|Year : 2017 | Volume
| Issue : 4 | Page : 196-202
Lichtenstein procedure versus darn repair in primary inguinal hernia surgery
Ahmed A.M Khyrallh
Department of General Surgery, Faculty of Medicine, Al-Azhar University, Assuit, Egypt
|Date of Submission||12-Nov-2017|
|Date of Acceptance||28-Mar-2018|
|Date of Web Publication||19-Jul-2018|
Ahmed A.M Khyrallh
Department of General Surgery, Faculty of Medicine, Al-Azhar University, Assuit
Source of Support: None, Conflict of Interest: None
Introduction With the advent of newer methods for inguinal hernia repair like laparoscopy and mesh, older techniques like darn repair have gone into the background. However, in developing countries like Egypt where cost-effectiveness is of prime concern, darn repair still enjoys a good reputation and popularity for the repair of inguinal hernia. This study was carried out to compare darn repair with Lichtenstein repair regarding early outcome.
Patients and methods A total of 100 male patients aged from 20 to 60 years old who presented with primary inguinal hernia were operated upon with Lichtenstein or darn repair as elective procedure from January 2013 to October 2016. They were subjected to this prospective randomized-controlled trial. The primary endpoint was to compare the early outcome of these two procedures.
Results The need for analgesia and hospital stay was higher in patients who had Lichtenstein repair. Hematoma occurred in one (1%) patient and seroma occurred in four (4%) patients in both groups. The prevalence of wound infections as superficial and deep infections in groups A and B was 4 and 4%, respectively, which were resolved through conservative management. Complications of recurrence in group A were 2% as compared with group B, which had a recurrence of 4%. This difference was not significant.
Conclusion Both darn repair and Lichtenstein repair resulted in rapid recovery and low recurrence rates; however, the advantage of the darn repair lies in the fact that it does not require mesh, so it is much cost effective.
Keywords: darn repair, inguinal hernia, Lichtenstein procedure
|How to cite this article:|
Khyrallh AA. Lichtenstein procedure versus darn repair in primary inguinal hernia surgery. Al-Azhar Assiut Med J 2017;15:196-202
| Introduction|| |
Among all hernias, inguinal one has been considered to be the commonest (25% in males and 2% in females) . The literature reported increased prevalence of groin hernia in advanced age, and it accounts for 50% in elderly male patients annually . Inguinal canal reconstruction is a common surgical operation undertaken in surgical practice, with an incidence of 13/1000 individuals of all ages per year .
This intervention puts the highest burden on healthcare system . Despite technical advancements during past decades, the recurrence rates still remain as high as 15% .
Inguinal hernia prevailed over all hernias, comprising approximately three-fourth of all abdominal wall hernias. Inguinal canal should be reconstructed electively to prevent strangulation. Many different techniques of inguinal hernia repair have been described. Hernia repair can be done through anterior or posterior approach, using open or laparoscopic procedures .
The important recent advancement was made by Lichtenstein in 1986. He described tension-free repair using polypropylene mesh for posterior wall reinforcement of the inguinal canal. The second innovation was the laparoscopic mesh repair which has become popular nowadays. Lichtenstein introduced mesh prosthesis to overcome the defect not to close it with sutures like Bassini and other techniques. This ostensibly results in a less painful operation and a reduced incidence of suture pulling out, which results in lower recurrence rate .
Best results are obtained with Lichtenstein mesh repair, with recurrence rates as low as none to 0.4% have been reported in international and local literature. The darn repair described originally by Moloney is a very effective procedure for inguinal hernia repair . Prospective randomized trials comparing Moloney darn herniorrhaphy and Lichtenstein hernioplasty have not been conclusive .
