Open preperitoneal vs. endoscopic repair for bilateral groin hernias: a registry-based two-arm comparison

Introduction

The concept of treating groin hernias through the placement of a large preperitoneal prosthesis, via both open and minimally invasive approaches, was first introduced by Franz Ugahary and published in 1995 (1-3). Although it yielded very good results in the hands of its creator, the technique has since been adopted by only a limited number of surgeons, and its underlying principle has remained relatively under-recognized. The development of a new prosthesis (4), which facilitates its deployment through a small incision, has permitted the emergence of several additional techniques that adhere to the same underlying principles. These include transinguinal approaches such as transinguinal preperitoneal (TIPP) (5-7) and minimal open preperitoneal (MOPP) (8-10), as well as strictly posterior approaches (like the Ugahary technique): the transrectus sheath preperitoneal (TREPP) technique (11,12). The open new simplified totally extraperitoneal (TEP) technique (ONSTEP) (13) should also be mentioned, although it involves only partial preperitoneal placement of the prosthesis and is therefore somewhat peripheral to the scope of our study. All of these techniques are grouped under the generic term ‘open preperitoneal techniques’, abbreviated as ‘OPPs’. A detailed history of these techniques was recently published (14). More recent articles have demonstrated the good outcomes of OPPs compared to Lichtenstein techniques for primary unilateral hernias (15-20) and to endoscopic repair (Endo) (21,22). Other studies have shown the relevance of OPPs for recurrent hernias (23,24), and even for inguinoscrotal hernias (25,26). Regarding bilateral hernias, it has been established that they can be treated in a single operation, with results comparable to those of a two-stage procedure (27). Current guidelines recommend the transabdominal preperitoneal (TAPP)-TEP approach (28), but the referenced article compares Endo to open Lichtenstein-type repairs.

To date, evidence specifically addressing bilateral primary groin hernia repair using OPPs remains limited. A recent study from the American College of Hernia Quality Collaborative registry included a small number of bilateral cases and reported outcomes of open preperitoneal repair comparable to those of both Lichtenstein techniques and Endo (29). More recently, two studies from the same expert group led by López-Cano further investigated open preperitoneal repair using a pure posterior approach, referred to as the modified Wantz technique, which is conceptually close to the Ugahary technique used in the present study (and to the TREPP technique, which was not included in our series). In the first study (30), the modified Wantz technique was compared with robot-assisted laparoscopic repair. Similar outcomes were observed in terms of complications, chronic pain, and recurrence, with no clear clinical advantage of robotic assistance over the open approach; however, this study was not specifically dedicated to bilateral hernia repair. In a second study (31), focusing on ambulatory bilateral groin hernia repair, the same modified Wantz technique was compared with laparoscopic TEP/TAPP, demonstrating comparable long-term outcomes and supporting open preperitoneal repair as a valid alternative in bilateral cases. While these two latter studies provide important insights, they are limited by their monocentric design and the involvement of highly specialized teams.

The present study, therefore, aims to extend this evidence by testing the hypothesis that OPPs, specifically TIPP, MOPP, and Ugahary repairs, achieve outcomes similar to laparoscopic TAPP/TEP specifically for bilateral primary groin hernia repair in a large, multicenter, registry-based, real-world setting. We present this article in accordance with the STROBE reporting checklist (32) (available at https://asj.amegroups.com/article/view/10.21037/asj-25-80/rc).

Methods

Study design

This retrospective comparative study analyzed prospectively collected data from the Club Hernie Registry database. All consecutive groin hernia repairs recorded between September 1, 2011, and December 22, 2024, were screened, and bilateral hernia repairs were identified. Participating surgeons commit to consecutive data entry over predefined periods, with the obligation to include all cases, minimizing inclusion-related selection bias; differences between groups therefore primarily reflect treatment-allocation and case-mix differences inherent to real-world practice. Exclusion criteria were: patients under 18 years of age, recurrent hernias, emergency surgeries, and missing postoperative data at day 30. The study was adhered to the recommendations of the European Abdominal Wall Hernia Registry Working Group (33) and the Club Hernie Registry. The registry complies with the European General Data Protection Regulation (34). All data were anonymized and de-identified, collected under a patient “non-opposition” agreement.

