In Sik Jang, et al. DISCUSSION There has been a significant change in the inguinal- her- nia treatment due to the introduction of Tesionless-hernia repair by Lichtenstein et al. [3] in 1989 since Bassini [2] es- tablished hernia repair in 1887 for the first time. Laparo- scopic hernia repair has drawn much attention of late as a treatment method for inguinal hernia, and its application has been increasing [5,7]. Laparoscopic hernia repair has a postoperative re- currence rate similar to that of tensionless-hernia repair, and has been considered a good indication for recurrent hernia after the bilateral anterior technique. The mechanism [8] of the recurrence after inguinal her- nia surgery includes the following cases: First, areas with possible hernia occurrence, such as unnoticed femoral de- fects, are not identified. Second, if the defective area in the inferior inguinal wall is repaired, a separate hernia may occur as more tensile strength is applied to the non-re- paired area. Third, metabolic disorder of collagen [9], wherein type III collagen, which cannot be applied to the tensile strength of the skin tissue and the rectus abdominis muscle in patients with recurrent hernia, has a higher con- centration compared to type I collagen. In addition, wound infection and unskillful surgical performance have been suggested as causes of recurrence. Small size, place- ment at an inaccurate position, and incomplete fixation of the mesh are also important causes of recurrence. Although the literatures that reported recurrence from the long-term results of laparoscopic TEP hernia repair are not adequate, Taylor and Wilson [10] conducted 100 cases of TEP for two years and reported a five-year recurrence rate of approximately 1%. Czechowski and Schafmayer [11] reported that the five-year recurrence rates of the trasnperitoneal preperitoneal and TEP approaches were 2.3 and 1.5%, respectively; that their re-recurrence rates were 6.7 and 4.8%, respectively; and that the mean times elapsed from the surgery to the recurrence were 45 and 36.6 months, respectively. Scheurlein et al. [12] conducted laparoscopic TEP hernia repair on 179 patients with re- current inguinal hernia and reported a 0.4% recurrence rate. Ferzil et al. [13] reported that they found no technical or safety issue in the application of the TEP approach to 316 Table 6. Comparison of the recurrence rates after TEP for recurrent inguinal hernia Authors Present study Bingener et al. [22] Keidar et al. [23] Frankum et al. [24] Järhult et al. [25] Knook et al. [26] Sayad and Ferzli [27] White et al. [28] Year 2010 2003 2002 1999 1999 1999 1999 1996 Mean Cases follow-up Recurrence rate (%) 19 39 150 175 168 35 75 56 15 mo 27 mo 37 mo 30 mo 2-4 yr 40 mo 40 mo 12 mo 0.0 2.5 5.7 0.5 2.0 20 0.0 1.8 patients who showed recurrence after laparoscopic TEP hernia repair. Despite a smaller subject size and a fol- low-up period of less than five years, these authors con- ducted laparoscopic TEP hernia repair on 191 patients with inguinal hernia. As a result, one recurrence case was found, and no recurrence has been found so far in the 19 patients with recurrent hernia after laparoscopic TEP her- nia repair, showing excellent outcomes compared to the various related literatures (Table 6). The single recurrence case that was reported in this study was a right recurrent hernia that occurred 20 months after bilateral inguinal her- nia surgery using the TEP approach. Re-operation was conducted using the TEP approach, and no recurrence has been found to date, after 19 months. At the time of the sur- gery, as the mesh was dislocated from its original position and was located at the posterior rectus sheath, the mesh was fixed with Tacker for bilateral hernia. In the case of TEP conduction due to recurrence after TEP, when the area between the back side of the rectus ab- dominis muscle and the posterior rectus sheath is dis- sected and the balloon trocar is inserted after anterior-rec- tus-sheath incision, and when peritoneal dissection is done to secure the necessary space for the surgery, pre- cautions should be required so as not to cause bleeding and peritoneal rupture. In the case of recurrent hernia, the importance of mesh [12,14,15] should be emphasized as weakened tissue re- pair cannot be appropriately done due to tissue weaken- ing, despite its suture. The complication rate after laparoscopic TEP hernia re- pair was reported to be 14.59% in a study conducted by thesurgery.or.kr