Now the gold-standard repair of inguinal hernia is polypropylene prosthetic repair all over the world. Lichtenstein operation became the preferred choice in the developed countries of the world. In developing countries, Bassini herniorrhaphy is still performed owing to the expensive nature of the polypropylene prosthetic mesh. Light-weight polypropylene mesh eliminates chronic groin pain and other postoperative groin symptoms . To decrease such complications, absorbable meshes − such as lactic and/or glycolic acid polymers − have been introduced. This predispose to inevitable recurrence because the hydrolytic reaction completely digests the implanted prosthetic material . After the introduction of tension-free surgical repair with the use of nonabsorbable prosthetic mesh, recurrence rates were reported to be less than 5%, and comfort of the patient has also improved compared with the tension-producing herniorrhaphies. For nonabsorbable mesh repairs, many studies have confirmed their association with certain complications, such as persistent pain, adhesions, infection, bowel erosion, shrinkage, and inflammation .
Inguinal hernia repair has undergone several modifications since the description of the Bassini technique. The various techniques described are aimed at improving outcome, particularly recurrence rate. The suspected factor as a cause of recurrence in most of these herniorrhaphies is the fraying and tearing of the inguinal ligament fibers as a result of increased tension associated with them. Darning is actually a relatively tension-free technique. It bridges the gap between the conjoint tendon and the inguinal ligament with monofilament polypropylene starting from the pubic tubercle medially to the internal ring laterally and back to the pubic tubercle without forcible approximation of the tissues with sutures weaved across the posterior wall defect of the inguinal canal .
Studies evaluating darning technique revealed satisfactory outcomes regarding recurrence and other expected postoperative complications. Some of these were comparable to the current gold standard of open inguinal hernia repair (Lichtenstein hernioplasty). In developing countries, studies on inguinal hernia repair using nonprosthetic methods are based on the less acceptable Bassini repair with few reports on other hernioplasty methods such as darning repair . Although, the use of mesh is now gaining worldwide acceptance, nonprosthetic methods still find relevance in emergency presentations such as complicated hernia, which are not uncommon presentation , and in hospitals where the experienced surgeon with mesh repair is not available. In these instances, herniorrhaphy techniques with acceptable rate of recurrence will be ideal.
The aim of this study was to evaluate the complications rate associated with Lichtenstein repair and tension-free darn repair regarding surgical site infections, hospital stay, return to routine activities and recurrence of the hernia.
| Patients and methods|| |
A total of 100 male patients aged between 20 and 60 years who had direct or indirect inguinal hernia and underwent surgery [hernioplasty or herniorrhaphy − Mesh repair (Lichtenstein) or darn repair] from January 2013 to October 2016 were enrolled in this prospective controlled trial. The ethical approval for the study from the hospital scientific committee was obtained (Alazher Universty Hospital). Informed signed consent was obtained from every patient. Patients having American Society of Anaesthesiologists (ASA) class III or above, malignancy, complicated hernia, bilateral hernia, previous surgery in the inguinal region, ascites, or female patients were excluded. Each patient was thoroughly assessed by detail history, clinical examination, and required investigations. Details of symptomatology were recorded in a special proforma. Patients were divided into two groups [group A (50 patients), and group B (50 patients)] before surgical intervention. The same surgeon operated on all the cases. Group A patients were treated with mesh hernioplasty and group B patients were treated with darn repair.
In both groups, prophylactic antibiotic (1 g of cefotaxime) was injected intravenously 0.5 h before surgery followed by two doses after 12 and 24 h of surgery. All patients had skin scrubbing with povidone iodine on operative table. Time taken from skin incision to the placement of last stitch was recorded. Anatomical type of hernias was recorded and also any intraoperative complication.
Lichtenstein tension-free hernioplasty was performed as follows: the subcutaneous fat and Scarpa’s fascia were incised in line of skin incision and external oblique aponeurosis was separated in lines of its fibers to expose and deliver spermatic card. Sac was identified, negotiated, inverted or ligated, and resected. Standard polypropylene mesh was placed in the posterior wall of the canal on the fascia transversalis between conjoint area above and the inguinal ligament below and fixed to the edges of defect with polypropylene sutures in a tension-free manner. The external oblique and scarpa’s fascia were closed, and the skin was closed with subcuticular vicryl sutures.