Five surgical techniques were included: TIPP, MOPP, Ugahary, TEP, and TAPP. For analysis, TIPP, MOPP, and Ugahary were grouped as OPPs, while TEP and TAPP were grouped as Endo. Other techniques for bilateral hernia repair were excluded from the analysis. The Ugahary procedure, first described in 1995, uses a purely posterior approach involving a short skin incision and penetration of the inguinal wall until the peritoneal plane approximately 2 cm above the deep inguinal ring. It requires specific instruments for space dissection, cord parietalization, and full preperitoneal prosthesis placement covering the myopectineal orifice (1-3). The TIPP technique (5-7) involves a skin incision over the deep inguinal ring, minimal canal dissection, nerve preservation, and preperitoneal mesh placement through the deep inguinal ring. The MOPP technique (8-10) follows the TIPP approach but uses Ugahary-derived instruments for broader dissection and mesh deployment.

Club Hernie Registry members enter preoperative, intraoperative, and postoperative data for the first week and at 30 days (M1) into the online registry. Intraoperative variables included the type of general anesthesia and the use of adjunct local and/or regional analgesic techniques. Adjunct analgesia was recorded at the patient level; its distribution according to surgical approach is detailed in Table 1. An optional 3-month visit is arranged if any issues are identified at M1. Long-term follow-up at 1, 2, and 5 years was conducted by an independent clinical research assistant (CRA) via standardized telephone-based patient-reported outcome measures (PROM) questionnaires (35). Patients were asked about rehospitalization, reoperation, recurrence confirmed or suspected, using the post-inguinal-repair questionnaire by telephone (PINQ-PHONE) (36), late abscess, chronic sinus, mesh removal, and other complications (e.g., bowel obstruction). Patients not reached after five contact attempts at different times and on different days were considered lost to follow-up. If abnormalities were detected, a visit to the operating surgeon was strongly recommended. Additionally, some surgeons, such as the first author, encourage systematic clinical follow-up visits. These results are recorded independently of the CRA data, in dedicated surgeon-specific tabs within the registry.

Postoperative pain was assessed on days 1, 2, 8, and 30 using a 0–10 Numeric Rating Scale (NRS) and compared to preoperative NRS scores. Chronic postoperative inguinal pain (CPIP), defined as pain persisting beyond 3 months, was assessed during follow-up using a 0–10 NRS and a 4-point Verbal Rating Scale (VRS): no pain, mild, moderate, severe, and compared with preoperative pain status.

Baseline variables included: age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, diabetes mellitus, antiplatelet/anticoagulant medication, smoking status, synchronous repair of multiple defects, hernia type according to the European Hernia Society (EHS) groin hernia classification (37), and the Tran et al. classification (38), operative time, and hospital stay.

Intraoperative complications included peritoneal tear, bladder/bowel injury, orchidectomy, major bleeding, or general complications.

Postoperative complications were categorized as follows: general medical: cardiac events, thromboembolic events, neurologic events, urinary retention, and injection site inflammation. Surgical site infection (SSI): superficial or deep/periprosthetic. Surgical site occurrence (SSO): non-infected superficial or deep/periprosthetic collections. Organ-space complications: intraperitoneal bleeding, peritonitis, bowel obstruction, and immediate recurrence. When multiple complications occurred, the Clavien-Dindo classification (39) was applied, grading based on the most severe complication.

The outcomes of interest were feasibility: conversion rate and intraoperative complications. Safety: 30-day and late complications.Effectiveness: recurrence rates. Patient-reported outcomes: pain scores, PROMs, and quality of life (QoL).

For clarity, the primary outcomes were long-term recurrence and severe CPIP. Secondary outcomes included operative time, 30-day morbidity (including Clavien-Dindo ≥ III), early postoperative pain, and other perioperative variables.

