ABSTRACT

Objective

The optimal surgical approach for bilateral inguinal hernia repair remains controversial. This study aimed to compare the clinical outcomes of laparoscopic total extraperitoneal repair (TEP) and open Lichtenstein repair in patients undergoing elective bilateral inguinal hernia surgery.

Methods

Patients who underwent elective surgery for bilateral inguinal hernia between January 2021 and December 2025 were retrospectively evaluated. Patients were divided into two groups according to the surgical technique: TEP and Lichtenstein repair. Demographic characteristics, perioperative findings, postoperative complications, recurrence, chronic pain, and length of hospital stay were compared between the groups.

Results

A total of 264 patients were included in the study. Of these, 145 underwent TEP repair and 119 underwent Lichtenstein repair. Operative time was significantly shorter in the TEP group compared with the Lichtenstein group (73.4±26.8 vs. 101.2±35.2 minutes, p<0.001). Overall morbidity rates were similar between the groups (22.1% vs. 30.3%, p=0.130). Chronic postoperative pain was significantly lower in the TEP group (2.8% vs. 8.4%, p=0.042). Although recurrence was numerically higher in the TEP group (6.9% vs. 3.4%), the difference was not statistically significant (p=0.202). No significant difference was observed in length of hospital stay (p=0.235).

Conclusion

Both TEP and Lichtenstein repairs are safe and effective options for bilateral inguinal hernia surgery, with comparable morbidity and recurrence rates. However, TEP repair was associated with shorter operative time and lower chronic postoperative pain. Surgical approach should be individualized according to patient characteristics, anesthetic risk, and surgeon experience.

INTRODUCTION

Inguinal hernias are among the most frequently encountered surgical conditions and account for nearly 75% of all abdominal wall hernias. An inguinal hernia is expected to occur over a lifetime in nearly 27% of men and 3% of women (1). Both open repair and laparo-endoscopic methods are widely accepted as standard surgical options for the management of inguinal hernias (2, 3). With recent advances in surgical techniques, laparoscopic approaches have increasingly been preferred because of benefits including less postoperative pain, shorter recovery time, and quicker resumption of normal daily activities (3, 4). International HerniaSurge guidelines  recommend that laparo-endoscopic approaches be considered the preferred option for bilateral inguinal hernias in experienced centers (2, 3).

Bilateral inguinal hernias represent a more complex group of patients for surgical planning than unilateral cases. The requirement for simultaneous repair of both sides increases the importance of surgical approach selection with regard to operative time, anesthesia choice, postoperative complication profile, chronic pain development, and recurrence rates (4, 5). Laparoscopic total extraperitoneal repair (TEP) may offer advantages in bilateral cases, as it allows simultaneous treatment of bilateral defects through a single preperitoneal approach. In contrast, open Lichtenstein repair remains a widely preferred and reliable method because of its technical feasibility, short learning curve, and safe applicability in a broad patient population (2, 5).

Although numerous studies have compared laparoscopic and open techniques, most have evaluated unilateral and bilateral cases together, leaving data specific to bilateral inguinal hernia relatively limited (5, 6). In a limited number of studies evaluating bilateral hernias, laparoscopic approaches have been associated with less early postoperative pain, shorter hospital stay, and lower rates of chronic pain. However, most of these data are derived from the transabdominal preperitoneal (TAPP) approach, whereas direct comparisons between TEP and open Lichtenstein repair remain scarce (6, 7).

This study evaluated the surgical outcomes of laparoscopic TEP and open Lichtenstein repair in patients undergoing surgery for bilateral inguinal hernias. The two techniques were  compared with respect to operative duration, length of hospitalization, development of long-term pain, postoperative adverse events, and hernia recurrence. In addition, the study aimed to contribute to the selection of an appropriate surgical strategy for the treatment of bilateral inguinal hernia.

METHODS

The medical records of patients who underwent elective bilateral inguinal hernia surgery in the Department of General Surgery at our hospital between January 2021 and December 2025 were retrospectively analyzed. Based on the surgical approach, the cases were evaluated in two groups: patients treated with TEP and those who underwent open Lichtenstein repair.

The study included adult patients aged 18 years or older who underwent elective bilateral inguinal hernia repair, either via TEP or open Lichtenstein repair. Excluded were patients treated under emergency conditions; those undergoing surgery for unilateral inguinal hernia; cases converted from laparoscopy to open surgery; patients who underwent laparoscopic repair on one side and open repair on the contralateral side; patients treated with the TAPP technique; cases requiring additional surgical procedures; and patients with incomplete clinical data.