These patients had tension-free darning repair with continuous polypropylene (0–2) suture between the conjoined tendon above and iliopubic tract (only if well-formed) and inguinal ligament below with apposition between these structures with the first row including the fascia transversalis. The darn was meticulously created without undue tension and incorporated transversalis fascia. An internal inguinal ring was always made, as defined in the original method. The same surgeon operated upon all these patients. The patients were returned home once their general condition became satisfactory.
Patients were encouraged to be ambulant after the operation without any restriction. Physical examinations were performed on postoperative days 1, 7, and 30, and then every 3 months thereafter for 1 year. The patients were only examined clinically. Immediate postoperative (within 7 days), early postoperative (within 1 month), and late postoperative (within 1 year) complications of both procedures were observed and recorded. Postoperative analgesic requirement, operative time, hospital stay, early postoperative complications (hematoma, surgical site infection, and hydrocele), chronic groin pain, and recurrence were the main endpoints.
Patients were advised to report any complication, such as fever, painful, swollen, or discharging wound. They were all advised to initiate their routine physical activities as soon as they considered themselves fit. During each visit, history was taken in brief, along with physical examination with local examination of the wound for the detection of wound infection, scar condition, and recurrence of the hernia. They were asked about any distressing complaints and start of their routine work. Chronic groin pain was defined in this study as the documentation of groin pain in the patients’ follow-up records beyond 3 months after surgery. Information regarding these outcome measures was based on documentation in the case notes during follow-up clinic visits.
Statistical analysis was performed using SPSS software, version 20 (SPSS Inc., Chicago, Illinois, USA) for Windows. Data are expressed as mean±SD. The standard descriptive statistical calculations (mean and SD) and the ‘unpaired t-test’ were used for comparing the two groups, nominal variables were analyzed with Fisher’s exact test, and the χ2-test was used to evaluate qualitative data. Statistical significance was assumed if P value less than 0.05.
| Results|| |
A total of 100 male patients were included in this study. Demographics characteristics, that is, age, types of inguinal hernia, comorbidities, and ASA score, in both groups A and B are summarized in [Table 1]. There were no statistically significant differences between groups A and B regarding age, ASA score, and comorbidities.
The age distribution ranged from 20 to 60 years. Mean age was 48.6 years in group A and 52.4 years in group B. In group A, 30 (60%) patients had inguinal swelling and 20 (40%) patients had inguinoscrotal swelling. In addition, 15 (30%) patients had pain, five (10%) patients had constipation, and seven (14%) had urinary manifestations. In group B, 28 (56%) patients presented with inguinal swelling and 22 (44%) patients with inguinoscrotal swelling. In addition, 12 (24%) patients had pain, six (12%) patients had constipation, and five (10%) had urinary complaints.
In group A, right-sided hernia was seen in 27 (54%) patients and left sided in 23 (46%) patients. Indirect hernias was present in 38 (76%), direct hernias in four (8%), and pantaloon in eight (16%). In group B, right-sided hernia was present in 24 (48%) patients and left sided in 26 (52%) patients. Moreover, indirect hernias were present in 41 (82%), direct hernias in three (6%), and pantaloon in six (12%).
Specific investigation was not required for the diagnosis of inguinal hernia in these patients. However, most investigations were performed for routine preoperative evaluation and to assess fitness for anesthesia and surgery. Hemoglobin assessment ranged from 10 to 14 g/dl in both groups. Blood urea was also in normal range in all patients of both groups, and blood sugar was within average limits except 16 cases that were diabetics (six in group A and 10 in group B). Their blood sugar was controlled and operation was done. All possible causes of straining and increased intra-abdominal pressure were excluded.
All cases were operated upon under spinal anesthesia. There was no difference in intensity and duration of pain in both groups postoperatively up to 2 weeks. The mean operative time in group A was 41.6±4.2 min and was 36.8±5.4 min in group B. Regarding analgesic DOSE, it was more in group A than group B. However, the hospital stay was higher in patients who had Lichtenstein repair. Superficial surgical infections in group A was 6.0% as compared with 4.0% in group B.
