Does the "switch the plane" strategy improve outcomes? Anterior vs. posterior repair for recurrence after prior inguinal hernia repair: a systematic review and meta-analysis.
Gabriela Lyons, Vitor Neves, Letícia Hanna Moura da Silva Gattas Graciolli et al.
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In 30 seconds
This systematic review and meta-analysis examined outcomes of recurrent unilateral inguinal hernia repair by operative plane, including comparative studies of posterior versus repeat anterior repair after prior anterior repair. Across 35 studies involving 4,902 patients, pooled comparative data showed no statistically significant difference in recurrence (OR 0.70, 95% CI 0.39-1.27). Posterior repair was associated with lower odds of surgical site infection (OR 0.24, 95% CI 0.07-0.79); chronic pain and seroma did not differ significantly in the primary analyses. The evidence therefore offers limited support for superiority of the “switch the plane” strategy on recurrence.
Key findings
- Recurrence did not differ significantly between posterior and repeat anterior repair after prior anterior repair (OR 0.70, 95% CI 0.39-1.27).
- Posterior repair was associated with lower odds of surgical site infection than repeat anterior repair (OR 0.24, 95% CI 0.07-0.79).
- Chronic postoperative pain showed no significant difference in the primary analysis (OR 0.47, 95% CI 0.22-1.00), but was lower with posterior repair in the RCT-only sensitivity analysis (OR 0.36, 95% CI 0.16-0.81).
- After posterior repair following prior anterior repair, pooled recurrence was 2% (95% CI 0.01-0.03) across 17 studies.
Why it matters
The review evaluates a widely used guideline-supported approach to recurrent hernia repair and finds that its presumed recurrence advantage is not demonstrated in the pooled comparative evidence. The lower odds of surgical site infection with posterior repair may inform discussion of operative approach, while the findings on pain and recurrence underscore that outcomes differ by endpoint and analysis.
What to keep in mind
Comparative evidence was limited: six studies compared approaches after prior anterior repair, and only one study assessed anterior repair after prior posterior repair, precluding quantitative synthesis. The abstract also reports substantial heterogeneity for some pooled outcomes.