Age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, Charlson comorbidity index, accompanying comorbidities, smoking and alcohol use, history of abdominal surgery, anticoagulant use, presenting complaints, and duration of symptoms were recorded.

Groin hernia defects were assessed according to the European Hernia Society classification. Based on clinical characteristics, hernias were classified as primary or recurrent, and anatomical distribution was defined as lateral, medial, or femoral. The size of the hernia defect was determined based on the transverse width of the hernia opening and classified into three categories: Grade 1 (<1.5 cm), Grade 2 (1.5-3 cm), and Grade 3 (>3 cm). Right- and left-sided hernias were recorded separately according to this classification (8).

Radiological findings (ultrasonography and computed tomography), defect diameters, anesthesia method, operative time, drain use, postoperative morbidity, chronic pain, recurrence rates, and length of hospital stay were also evaluated. Chronic pain was defined as groin pain persisting beyond the third postoperative month. Hernia recurrence was defined as detection during follow-up by physical examination and/or radiological imaging.

The study groups were compared with respect to operative duration, postoperative adverse events, chronic postoperative pain, recurrence, and duration of hospitalization.

Ethical Approval

The study protocol was conducted in line with the ethical standards outlined in the Declaration of Helsinki. Prior to commencing study, approval was obtained from the University of Health Sciences Türkiye, Bakırköy Dr. Sadi Konuk Training and Research Hospital Clinical Research Ethics Committee (approval no: 2026-07-08, date: 18.03.2026). Informed consent was obtained from all patients included in the study.

Statistical Analysis

Statistical findings were expressed using measures of central tendency and dispersion, together with frequency distributions. Data distribution was assessed using the Kolmogorov-Smirnov and Shapiro-Wilk tests. Parametric continuous variables were compared using Student’s t-test, whereas non-parametric variables were analyzed using the Mann-Whitney U test. Relationships between categorical parameters were evaluated by chi-square analysis, and Fisher’s exact test was preferred in cases where chi-square assumptions were not fulfilled. All analyses were conducted with IBM SPSS Statistics version 28.0 (IBM Corp., Armonk, NY, USA).

RESULTS

A total of 308 patients who underwent elective bilateral inguinal hernia repair during the study interval were retrospectively evaluated. Among them, 9 patients who required conversion from laparoscopic to open surgery and 8 patients who were  treated with a laparoscopic approach on one side and an  open repair on the opposite side were excluded. Of the 291 patients who met the eligibility criteria, 167 had received laparoscopic surgery and 124 had undergone open repair. Within the laparoscopic cohort, 17 patients who were managed with the TAPP technique and 5 patients with missing data were further excluded. In the open surgery cohort, 5 additional patients were excluded because of incomplete records. As a result, the final study population consisted of 264 patients, including 145 in the TEP group and 119 in the Lichtenstein group. Figure 1 presents  the patient selection process and study grouping.

The mean age of the 264 included patients was 56.7±12.3 years, and the vast majority were male (97.7%). The mean BMI was 26.6±3.3 kg/m². While 74.2% of the patients were classified as ASA II, the mean Charlson comorbidity index was 1.7±1.4. The most common presenting complaint was swelling (48.5%), followed by pain (40.5%). At least one comorbidity was present in 60.6% of patients; smoking was present in 41.3%, and anticoagulant use in 20.8%. Demographic and baseline clinical characteristics are summarized in Table 1.

The most common hernia type on the right side was PL2 (28.4%), followed by PL1 (24.6%) and PM1 (17.0%). On the left side, PL1 was the most common type (31.1%), followed by PL2 (22.3%) and PM1 (15.9%). Primary lateral hernias constituted the predominant subgroup on both sides. Ultrasonographic evaluation was available for 84.1% of the cohort. The average defect size measured 18.5±9.5 mm on the right side and 17.9±8.3 mm on the left side. Computed tomography was performed in 17.0% of patients, and bilateral hernia defects were detected in 66.7% of these patients. Details regarding hernia classification and radiological assessment findings are presented in Table 2.