Statistical analysis

Normality of continuous variables was assessed using the Shapiro-Wilk test. Statistical analyses were performed using R statistical software (R Foundation for Statistical Computing, Vienna, Austria), version 4.2.2. Continuous variables are summarized as mean ± standard deviation (SD) [or median (interquartile range) when non-normally distributed] and compared between groups using the Student’s t-test or the Mann-Whitney U test, as appropriate. Categorical variables are reported as n/N (%) and compared using the χ² test (with Yates’ continuity correction when applicable); Fisher’s exact test was used when expected cell counts were <5. Two-sided P values <0.05 were considered statistically significant. Percentages were calculated from non-missing observations; the number of missing values is reported per row. No imputation was performed. In our registry, bilateral repairs are recorded per side, so each bilateral case yields two records for one patient. If this structure isn’t handled correctly, denominators can be double-counted, and precision overstated. To prevent that, we prespecified the unit of analysis for every endpoint. For patient-level endpoints, we combined both sides into a single record per patient, used the number of unique patients with non-missing data as the denominator for P values, and rebuilt those denominators from the raw records (rather than halving side counts) to avoid double-counting when missingness differs by side. Thus, patient-level endpoints included demographics (age, sex, BMI), comorbidities (e.g., diabetes), ASA class, anesthesia, antibiotic prophylaxis, length of stay (outpatient vs. inpatient), systemic/general complications, Clavien-Dindo grades, readmission, reoperation, late complications, and late pain. Whereas side-level analyses were used only for outcomes that pertain to a specific groin. These endpoints included EHS hernia type and defect size, mesh fixation method, intraoperative technical difficulties, nerve handling, local complications (e.g., seroma/SSO, SSI, orchitis, hydrocele), early recurrence, and pain localized to the operated side, assessed preoperatively and within the first 30 postoperative days. Tables are organized accordingly (patient-level vs. side-level). Given the observational design, no causal inference was intended, and all analyses should be interpreted as descriptive comparisons reflecting real-world practice.

Ethical consideration

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Data for this study were obtained from the Club Hernie Registry, which complies with the European General Data Protection Regulation and the standards of the French Commission Nationale de l’Informatique et des Libertés (CNIL; registration No. 1993959v0). As this was a retrospective analysis of de-identified registry data, additional institutional review board approval was not required under national legislation. All data were anonymized and collected under a patient opt-out (“non-opposition”) process; therefore, individual informed consent was waived.

Results

Between September 1, 2011, and December 22, 2024, 43,281 groin hernia repairs were recorded in the Club Hernie Registry, including 13,120 bilateral cases. Of these, 10,168 repairs (5,084 patients) met the inclusion criteria and were analyzed, including 1,592 OPPs and 8,576 Endo (Figure 1). Baseline patient characteristics are summarized in Table 2. The groups were comparable with respect to sex, BMI, comorbidities, smoking status, and ASA class. Patients treated with OPPs were older and had more complex hernia profiles, with significantly more large (L3/M3) defects and a higher preoperative pain and symptom burden (Tables 2,3). These differences reflect real-world treatment selection and case-mix variation rather than protocol-driven allocation.

Figure 1 Prisma flowchart. OPPs: transinguinal preperitoneal, minimal open preperitoneal, and the Ugahary techniques; Endo: transabdominal preperitoneal and totally extraperitoneal techniques. Endo, endoscopic repair; GHR, groin hernia repair; OPPs, open preperitoneal techniques.

Intraoperative management and technical details are reported in Tables 4-6. General anesthesia was used in nearly all patients; tracheal intubation was nearly universal in the Endo group, whereas laryngeal mask general anesthesia predominated in the OPPs group (both P<0.001). Endo repairs had shorter operative times and higher conversion rates, while nerve resections were rare overall but more frequent in OPPs. Mesh fixation was uncommon in OPPs, whereas fixation was used in approximately half of Endo cases (P<0.001).

Early postoperative outcomes are detailed in Tables 7-9. Serious complications (Clavien-Dindo ≥ III) were uncommon and similar between groups. General complications, postoperative organ-space complications, reoperation, and rehospitalization were rare and did not differ significantly between groups.

Outpatient management was less frequent after Endo than after OPPs (P=0.005). Despite a more frequent use of adjunct local or regional analgesia in the OPPs group (Table 1), early postoperative pain scores during the first postoperative days were higher after OPPs repair compared with Endo (Table 9), but pain scores converged by day 30.

