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

26 October 2026Meta-analysis3 min read

By Lyons G, Neves V, da Silva Gattas Graciolli LHM and 5 others.

Abstract

Introduction

Recurrent inguinal hernia remains a common challenge in abdominal wall surgery. Current guidelines from the European Hernia Society recommend repairing recurrent inguinal hernias through the previously unoperated anatomical plane ("switch the plane" strategy), supporting a posterior repair after failed anterior repair. Although this strategy is widely adopted in clinical practice, the evidence supporting its superiority remains limited. This systematic review and meta-analysis aimed to evaluate surgical outcomes after recurrent inguinal hernia repair according to the anatomical plane of the index and subsequent repair.

Methods

A systematic review and meta-analysis were conducted according to PRISMA guidelines. Databases including PubMed, Embase, Web of Science, Cochrane Library, and LILACS were searched for studies evaluating surgical repair of recurrent unilateral inguinal hernia. Comparative studies assessing posterior versus anterior repair were included for pooled comparative meta-analysis. Outcomes included hernia recurrence, chronic postoperative inguinal pain, surgical site infection (SSI), and seroma. Meta-analyses were performed in R studio using random-effects models, with results reported as odds ratios (OR) with 95% confidence intervals (CI). Additional single-arm meta-analyses were conducted to estimate pooled outcome proportions among studies evaluating posterior repair after prior anterior repair and posterior repair after prior posterior repair.

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Results

After screening 14,197 records, 35 met the inclusion criteria and were included in the review. These studies comprised 4,902 patients, predominantly male (97.9%), with a mean age of 57.2 years. Six studies compared posterior versus anterior repair after prior anterior repair. Recurrence was assessed in six studies (869 patients; 63 events), with no statistically significant difference between approaches (OR 0.70, 95% CI 0.39-1.27; I²=7.5%). Chronic postoperative pain was assessed in five studies (722 patients; 92 events), with no statistically significant difference in the primary analysis (OR 0.47, 95% CI 0.22-1.00; I²=52.7%), although posterior repair was associated with significantly lower odds in the RCT-only sensitivity analysis (OR 0.36, 95% CI 0.16-0.81; I²=44.1%). SSI was assessed in five studies (604 patients; 14 events), with significantly lower odds following posterior repair (OR 0.24, 95% CI 0.07-0.79; I²=0%). Seroma was assessed in three studies (386 patients; 15 events), with no significant difference between approaches (OR 0.77, 95% CI 0.26-2.29; I²=0%). Among studies evaluating posterior repair after prior anterior repair, recurrence was assessed in seventeen studies (3,551 patients; 59 events), with a pooled rate of 2% (95% CI 0.01-0.03; I²=16.5%); chronic postoperative pain in fifteen studies (3,396 patients; 137 events), with a pooled rate of 3% (95% CI 0.01-0.06; I²=65.3%); SSI in fifteen studies (3,370 patients; 25 events), with a pooled rate of 1% (95% CI 0.00-0.02; I²=76.3%); and seroma in fourteen studies (3,339 patients; 110 events), with a pooled rate of 5% (95% CI 0.03-0.07; I²=74.5%). Among studies evaluating posterior re-repair after prior posterior repair, recurrence was assessed in eleven studies (316 patients; 8 events), with a pooled rate of 1% (95% CI 0.00-0.06; I²=0%); chronic postoperative pain in eight studies (224 patients; 19 events), with a pooled rate of 6% (95% CI 0.02-0.15; I²=0%); SSI in seven studies (231 patients; 3 events), with a pooled rate of 1% (95% CI 0.00-0.04; I²=0%); and seroma in eleven studies (316 patients; 21 events), with a pooled rate of 6% (95% CI 0.03-0.12; I²=34.8%). Only one study evaluated anterior repair following prior posterior repair, precluding quantitative synthesis.

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

Abstract

Introduction

Methods

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Results

Conclusion

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