Among the 191 patients who were diagnosed with inguinal hernia and who underwent TEP hernia repair at these authors' hospital within the period from June 2006 to January 2010, 24 patients with bilateral hernia and 15 patients with a previous history of pelvic surgery were excluded. Among the remaining 152 patients, 19 patients with recurrent hernia were selected as subjects. The patients with bilateral hernia were excluded as no bilateral hernia existed in the group with recurrent inguinal hernia. Laparoscopic TEP hernia repair was conducted by a single surgeon in all the cases. The gender, age, number and method of the previous surgeries, time elapsed from the surgery to the recurrence, recurrent hernia type, operation time, hospital stay, and recurrence after surgery were retrospectively examined based on the medical records.

Chi-square test was conducted, using SPSS (SPSS Inc., Chicago, IL, USA) for statistical analysis. Statistical significance was pegged at P < 0.05.

In a supine position after general anesthesia, a skin incision was made 15 mm vertically to the directly inferior umbilicus. The anterior rectus sheath in the direction of the hernia was exposed and then incised. The index finger was inserted between the back side of the rectus abdominis muscle and the posterior rectus sheath, and dissection was done inferiorly to create a space for two index finger knuckles. Then a distention balloon was inflated using Spacemaker (Autosuture, Norwalk, CT, USA), with a 10-mm balloon trocar and a distention balloon combined to secure the appropriate space. After removing the balloon, the balloon trocar was filled with about 25 mL air and 12 mmHg CO₂ gas, followed by camera insertion. A 5-mm trocar was inserted 5 mm directly superiorly to the pubic symphysis and 5 mm superiorly to the middle of the camera insertion trocar and the pubic trocar to secure the necessary space for the surgery. The space was secured to sufficiently expose the central line and the pubic symphysis internally, the anterior superior iliac spine laterally, Cooper's ligament and the psoas muscle inferiorly, and the rectus abdominis anteriorly. The hernia sac was repaired in almost all the cases (which led to a longer operation time). In the case of large and damaged hernia sacs, they were incised and removed after ligation. Parietex (Sofradim, Formans, France) mesh, which is made of polyester with good compliance and ease of use [6], was used. MIf the patient's height was 175 cm or lower, the 13 × 9 cm size mesh was used, and if the patient was taller than 175 cm, the 15 × 10 cm size mesh was used, based on the previous related experiences. Initially, the mesh was not fixed in patients with unilateral hernia, but it was later fixed at the lateral pubic symphysis, Cooper's ligament, and lateral anterior abdominal wall, respectively, using Tacker (Autosuture), for surgical convenience, since 2009, except for the case of the easy spread of the mesh. When the mesh was sufficiently unfolded, the CO₂ gas was blocked and was then slowly released through the trocar on the suprapubic area. After confirming the complete release of the CO₂ gas, the trocar was removed, and the surgery was completed.

The 152 subject patients consisted of 133 patients (87.5%) with primary inguinal hernia (hereinafter referred to as "group P") and 19 patients (12.5%) with recurrent inguinal hernia (hereinafter referred to as "group R"). The male-to-female ratio was 127:6 for the primary-hernia group and 18:1 for the recurrent-hernia group, showing a higher male proportion. The mean age was 56.4 years for the primary-hernia group and 55.6 years for the recurrent-hernia group. For recurrence, there were 16 first-recurrence cases (84.2%) and three second-recurrence cases (15.8%) (Table 1).

For the time that relapsed from the surgery to the recurrence in the group R, there were two cases (10.5%) with one year or less, two cases (10.5%) with two years or less, three cases (15.8%) with five years or less, three cases (15.8%) with 10 years or less, and nine cases (47.4%) with more than 10 years (Table 2). The previous surgery methods that were used in the recurrent patients were the anterior approach technique (18 cases) and the laparoscopic TEP approach (one case). In all the 18 cases where the anterior approach technique was used, the technique was conducted in other hospitals, and in the case where the laparoscopic TEP approach was used, the approach was conducted in these authors' hospital for the treatment of bilateral inguinal hernia. In the latter case, right recurrence was shown 20 months after the surgery. For the type of recurrent, there were nine cases of indirect hernia (seven cases right, two cases left) and 10 cases of direct hernia (seven cases right, three cases left). The results showed 14 right hernia (73.7%) and five left hernia (23.6%) cases, showing no significant difference in recurrence direction according to the hernia type (P = 0.141) (Table 3).

The operation time, number of analgesics used until discharge, and duration of hospital stay after surgery were 99.2 minutes, 0.5 times, and 1.4 days, respectively, in the group P, and 100.1 minutes (110 minutes for recurrence after TEP), 0.3 times, and 1.7 days in the group R, showing no significant difference between the two groups (Table 4).

The complications after surgery included four cases of peritoneal rupture and six cases of groin swelling/seroma in the group P. Meanwhile, four cases of urinary retention (22.5%) were found in the group R, but no significant difference was found between the two groups (P = 0.839) (Table 5). All the complications occurred individually in the patients, except for one patient in the group P, who showed both groin swelling and urinary retention. No wound infection, chronic pain, or recurrence was found in both groups. The mean follow-up period after surgery was 18.0 ± 11.3 months in the group P and 15.8 ± 11.9 months in the group R.