Long-term outcomes are presented in Tables 10-12. Very rare complications were observed in both groups. Mesh infections occurred only in the OPPs group (0.4%), with a statistically significant between-group difference (P=0.004). Recurrence rates and severe CPIP were low and similar between groups. At the first follow-up questionnaire, moderate CPIP was less frequent after OPPs than after Endo (P<0.001), whereas severe CPIP rates were similar. At later follow-up, CPIP prevalence and patient-reported outcomes did not differ significantly between approaches in univariate analyses.

Discussion

In this large, prospective registry focused on bilateral inguinal hernias, OPPs (TIPP/MOPP/Ugahary) achieved safety, effectiveness, and patient-reported outcomes without statistically significant differences compared with Endo, despite older age and larger, more symptomatic hernias in the OPPs cohort at baseline. OPPs relied more on lighter anesthesia and limited mesh fixation, while Endo tended to involve general anesthesia with intubation. Endo has shorter operative times. Early serious complications were uncommon in both groups, early postoperative pain favored Endo but converged by day 30, and longer-term PROMs and recurrence rates were similar.

Consistent with these findings, only one study has compared bilateral hernia repair across OPPs (TREPP and Kugel), Endo, and Lichtenstein techniques (29), but it grouped OPPs and Lichtenstein together under ‘open repair’, complicating interpretation. Data directly comparing open posterior preperitoneal and laparoscopic approaches remain scarce, particularly in the setting of bilateral hernia repair. Consistent with our findings, a recent prospective single-center study comparing open posterior preperitoneal repair with laparoscopic TAPP for recurrent inguinal hernias reported outcomes without statistically significant differences between approaches (40), while emphasizing the importance of surgeon experience and the impact of the learning curve; however, its focus on recurrent disease and its limited sample size differentiate it substantially from the present registry-based analysis of elective bilateral primary repairs. Our study adds new evidence by comparing two homogeneous groups, OPPs vs. Endo, and clarifies outcomes specifically for bilateral repairs. Our findings align with prior evidence that OPPs perform well vs. Endo in unilateral primary hernias (21,22). Using the Club Hernie Registry, our group previously showed favorable outcomes with MOPP/TIPP in experienced hands (8-10), extended these results to inguinoscrotal vs. non-scrotal primary hernias (25), and reported equivalence between TIPP/MOPP, Endo, and Lichtenstein for inguinoscrotal cases (26). Other teams have likewise reported good results for OPPs in both primary and recurrent unilateral hernias (15-18,23,24), and several studies indicate superior patient-reported outcomes for preperitoneal repair compared with Lichtenstein (15-20). Much of the current literature compares Endo with ‘open’ repair, but ‘open’ almost always means Lichtenstein, even when this is not stated. For example, in a recent large study (41), direct author confirmation showed the ‘open’ group consisted exclusively of Lichtenstein repairs. Similar ambiguity appears in current guidelines (28,38). With the growing use of OPPs, it is now essential to distinguish clearly between ‘classic open’ (Lichtenstein) and ‘open preperitoneal’ (OPPs) in both studies and recommendations. This study challenges the notion that laparo-endoscopic approaches should be the preferred approach for bilateral inguinal hernias (whenever expertise and resources are available). Beyond the single previous study (29), evidence specifically supporting OPPs in bilateral repair is lacking. Our results, therefore, add substantially to the field. In practice, either by deliberate choice, as in our centers, or where endo-robotic resources are limited, OPPs offer a credible alternative that still meets high surgical standards (broad myopectineal orifice coverage, tension-free, and fixation-sparing). Importantly, OPPs can be performed under local or loco-regional anesthesia, or under general anesthesia without endotracheal intubation, thereby limiting the need for neuromuscular blockade. Consistent with another report (21), OPPs provide outcomes that do not differ significantly from laparo-endoscopic unilateral repairs while avoiding general anesthesia, making them particularly suitable for frail or comorbid patients. Interpretation of outcomes with OPPs may still be subject to bias, as these procedures are advocated and performed by a relatively small group of surgeons, often abdominal wall specialists (12,42). Although current data suggest that OPPs can deliver outcomes without significant differences compared with laparo-endoscopic approaches for primary inguinal hernia repair, and in selected patients potentially better outcomes (21), these findings require confirmation across a broader spectrum of surgeons and practice settings. Our series, spanning nine French surgeons, together with a growing number of European and North American colleagues reporting their results, helps to expand the evidence base. It is important to acknowledge the learning curve associated with OPPs. Although OPPs aim to achieve minimal-access surgery, this feature may represent an initial technical challenge. This issue has been previously discussed by our group in a 2024 publication (10). As reported in that publication, international guidelines indicate that learning curves vary widely across groin hernia repair approaches, with laparo-endoscopic approaches generally requiring longer training periods than conventional open repairs, and the learning phase appears to mainly affect operative time rather than early or late clinical outcomes. However, it is currently not possible to define an objective number of procedures required to overcome the learning curve.

