair was performed in 1,120 men ( median age 23 years , range 18–30 ) and a Lichtenstein mesh repair in 2,061 young men ( 24 years , range 18–30 ) ( total 3,181 patients ) . The observation time after  conventional hernia repair  was median 62 months ( range 0–96 ) and 41 months ( range 0–96 ) after a Lichtenstein repair . The cumulative incidence of reoperation at 5 years was 1.6 % ( Lichtenstein ) versus 3.9 % ( sutured repair ) , while overall reoperation rates were almost three-fold as high after a sutured repair ( 39 reoperations , overall reoperation rate = 3.5 % ) compared to a Lichtenstein repair ( 24 reoperations , overall reoperation rate = 1.2 % ; P = 0.0003 ) . Conclusions Lichtenstein repair for an indirect inguinal hernia reduces the risk of recurrence in young men between the age of 18 and 30 years compared with a sutured repair . The use of a Lichtenstein mesh repair in young males must be balanced against the risk of chronic pain Laparoscopic transperitoneal hernioplasty ( TAPP ) repair  of inguinal hernias is thought to be a difficult surgical technique with high complication rates . The present study evaluated TAPP based on prospect i ve documentation BACKGROUND We sought to determine perioperative variables predictive of complications or recurrence for patients undergoing surgical repair of inguinal hernias . PATIENTS AND METHODS Using data from the Veterans Affairs trial , regression analyses were utilized to identify perioperative factors significantly associated with complications ( overall , short-term and long-term ) , long-term pain , and to develop a risk model for recurrence . RESULTS Recurrent and scrotal hernias were predictors for short term and overall complications , regardless of technique . Older age and higher Mental Component Score of the SF-36 were associated with higher risk of long term complications in the open group while prostatism and increased body mass index were the significant predictors in the laparoscopic group . Long-term pain complaints decreased as patient age increased in both groups . Patient and surgeon factors were predictive of recurrence but varied greatly depending on surgical technique . CONCLUSIONS Regardless of technique , scrotal and recurrent hernias were associated with a greater risk of complications and younger patients had more long-term pain . Predictors of recurrence vary based on surgical technique Cigarette smokers deposit less collagen , expressed as hydroxyproline , in granulation tissue than nonsmokers . We studied the effect of abstinence from smoking and transdermal nicotine patches on deposition of hydroxyproline , proline , type I procollagen , and total proteins . Fifty-four healthy smokers were studied during 10 days of smoking and again from days 10 to 20 following smoking cessation . After the first 10 days of abstinence they were r and omized to double-blind treatment with transdermal nicotine patches of 25 mg/day or placebo for a period of 10 days . During this period and during smoking , an exp and ed polytetrafluoroethylene tube was implanted into the subcutis . Following removal of the implant , total amino acids and peptides were extracted . Hydroxyproline and proline were analyzed by high-pressure liquid chromatography , type I procollagen was analyzed by enzyme-linked immunoassay , and total proteins were determined colorimetrically . In the 39 subjects who complied with the study protocol , abstinence from smoking did not affect the deposition of hydroxyproline , proline , type I procollagen , or total protein in the implants . During abstinence , the type I procollagen level increased by 18 % in the transdermal nicotine patches group and decreased by 10 % in the placebo group ( p<0.05 ) . We conclude that 20 days of abstinence from smoking does not affect collagen deposition in granulation tissue . However , in abstinent smokers , transdermal nicotine patches appears to increase type I collagen synthesis OBJECTIVE To establish a register of  inguinal hernia surgery  that allows audit and analyses of data from several centres . DESIGN Prospect i ve recording of data on a common protocol . SETTING Eight Swedish hospitals . SUBJECTS All groin hernia operations done for patients over 15 years old from January 1992 to December 1994 . MAIN OUTCOME MEASURES Methods of repair , postoperative complications including mortality , day surgery rate , and reoperations for recurrence . RESULTS During the three years studied 4879 hernia operations were undertaken in 4474 patients .  