TEP repair was performed in 54.9% of patients, and Lichtenstein repair in 45.1%. The most  preferred anesthesia method was general anesthesia (72.3%), followed by spinal anesthesia (18.9%) and laryngeal mask airway anesthesia (8.7%). Average operative duration was calculated as 86.0±33.8 minutes, while the average hospitalization period was 1.1±0.6 days. Drain use was required in 12.1% of patients. The overall morbidity rate was 25.8%. The most common postoperative complications were hematoma, chronic pain, and recurrence (5.3% each), followed by seroma and scrotal edema (3.8% each). Wound infection was observed in 2.7% of patients,  urinary complaints and groin numbness or burning sensation in 0.8%, and testicular ischemia in 0.4%. No mortality was observed. Postoperative outcomes were assessed using hospital records and outpatient follow-up data, with a mean follow-up duration of 16.2±8.4 months. Operative and postoperative outcomes are summarized in Table 3.

Baseline demographic and clinical characteristics, including age, sex, BMI, Charlson comorbidity index, and accompanying comorbid conditions, were comparable between the TEP and Lichtenstein groups (all p>0.05). The Lichtenstein group had significantly higher ASA scores (p=0.016), and anticoagulant use was more common in this group (p=0.028). Regarding presenting symptoms, pain was reported more frequently in the Lichtenstein group, whereas swelling alone and combined pain and swelling were more prevalent in the TEP group (all p<0.001). Regarding anesthesia preference, general anesthesia was used more often in the TEP group, while spinal anesthesia was used more often in the Lichtenstein group (p<0.001). The TEP group demonstrated a significantly shorter operative duration compared with the Lichtenstein group (73.4±26.8 vs. 101.2±35.2 minutes, p<0.001). Recurrence rates, overall morbidity, drain utilization, and length of hospitalization did not differ significantly across the study groups (all p>0.05). Detailed comparative results are shown in Table 4.

Postoperative morbidity rates did not differ significantly between the study groups (22.1% vs. 30.3%, p=0.130). Evaluation of individual postoperative complications demonstrated a statistically significant difference only for chronic postoperative pain, which occurred less frequently in patients treated with TEP than in those undergoing Lichtenstein repair (2.8% vs. 8.4%, p=0.042). Although recurrence was observed more often in the TEP cohort (6.9% vs. 3.4%), this difference did not reach statistical significance (p=0.202). The frequencies of hematoma, seroma, scrotal edema, wound infection, urinary symptoms, groin numbness or burning sensation, and testicular ischemia were similar in both treatment groups (all p>0.05). Detailed postoperative complication data are summarized in Table 5.

DISCUSSION

In our cohort, patients treated with TEP demonstrated a markedly reduced operative duration in comparison with those who underwent Lichtenstein repair (73.4±26.8 vs. 101.2±35.2 minutes, p<0.001). Traditionally, laparoscopic inguinal hernia repair has been considered more time-consuming than open surgery because of technical complexity and the learning curve (2, 4). However, in bilateral cases, simultaneous repair of both defects through a single preperitoneal dissection plane may provide an important time advantage for the TEP approach. In a prospective randomized study by Ielpo et al. (6) comparing TAPP and Lichtenstein repair in bilateral inguinal hernias, operative times were similar. In contrast, Mahon et al. (7) reported shorter operative times in the laparoscopic group in bilateral cases. Likewise, Feliu et al. (9) demonstrated shorter operative duration in the TEP group compared with Lichtenstein repair in bilateral inguinal hernias. The difference observed in our cohort may be explained by the open technique’s requirement for separate dissections on each side, whereas TEP allows bilateral repair through a single working space. In addition, the experience of our center in laparoscopic hernia surgery may have contributed to this result. These findings suggest that TEP may also be an efficient time-saving option in experienced centers with appropriate infrastructure.

A significantly lower incidence of chronic postoperative pain was observed in the TEP group compared with the Lichtenstein group (2.8% vs. 8.4%, p=0.042). Chronic pain following inguinal hernia repair is a major long-term postoperative concern and can negatively affect patients’ quality of life. The risk of postoperative neuralgia may be greater in anterior open techniques because of more extensive tissue dissection and increased manipulation of the ilioinguinal, iliohypogastric, and genitofemoral nerves (10, 11). Numerous studies have shown that laparo-endoscopic techniques offer an advantage with respect to chronic pain. In the prospective randomized study by Yosypenko et al. (12) involving bilateral inguinal hernia patients, lower postoperative pain scores were reported in the TEP group. Feliu et al. (9) also reported better postoperative comfort in patients undergoing TEP repair.
Furthermore, the meta-analysis by Bobo et al. (13) demonstrated that TEP repair was associated with lower rates of chronic pain than the Lichtenstein technique. Our findings are consistent with these data and suggest that the TEP approach may provide an advantage in long-term pain control and in quality of life for patients with bilateral inguinal hernias. Reduced contact with neural structures in the posterior preperitoneal approach and less irritating mesh placement, compared with the anterior plane, may partly explain this difference.