The postoperative analgesic requirements for the first 24 h, mean operative time, postoperative hospital stay, early postoperative complication rate, time until return to work, and recurrences are shown in [Table 2]. The postoperative analgesic doses till discharge were more in group A than group B ([Table 3]).
The early postoperative complications including wound infection, seroma, testicular swelling, and hematoma are shown in [Table 4]. All postoperative complications were resolved without intervention, and no mesh had to be removed as a result of complications.
There was one case of recurrence in group A (1/50, 2.0%), which developed 8 months after surgery, and two cases of recurrence occurred in group B (2/50, 4.0%), which developed 6 and 10 months after surgery ([Table 2]). This difference was not statistically significant (χ2=0.02; P=0.882).
| Discussion|| |
Repair of inguinal hernia is one of the most common (10–15%) surgical procedures performed all over the world. Since the Bassini’s repair in 1887, numerous operative techniques have been reported, but yet no definitive operative technique is considered the best .
The conventional open repair depends on line of sutures to approximate the hernia defect. Recently, synthetic mesh replaced conventional methods worldwide (open or laparoscopic hernioplasty). These methods are associated with early return to casual activities with low recurrence rates .
The various techniques of inguinal hernia surgery can be broadly classified into tissue-based and prosthetic methods. Tissue-based repairs have major drawback; the increased amount of tissue tension of most of them is a leading factor incriminated in recurrence .
Although tissue based, darning is believed to have an advantage over many other nonprosthetic techniques being relatively tension free, as the posterior wall is repaired without forcefully opposing the tissues. Rather, the sutures are passed in a continuous fashion forming a weave in the posterior wall. This method of repair is common in the UK and some other English-speaking countries where most studies on this technique have been conducted .
The African studies on inguinal hernia surgery lack variation of the used techniques. Except for a few mentions of the darning technique, most were based on Bassini technique of repair, which is no more recommended because of its relatively high recurrence rate. This important fact was observed by Ohene-Yeboah and Abantanga  in their review about inguinal hernia disease in Africa.
In a large population like Egypt where occupations with manual labor is common, both the development and progression of groin hernias will be common. The is a hope of engagement in effective health communication interventions at community level in conjunction with community health physicians promoting early presentation of abdominal hernias, thereby reducing the incidence of complications in patint with abdominal hernias. The darning technique has been acclaimed to have the advantage of a short learning curve, particularly when compared with other popular nonprosthetic methods of repair such as the Shouldice technique. The fact that most of the cases were performed by residents with majority of them carried out under spinal anesthesia is a testimony to this fact. The procedure therefore, can be learned by surgeons who perform hernia surgery in many public healthcare facilities as well as those in private settings, many of whom continue to practice only the Bassini method .
The material used remains controversial. Some of these techniques are very much practiced today, whereas some have become obsolete. In spite of these ever-changing trends of techniques, tension-free repair is the optimal strategy, and in this regard, rigorous research in inguinal surgery has reported that weakness and deficiency lies in anterior abdominal wall, but the price is paid by fascia transversalis to cope with the intra-abdominal pressure, which subsequently ends up with hernia. Logically, this needs restoration with strengthening of the posterior wall .
The cost of using synthetic mesh is an issue in developing countries which affects surgical procedure choice (conventional or mesh repair). In this study, the peak age for inguinal hernia in both groups was from 20 to 60 years, which is similar to that reported in studies. The patients were randomized to two groups (group A: underwent mesh repair and group B: Moloney’s darn repair). In most cases, hernia was right sided in our study, which is comparable to other studies .
Hematoma occurred in one (1%) patient and seroma occurred in four (4%) patients in both groups. The prevalence of wound infections as superficial and deep infections in groups A and B was 4% and 4% respectively, which were resolved through conservative management.