Methodologically, the key was to align the unit of analysis with each variable, as detailed in the “Statistical analysis” section (patient- and side-level).

Limitations and strengths

Limitations of this study, partly inherent to its registry-based design, include its retrospective analysis of a prospectively maintained database and some loss to follow-up for long-term outcomes. Although there were no significant between-group differences in BMI, diabetes, or tobacco use, the cohorts differed in other respects: the OPPs group was older and showed a non-significant trend toward more frequent anticoagulant/antiplatelet use; preoperative pain or discomfort was significantly more common and more disabling in the OPPs group; and larger hernias (M3/L3) were more frequent. These differences are likely attributable, at least in part, to selection bias inherent to a tailored approach, which tends to steer older patients or those with larger hernias away from Endo techniques, thereby introducing heterogeneity between groups. This pattern is consistent with prior reports (38) indicating that open techniques are more often chosen for more complex or difficult-to-manage patients. Despite this case-mix heterogeneity favoring the Endo group, our experience is that postoperative outcomes are generally similar between the two groups. Several limitations related to missing data should be acknowledged. First, the higher proportion of missing ASA values in the OPPs group resulted from incorrect ASA coding by a single contributor. To avoid classification bias, these ASA data were excluded from the analysis. Second, data on antibiotic prophylaxis were incomplete because this variable was introduced at a later stage in the registry and therefore was not recorded for the earliest patients included; it was subsequently recorded prospectively and consecutively for later patients. In addition, pain assessment relied on PROM and is inherently subjective. However, pain was consistently assessed using standardized scales, namely the NRS for postoperative pain and a 4-point VRS for CPIP. The manuscript was carefully revised to harmonize terminology and ensure appropriate and consistent use of these validated instruments throughout. Another limitation is the small number of key events, such as serious complications or severe chronic pain, which yields wide confidence intervals and appreciable uncertainty. These issues cannot be fully mitigated without randomization (or robust causal methods); therefore, residual confounding cannot be excluded. In addition, the imbalance between groups further limited our ability to perform sensitivity or stratified analyses exploring the potential influence of factors such as age, hernia type, preoperative pain, or surgeon distribution. Finally, a practical limitation to wider, effective adoption should be acknowledged: the authors devote a substantial share of their practice to inguinal hernia repair and have specific expertise with preperitoneal approaches. This specialization likely facilitates efficient performance of these operations. Surgeons with limited experience in preperitoneal mesh placement may prefer conventional open techniques such as Lichtenstein. For surgeons interested in adopting these approaches, we recommend a structured learning pathway: careful study of key publications, particularly the TIPP technique paper (7), the MOPP technique paper (10), the TREPP technique report (12), and the Ugahary technique (1-3), followed by dedicated hands-on training with experienced specialists to ensure reproducibility.

Strengths of this study include the use of a standardized follow-up protocol via a structured telephone questionnaire, which is highly practical for a large patient population (currently >43,000 patients in our registry) and has proven reliable for assessing chronic pain, QoL, and for detecting late events such as rehospitalizations, reoperations, bowel obstruction, and mesh infection. All procedures were performed by high-volume surgeons. Moreover, data were prospectively collected, with consecutive enrollment for each participating surgeon. Finally, it should be emphasized that the present study complements previous work, notably that reported by the team of López-Cano (30,31). These authors evaluated a pure posterior open preperitoneal approach, referred to as the modified Wantz technique, which is conceptually close to the OPPs described in the present study, particularly the Ugahary technique (and to the TREPP technique, which was not used in our series). In selected bilateral cases, they demonstrated outcomes similar to those achieved with laparoscopic or robotic repairs. However, these studies were monocentric and conducted by a highly specialized surgical team. In contrast, our present analysis is based on a multicenter registry and includes several OPPs (TIPP, MOPP, and Ugahary). By focusing specifically on bilateral primary groin hernia repair, our study both confirms the findings reported by the López-Cano group and provides more specific data comparing OPPs with laparoscopic TAPP/TEP approaches in the setting of bilateral hernia repair.