Postoperative mortality within 30 days of operation for emergency and elective hernia repairs was 3.5 % and 0.07 % , respectively . Of all herniorrhaphies 798 ( 16 % ) were done for recurrences , 142 of these after operations between 1992 and 1994 . At 24 months 4 % of all operations had been redone because of recurrences with highly significant variations among hospitals ranging from 1.5 % to 6.7 % . Postoperative complications within 30 days after operation , direct hernia , recurrent hernia , and the use of absorbable sutures were associated with an increased risk of reoperation . CONCLUSIONS A quality register recorded voluntarily can identify significant interhospital differences in outcome as well as variables associated with an increased risk of reoperation , thereby raising quality awareness and facilitating the process of improvement Objective :  Inguinal  hernias are very common disorders , especially in men , with inguinal herniorrhaphy being one of the most frequently performed general surgical procedures in men . Theoretically , obesity might increase the risk of groin hernia by increasing intra-abdominal pressure . The objective of the present study was to investigate whether overweight and obesity in middle age could significantly predict future groin hernia  in men . Summary Background Data : Design : Prospect i ve cohort study ; Setting : General population of men living in Gothenburg , Sweden ; Participants : A community-based sample of 7483 men aged 47 to 55 years were followed-up from baseline ( 1970–1973 ) for a maximum of 34 years . Main Outcome Measures : A diagnosis of groin hernia according to the Swedish hospital discharge register . Results : A total of 1017 men ( 13.6 % ) were diagnosed with groin hernia .  An inverse relationship was found between body mass index ( BMI ) and risk of groin hernia . With each BMI unit ( 3–4 kg ) , the relative risk for groin hernia decreased by 4 % ( P < 0.0001 ) . Compared with men of normal weight , obese men had a 43 % lower risk ( P = 0.0008 , 95 % confidence interval 21%–59 % ) . Heavy smokers demonstrated a 26 % lower risk for groin hernia ( P = 0.003 , 95 % confidence interval 10%–39 % ) . Diabetes , high physical activity , and blood pressure were not associated with groin hernia . Entering other variables potentially associated with groin hernia , as age , BMI , smoking , and serum cholesterol , in a multivariable analysis left the risk estimates for BMI and smoking virtually unchanged . Conclusions : In a large community-based sample of middle-aged men overweight and obesity were associated with a lower risk for groin hernia during an extended follow-up . Obesity , in comparison with normal weight , reduced the risk of groin hernia by 43 % . A reduced risk of groin hernia was also noted in heavy smokers . Obviously , hernia may be more easily detected in lean men but a true protective effect can not be excluded Background During totally extraperitoneal ( TEP ) endoscopic repair of inguinal hernias , it is possible to see the internal opening of the femoral canal . The aim of our study was to determine the incidence of synchronous femoral hernias found in patients undergoing TEP endoscopic inguinal hernia repair .  Method This was a retrospective review of prospect ively collected data on 362 consecutive patients who underwent 484 TEP endoscopic inguinal hernia repairs during a 5-year period , May 2005 to May 2010 . During surgery , both inguinal and femoral canal orifices were routinely inspected . The presence of unilateral or bilateral inguinal and femoral hernias was recorded and repaired accordingly . Results There were a total of 362 patients . More males ( 343 , 95 % ) underwent a TEP hernia repair than females ( 19 , 5 % ) . There were more cases of unilateral ( 240/362 , 66 % ) than bilateral ( 122/362 , 34 % ) inguinal hernias . A total of 18 cases of synchronous femoral hernias were found during operation . There was a higher incidence of femoral hernia in females ( 7/19 , 37 % ) compared to males ( 11/343 , 3 % ) ( P < 0.001 ) . None of the femoral hernias were clinical ly detectable preoperatively . Conclusion Females undergoing elective inguinal hernia repair are more likely to have a synchronous femoral hernia than males . We suggest that all women presenting with an inguinal hernia also have a formal assessment of the femoral