There was no statistically significant difference of early complication rate between the two groups (e.g. wound infection, hematoma formation, and retention of urine). This is reflected in a study by Das et al.  where hematoma formation in mesh and nonmesh was 4.2 versus 5.26%, seroma formation was 3.63 versus 3.15%, wound infection was 2.42 versus 3.15%, and neuralgia was 1.81 versus 2.10%.
Zeybek et al.  found 4.4% hematoma and 1.7% wound infections in their study; however literature is crowded with studies where each of them have different rates of hematoma and infections . The length of hospital stay was 1–3 and 1–2 days in groups A and B, respectively, which is also similar to other studies .
This is also reflected in one large randomized-controlled trial by Vasantharaja and Sreejayan . It was also reflected in this study that patients who underwent Moloney’s darn repair returned to the routine activities in almost same period as the patients with mesh repair did.
Chronic groin pain is considered currently as a significant outcome measure after inguinal hernia surgery particularly as it affects the quality of life. It is defined as any visual analog score above 0, which lasts longer than 3 months postoperatively . The 0% chronic groin pain rate recorded in this study compares well with the work of Courtney et al. . They reported chronic groin pain in 1% of a population-based research on more than 5000 patients who had inguinal hernia repair.
Patients in either groups of this study did not present with chronic persistent pain. This is in contrast with other studies which have compared mesh versus nonmesh repair. Mesh repair reduces significantly persistent pain .
The time taken to return to daily activities was higher in group A as compared with group B. This may be explained as those patient who performed mesh repair experienced more pain for longer duration . This study reported recurrence rate of 2% in Lichtenstein and 4% in simple darn repair. The higher rates of hernia recurrence in darn repair may be because there are more chances for injury to vessels and ilioinguinal nerve in comparison with Lichtenstein repair. These results also correspond to other studies ,. The design of this clinical trial was rational and well executed to extract the logical endpoints between two procedures; hence, this study findings are comparable with other series. In the current study, the recurrence rate after Lichtenstein mesh repair was 2%, which was equal to 1.2% reported by Moloney .
This is contrast with the available studies, where hernia recurrence is about 6% higher in nonmesh group. The study by Ali et al. , comparing mesh repair with darn, reported recurrence rate of 1.81% in mesh repair and 3.15% in darn repair group. However, short-term follow-up may not show actual recurrence rate after hernia repair, and it has been suggested that a minimum of 10 years of follow-up is needed, as 20% of recurrences will not be apparent for 15 years, so it is more likely that recurrence rates are underestimated owing to lack of long-term follow-up.
A recurrence rate of 4% recorded in the darn group compares favorably with previous studies that recorded rates in the range of 0.5–4% . This is lower than 10% recurrence recorded after Bassini technique in many series and comparable to the 2% recurrence rate following Lichtenstein mesh repair . A longer follow-up may reveal higher recurrence rates than what was recorded in this study.
Comparison between the two techniques of tension-free repair of the inguinal floor showed no advantage of Lichtenstein mesh repair over simple darn repair with respect to early postoperative analgesic requirement, operative time, hospital stay, time until return to work, early complications, or recurrence. Findings of this study support those of a randomized trial by Koukourou et al. , which compared mesh repair and nylon darn. They also found no significant differences in analgesia requirement, time until return to work, and early recurrence between the two groups. Celik et al.  compared the Moloney, Bassini, and Shouldice procedures and found that although the Moloney technique had no advantage over the Shouldice technique, the rates of recurrence, postoperative infection, and hematoma after the Bassini technique were significantly higher than those after the other two procedures. Kingsnorth et al.  found no significant difference in recurrence rates after the Moloney and Shouldice procedures.
| Conclusion|| |
Open primary inguinal hernia repair with a darn technique was equivalent to polypropylene mesh with respect to postoperative outcome and recurrence. Darn repair using nonabsorbable suture is safe and inexpensive alternative surgical procedure. It is easily performed and has a very low recurrence rate. Its excellent results are comparable to any existing well-reputed technique for inguinal hernia repair.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]