Generalizability

Based on our results, we focus on why OPPs can be used in the same indications as Endo for bilateral hernias, and in some situations can reasonably be proposed as preferred options. In routine practice, case-mix selection is common: laparo-endoscopic approaches are preferentially offered to younger patients with fewer comorbidities, whereas open approaches are more often used in older or more symptomatic patients or in more complex hernias (22,26,43-45). Large registry datasets confirm baseline imbalances that require propensity adjustment, with difficult phenotypes (for example, scrotal hernias or large medial/lateral defects) more frequently treated by open rather than Endo (28). The usual rationale is that open techniques can be performed under lighter anesthesia than Endo; older, more comorbid, and frailer patients are therefore more often directed toward an open repair. Historically, many such patients have undergone a Lichtenstein repair. Our argument is that OPPs preserve the practical advantages of open surgery (including anesthetic flexibility) while providing a superior preperitoneal, posterior prosthetic concept compared with Lichtenstein. It is therefore preferable to orient patients who are not easily indicated for Endo toward OPPs, and a wider adoption of OPPs is desirable. Regarding intervention costs, most studies report higher direct hospital costs for Endo (28,46-48), although increasing rationalization can narrow this gap, particularly for bilateral hernias (28,49). When lower costs are reported for bilateral Endo, two features typically explain the finding: first, the comparator is often two separate open operations rather than a single-session open repair (48,50); second, the same studies frequently report shorter length of stay, fewer postoperative complications, and fewer readmissions after Endo, which further shifts the cost balance toward laparoscopy (50,51). In our study, OPPs achieved postoperative outcomes that did not differ significantly from those of Endo in univariate analyses, and we recommend treating bilateral hernias in a single session. This single-session strategy removes the two-stage open comparator bias and enables a like-for-like comparison of postoperative outcomes (length of stay, complications, readmissions). Taken together, OPPs should therefore retain a direct-cost advantage over Endo in many settings, a point that now warrants confirmation in targeted economic studies. This cost convergence is far less likely in low- and middle-income countries (52-55), where limited endoscopic infrastructure and training keep open mesh repair predominant; in these contexts, OPPs represent a particularly relevant option that can extend the benefits of a posterior repair without the capital and maintenance burden of laparoscopy. Although this is not the primary focus of the present study, it is worth noting that the higher procedural costs generally reported for endoscopic inguinal hernia repair compared with open approaches may be further amplified by the increasing shift from laparoscopy to robotic platforms among surgeons (56), while large database analyses have shown that robotic procedures are associated with higher overall costs, although the underlying cost drivers remain complex and variably reported (57).

Future research

To confirm and refine these findings, compare OPPs with TEP/TAPP in real-world settings (ideally randomized or registry-based). Use simple, clinically meaningful endpoints: recurrence per side, CPIP per patient, and PROMs at 2–5 years. In parallel, run a multicenter, itemized cost analysis that compares single-session OPPs with single-session Endo, so the two-stage open bias is avoided. Implementation studies should describe the learning curve, training pathway, and safety outside expert centers, including resource-limited systems. Finally, standardize reporting by stating clearly when outcomes are patient-level vs. side-level and by showing the exact denominators in the tables.

Conclusions

In this prospective registry analysis of 10,168 operated sides (5,084 patients), OPPs and Endo showed comparable overall safety and effectiveness, with low rates of serious 30-day complications and similar long-term recurrence, severe CPIP, and patient-reported outcomes. These results support OPPs as a valid posterior option for bilateral inguinal hernia repair in routine practice. Technique selection should prioritize patient characteristics, hernia morphology, and local expertise, rather than a one-size-fits-all approach.