canal . TEP endoscopic inguinal hernia repair is an ideal approach as both inguinal and femoral orifices can be assessed and hernias repaired simultaneously during surgery Objective To analyze reoperation rates for recurrent and primary groin hernia repair documented in the Swedish Hernia Register from 1996 to 1998 , and to study variables associated with increased or decreased relative risks for reoperation after recurrent hernia . Methods Data were retrieved for all groin hernia repairs prospect ively recorded in the Swedish Hernia register from 1996 to 1998 . Actuarial analysis adjusted for patients ’ death was used for calculating the cumulative incidence of reoperation . Relative risk for reoperation was estimated using the Cox proportional hazards model . Results From 1996 to 1998 , 17,985 groin hernia operations were recorded in the Swedish Hernia Register , 15 % for recurrent hernia and 85 % for primary hernia . At 24 months the risk for having had a reoperation was 4.6 % after recurrent hernia repair and 1.7 % after primary hernia repair . The relative risk for reoperation was significantly lower for laparoscopic methods and for anterior tension-free repair than for other techniques . Postoperative complications and direct hernia were associated with an increased relative risk for reoperation . Day-case surgery and local infiltration anesthesia were used less frequently for recurrent hernia than for primary hernia . Conclusions Recurrent groin hernia still constitutes a significant quantitative problem for the surgical community . This study supports the use of mesh by laparoscopy or anterior tension-free repair for recurrent hernia operations OBJECTIVE To find out whether simultaneous repair of bilateral hernias increases the risk of recurrence compared with unilateral repair . DESIGN Prospect i ve study . SETTING Swedish hospitals participating in the Swedish Hernia Register ( SHR ) . INTERVENTIONS Prospect i ve collection of data from the SHR , 1992 - 1999 inclusive . The Cox proportional hazard test was used for calculating odds ratio ( OR ) . MAIN OUTCOME MEASURES  Hernia repairs  were followed up in a life table fashion until re-operation for recurrence or death of the patient . RESULTS 33416 unilateral and 1487 bilateral operations on 2974 groin hernias were found .  Direct hernias were more common in the bilateral than in the unilateral group , 1,825 , 61 % compared with 13,336 , 40 % , ( p < 0.0001 ) . A laparoscopic method was used for 1774 ( 60 % ) of bilateral and 3285 ( 10 % ) unilateral repairs , and 455 bilateral operations ( 31 % ) were done as day cases compared with 18376 ( 55 % ) unilateral ones ( p < 0.0001 for both comparisons ) . The cumulative incidence of reoperation at three years for groin hernias after bilateral and unilateral repair was 4.1 % ( 95 % confidence interval 3.1 % to 5.1 % ) and 3.4 % ( 95 % Cl 3.1 % to 3.7 % , respectively . After adjustment for other risk factors , the OR for reoperation for recurrence after bilateral repair was 1.2 ( 95 % CI 0.9 to 1.5 ) with unilateral repair as reference . The OR for reoperation after laparoscopic bilateral repair compared with open bilateral repair was 0.9 ( 95 % CI 0.6 to 1.4 ) . CONCLUSIONS Simultaneous repair of bilateral hernias does not increase the risk of reoperation for recurrence and there is no significant difference in the risk of reoperation after bilateral repair using open or laparoscopic techniques BACKGROUND We compare the use of unilateral and simultaneous bilateral laparoscopic hernioplasty [ transabdominal preperitoneal patch ( TAPP ) ] METHOD We employed a prospect i ve consecutive single-center trial lasting from April 1993 to December 2000 . RESULTS In our study , 5524 consecutive patients underwent 6860 laparoscopic hernia repairs . The median age in group A ( unilateral repair , n = 4188 ) was 58 years ( 16 - 94 years ) , and that in group B ( simultaneous bilateral repair , n = 1336 ) was 60 years ( 19 - 97 years ) in ( simultaneous bilateral repair  , n = 1336 ) . Morbidity in group A was 3.2 % ( 135/4188 ) with a 0.6 % reoperation rate ( 24/4188 ) ; in group B morbidity was 5.0 % ( 67/1336 ) with a 1.4 % reoperation rate . ( 19/1336 ) . Morbidity and reoperation rates showed no statistically significant difference between the two groups in relation to number of repairs in group B. After a median 24-month clinical follow-up period ( 1 - 84 months ) ( follow-up rate 93.1 % ) 38 