Despite a numerically greater recurrence frequency in the TEP cohort (6.9% vs. 3.4%), the intergroup difference did not reach statistical significance (p=0.202). This finding suggests that both techniques provide comparable effectiveness and durability in the treatment of bilateral inguinal hernias. Previous studies have similarly reported no marked difference in recurrence rates between laparoscopic and open mesh repairs. In bilateral cases, both Yosypenko et al. (12) and Feliu et al. (9) reported similar recurrence outcomes between TEP and Lichtenstein techniques. The numerically higher recurrence rate in the TEP group may be attributable to technical factors such as the learning curve, mesh positioning, insufficient overlap area, or mesh fixation strategy. Because bilateral repair requires wider preperitoneal dissection, the surgeon’s experience likely plays a decisive role in long-term recurrence rates.

The TEP group demonstrated a lower overall postoperative morbidity rate; however, the observed difference between groups was not statistically significant (22.1% vs. 30.3%, p=0.130). No significant differences were found between the groups regarding hematoma, seroma, scrotal edema, wound infection, or urinary complications. These findings indicate that both approaches have comparable safety profiles. In the randomized controlled study by Langeveld et al. (14), no significant difference in major complications was reported between TEP and Lichtenstein repair. Similarly, the meta-analysis by Bobo et al. (13) showed comparable overall complication rates. In contrast, Neumayer et al. (15) reported higher complication rates in the laparoscopic group, whereas Timişescu et al. (16) found lower complication rates in the TEP group. These heterogeneous findings may be related to differences in surgeon experience, patient selection, complication definitions, and duration of follow-up. The numerically lower morbidity observed in the TEP group in our cohort may be explained by reduced tissue trauma, smaller incisions, and avoidance of anterior inguinal canal dissection. Nevertheless, the lack of statistical significance may be due to the limited sample size and the relatively low number of complication events.

A marked difference was also observed in anesthesia preference. General anesthesia was used more frequently in the TEP group, whereas spinal anesthesia was more commonly used in the Lichtenstein group (p<0.001). This finding is expected, as TEP repair generally requires the  creation of a preperitoneal working space and the use of laparo-endoscopic equipment, and is therefore most often performed under general anesthesia. In contrast, Lichtenstein repair can be safely performed with spinal or other regional anesthesia. The higher ASA scores observed in the open surgery group also suggest that the open technique may have been preferred for patients with greater anesthetic risk. Therefore, open Lichtenstein repair remains an important alternative, particularly in patients at high risk for general anesthesia.

This study has several strengths. First, focusing exclusively on patients with bilateral inguinal hernia provided a more homogeneous study population than heterogeneous series that included both unilateral and bilateral cases. Second, the evaluation of all cases at a single center under similar surgical practice increased internal consistency. A comprehensive assessment of both techniques in terms of demographic characteristics, perioperative outcomes, and postoperative complications adds value to the study.

Study Limitations

Nevertheless, several limitations should be acknowledged. The retrospective single-center design cannot completely eliminate the risk of selection bias. Another limitation of the study is the lack of a standardized postoperative pain scoring system, such as the visual analog scale, due to the retrospective design. The non-randomized choice of surgical technique and the higher ASA scores in the open surgery group may have led to baseline differences between the groups. In addition, the sample size may have limited the  statistical power, particularly for rare complications and recurrence outcomes. Additionally, the inability to perform multivariate analysis due to the limited number of outcome events, particularly for chronic pain and recurrence, represents another limitation of the study. Larger multicenter prospective randomized studies are needed to validate these findings.

CONCLUSION

Both TEP and Lichtenstein repairs can be safely performed in cases of bilateral inguinal hernia, with comparable overall morbidity and recurrence rates. However, TEP repair was associated with shorter operative time and lower rates of chronic postoperative pain. Open Lichtenstein repair remains an important alternative, particularly in patients with increased anesthetic risk. Surgical technique should be individualized according to patient characteristics, anesthetic risk, surgeon experience, and institutional resources. Larger prospective randomized studies may help determine the optimal approach for the treatment of bilateral inguinal hernia.