Acknowledgments

We would like to thank all the members of the Club Hernie Registry, especially those who have registered more than 10 cases of bilateral hernia repair: D. Amielh (Polyclinique Grand Sud, Nîmes, France), A. C. Couchard (Department of General Surgery, Hôpital Privé d’Antony, Antony, France), A. Lamblin (Department of General Surgery, Hôpital Privé La Louvière, Lille, France), L. Arnalsteen (Hôpital Privé La Louvière, Lille, France), J. Atger (Polyclinique des Alpes du Sud, Gap, France), M. Beck (Clinique Ambroise Paré, Thionville, France), C. Berney (Prince of Wales Private Hospital, Randwick, Australia), D. Binot (MCO Côte d’Opale, Boulogne-sur-Mer, France), C. Buisset, A. Bonan (Hôpital Privé d’Antony, Antony, France), J. L. Cardin (Polyclinique du Maine, Laval, France), J. Cahais (Clinique Saint Hilaire, Rouen, France), A. Champault-Fezais (Groupe Hospitalier Paris Saint-Joseph, Paris, France), J. M. Chollet (Hôpital Privé d’Antony, Antony, France), J. P. Cossa (Department of General Surgery, CMC Bizet, Paris, France), A. Dabrowski (Clinique de Saint-Omer, Saint-Omer, France), S. Derieux (Groupe Hospitalier Diaconesses-La Croix Saint-Simon, Paris, France), S. Demaret (Clinique Saint-Vincent, Besançon, France), V. Dubuisson (CHU Pellegrin, Bordeaux, France), T. Dugué (Clinique Saint-Pierre, Perpignan, France), B. Foppa (CMCO Claude Bernard, Albi, France), D. Framery (CMC de la Baie de Morlaix, Morlaix, France), R. Fara (Hôpital Européen, Marseille, France), G. Fromont (Clinique de Bois-Bernard, Bois-Bernard, France), N. Goasguen (Groupe Diaconesses-Croix Saint-Simon, Paris, France), P. Grandcoin (Clinique Les Fontaines, Melun, France), A. Guillaud (Clinique du Parc, Castelnau-le-Lez, France), M. Herjean (Clinique des Deux Caps, Coquelles, France), A. Idrissi (MCO Côte d’Opale, Boulogne-sur-Mer, France), F. Jurczak (Department of General Surgery, Clinique Mutualiste, Saint-Nazaire, France), P. Jannot (Hôpital Privé Pays de Savoie, Annemasse, France), H. Khalil (CHRU Rouen, Rouen, France), C. Largenton (Polyclinique de la Manche, Carentan, France), P. Ledaguenel (Polyclinique Jean Villar, Bruges, France), M. Lepère (Clinique Saint-Charles, La Roche-sur-Yon, France), D. Lépront (Polyclinique de Navarre, Pau, France), J. H. Longeville (Clinique du Val-de-Loire, Nevers, France), J. H. Maillochaud (Clinique de l’Europe, Bois-Guillaume, France), N. Maillot (Polyclinique du Parc, Cholet, France), B. Marchand (Polyclinique des Alpes du Sud, Gap, France), E. Magne (Clinique Tivoli, Bordeaux, France), P. Ngo (Hôpital Américain, Neuilly-sur-Seine, France), O. Oberlin (Clinique Turin, Paris, France), L. Potiron (Clinique Jules Verne, Nantes, France), M. Putinier (CH Mutualiste, Grenoble, France), K. Raynaud (Hôpital Privé de Bois-Bernard, Bois-Bernard, France), S. Roos (Clinique Claude Bernard, Albi, France), P. Rignier (Polyclinique des Bleuets, Reims, France), P. Vu (HPMV, Bry-sur-Marne, France), R. Verhaeghe (MCO Côte d’Opale, Boulogne-sur-Mer, France), and C. Zaranis (Clinique de La Rochelle, La Rochelle, France).

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-80/rc

Data Sharing Statement: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-80/dss

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-80/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-80/coif). J.F.G. received support for attending meetings and/or travel from IHS 2025 (BARD BD). The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Data for this study were obtained from the Club Hernie Registry, which complies with the European General Data Protection Regulation and the standards of the French Commission Nationale de l’Informatique et des Libertés (CNIL; registration No. 1993959v0). As this was a retrospective analysis of de-identified registry data, additional institutional review board approval was not required under national legislation. All data were anonymized and collected under a patient opt-out (“non-opposition”) process; therefore, individual informed consent was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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