recurrences were observed in group A ( 0.9 % ) and 17 in group B ( 0.6 % ; 17/2672 ) ( p = 0.2668 ) . Median time off work was 14 days after unilateral ( 2 - 63 days ) and 17 days after bilateral repair ( 3 - 100 days ) ( p = 0.1359 ) . Pain levels ( numerical analogue scale ) and incidence of persistent inguinal and scrotal pain are not higher after bilateral repair . CONCLUSION Compared to unilateral repair , bilateral simultaneous laparoscopic hernia repair ( TAPP ) is safe , comfortable for patients , and cost-effective , without increased morbidity or recurrence risk . Bilateral inguinal hernia is an ideal indication for endoscopic transabdominal repair OBJECTIVES To examine the relationship between operating time and reoperation for recurrence and other complications in groin hernia repairs . DESIGN Observational population -based register study . SETTING Data from the nationwide Swedish Hernia Register , which prospect ively collects data from almost all groin hernia repairs performed in Sweden . PATIENTS There were 123,917 primary groin hernia repairs recorded in the Swedish Hernia Register from January 1 , 1998 , through December 31 , 2007 . MAIN OUTCOME MEASURES Relative risk of reoperation for recurrence and odds ratios for postoperative complications in 4 operating time groups . RESULTS The relative risk of reoperation for recurrence of all patients operated on in less than 36 minutes was 26 % higher than that of all patients with an operating time of more than 66 minutes ( 1.26 ; 95 % CI , 1.11 - 1.43 ) . Because the Lichtenstein procedure is the st and ard procedure in Sweden today , its results were also analyzed separately . In this homogeneous group , the difference was even more striking with an increased relative risk of 45 % ( 1.45 ; 95 % CI , 1.21 - 1.75 ) . The odds ratio for infection and other postoperative complications increased with increasing operating time . CONCLUSION A significant decrease in reoperation for recurrence with increasing operating time exhorts the hernia surgeon to avoid speed and to maintain thoroughness throughout the procedure Objective : To describe the characteristics of patients undergoing multiple groin hernia repairs  and to identify strategies that prevent further recurrence . Summary Background Data : Although relatively infrequent , recurrent groin hernias where several repairs have previously been undertaken constitutes a major problem in hernia surgery . Low numbers and heterogeneity have made it difficult to perform large prospect i ve studies on this group . Methods : The study was design ed as an observational population -based register study . All repairs for recurrent hernia recorded in the Swedish Hernia Register ( SHR ) 1992–2006 were identified . Risk for reoperation by number of previous repairs , with adjustment for gender and age , and risk for reoperation by unit responsible for previous repair were determined using Cox proportional hazard analysis . Results : There were 12,104 cases of hernia repaired once , 2 repairs in 4199 cases , 3 repairs in 310 cases , 4 repairs in 32 cases , and 5 repairs in 3 cases . The risk for further reoperation increased with the number of previous repairs ( P < 0.001 ) . The hazard ratios for reoperation following  open preperitoneal mesh repair and  laparoscopic repair  decreased ; whereas , the hazard ratio for sutured repair  increased with the number of previous repairs . The difference between Lichtenstein repair and laparoscopic repair was significant for the first 2 repairs ( P < 0.05 ) . Conclusion : Laparoscopic preperitoneal repair provides the best surgical outcome in repeated groin hernia recurrence Objectives : We examined the influence of surgeon age and other factors on proficiency in laparoscopic or open hernia repair .  Summary Background Data : In a multicenter , r and omized trial comparing  open and laparoscopic herniorrhaphies  , conducted in Veterans Administration hospitals ( CSP 456 ) , we reported significant differences in recurrence rates ( RR ) for the laparoscopic procedure as a result of surgeons ’ experience . We have also reported significant differences in RR for the open procedure related to resident postgraduate year ( PGY ) level . Methods : We analyzed data from unilateral laparoscopic and open herniorrhaphies from CSP 456 ( n = 1629 ) . Surgeon 's experience ( experienced ≥250 procedures ; inexperienced < 250 ) , surgeon 's age , median PGY level of the participating resident , operation time , and hospital observed-to-expected ( O/E ) ratios for mortality were potential independent predictors of RR . Results : Age was dichotomized into older ( ≥45 years ) and younger ( < 45 years ) . Surgeon 's inexperience and older age were significant predictors of recurrence in laparoscopic herniorrhaphy . The odds of recurrence for an inexperienced surgeon aged 45 years or older was 1.72 times that of a younger inexperienced surgeon . For open repairs , although surgeon 's age and operation time appeared to be related to recurrence , only median PGY level of <3 was a significant independent predictor . Conclusion : This analysis demonstrates that surgeon 's age of 45 years and older , when combined with inexperience in laparoscopic inguinal herniorrhaphies , increases risk of recurrence . For open repairs , only a median PGY level of <3 was a significant risk factor OBJECTIVE Analysis of reoperation and recurrence rates three years after repair of groin hernias . DESIGN Prospect i ve audit by question naire and selective follow-up . SETTING Eight Swedish hospitals . SUBJECTS All groin hernia operations done during 1992 on patients between the ages of 15 and 80 years . MAIN OUTCOME MEASURES Postoperative complications , reoperation for recurrence , and recurrence . RESULTS During 1992 , 1565 hernia operations were done . The postoperative complication rate was 8 % ( 125/1565 ) . At 36 months postoperatively 108 recurrences had already been reoperated on , six patients with recurrences were on the waiting list for reoperation and a further 36 recurrences had been detected at follow-up . The interhospital variation in recurrence rate ranged from 3 % to 20 % . Postoperative complications , recurrent hernia , direct hernia and hospital catchment area over 100000 inhabitants were all factors associated with an increased relative risk of recurrence . CONCLUSIONS The recurrence rate exceeded the reoperation rate for recurrence by almost 40 % which should be taken into account if the reoperation rate is used as the endpoint after repairs of groin hernia . An audit scheme , based on prospect i ve recording , reoperation rate , and ( periodic ) calculation of the recurrence rate may be used to identify risk factors for recurrence and areas in need of improvement BACKGROUND More than sixty thous and inguinal hernia operations are performed every year in Pol and . Despite many years of related research , the exact pathologic mechanism of this condition is still not fully understood . Recent studies suggested a pronounced relationship between the molecular structure of collagen fibers and the activity of metalloproteinases , the enzymes taking part in the degradation of collagen , as well as their tissue inhibitors . MATERIAL S AND METHODS A prospect i ve study has been established to measure serum levels of the matrix metalloproteinase 2 ( MMP-2 ) and Matrix metalloproteinase tissue inhibitor 2 ( TIMP-2 ) in 150 males between the ages of 26 and 70 . The control group ( CG ) consisted of thirty healthy male volunteers of a similar age distribution . RESULTS Our results indicate that MMP-2 was highest in the direct hernia group , a statistically very significant elevation ( P<0 ( . ) 05 ) of 1562ng mL(-1 ) against the CG 684ng mL(-1 ) . The highest level of TIMP , 78ng mL(-1 ) , was found in the group with recurrent hernia , against 49 ( . ) 5ng mL(-1 ) of the CG ( statistical significance of P<0 ( . ) 05 ) . DISCUSSION The MMP-2 and TIMP-2 levels were concurrently elevated only in the recurrent hernia group . CONCLUSIONS The patients with inguinal hernia have a statistically significant increase in serum levels of MMP-2 . Our finding of the MMP-2 and TIMP-2 distinctly higher in the patients suffering from recurrence of direct inguinal hernia ( reflecting a previous surgical failure ) may suggest the theory that the extracellular matrix defect lies at the basis of this disorder
target: We found that female sex , direct inguinal hernias at the primary procedure , operation for a recurrent inguinal hernia , and smoking were significant risk factors for recurrence after inguinal hernia surgery .
background: Background .
  Several factors influence the risk of recurrence after inguinal hernia surgery ; however , a systematic review and meta- analysis of patient-related risk factors for recurrence after inguinal hernia surgery has not been performed earlier .