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 Table of Contents  
Year : 2018  |  Volume : 16  |  Issue : 1  |  Page : 66-72

Evaluation of open hernioplasty in bilateral inguinal hernia repair

General Surgery Department, Faculty of Medicine, Al-Azhar University, Assiut, Egypt

Date of Submission26-Apr-2018
Date of Acceptance27-May-2018
Date of Web Publication20-Nov-2018

Correspondence Address:
Gamal Al-Shemy
General Surgery Department, Faculty of Medicine, Al-Azhar University, Assiut, 71511
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AZMJ.AZMJ_34_18

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Background Inguinal hernia occurs in ∼1.5% of the general population and in 5% of male individuals. The bilateral type affects about 12% of patients, the direct and the combined ones being more frequent than the indirect. Simultaneous or sequential repair has been debated especially after tension-free repairs.
Aim This study was carried out to compare Stoppa procedure with bilateral Lichtenstein hernioplasty for the treatment of primary bilateral inguinal hernia.
Patients and methods This trial included 80 male patients with primary bilateral inguinal hernias. They were divided randomly into two equal groups. Group A underwent bilateral Lichtenstein hernioplasty and group B underwent Stoppa repair. Preoperative, operative, and postoperative characteristics were recorded for each patient in the study. Patients were followed up at 3, 6, and 12 months postoperatively.
Results As regards preoperative data, there was no statistically significant difference between both groups. The Stoppa operation took a significantly shorter time than the bilateral Lichtenstein technique; the mean operative time for Stoppa and bilateral Lichtenstein was 84.0±8.6 and 96.4±6.2 min, respectively. Visual analogue scoring of pain 12 h postoperatively was significantly lower in the Stoppa group than in the bilateral Lichtenstein group. As regards operative and postoperative complications, there was no significant difference between both groups. Hospital stay, return to normal daily activities, and inguinodynia rates were similar in both groups. There was no recorded recurrence in both groups up to 1 year of follow-up.
Conclusion Bilateral primary inguinal hernias can be operated upon in one setting without an increase in morbidity or recurrence rate. The Stoppa technique can be a good alternative to bilateral Lichtenstein procedure for the treatment of bilateral inguinal hernia, with comparable outcome.

Keywords: bilateral, hernioplasty, inguinal hernia, Lichtenstein, Stoppa

How to cite this article:
Al-Shemy G, Hassan A, Al-Kareem Elias A, Nagi A. Evaluation of open hernioplasty in bilateral inguinal hernia repair. Al-Azhar Assiut Med J 2018;16:66-72

How to cite this URL:
Al-Shemy G, Hassan A, Al-Kareem Elias A, Nagi A. Evaluation of open hernioplasty in bilateral inguinal hernia repair. Al-Azhar Assiut Med J [serial online] 2018 [cited 2021 Apr 18];16:66-72. Available from: http://www.azmj.eg.net/text.asp?2018/16/1/66/244146

  Introduction Top

A hernia is the protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity. Seventy-five percent of all abdominal wall hernias occur in the groin. Inguinal hernia repair is the commonest operation in general surgical practice. Hernias occur in about 1–5% of the general population. Inguinal hernias are usually unilateral, and about 20% of patients with inguinal hernia present bilateral hernias in the diagnosis [1].

The term hernia is derived from the Greek hernios (meaning budding). A hernia is defined as weakness of the fibromuscular tissues of the wall from which contents of the cavity underlying it arise from the wall. The strengthening of the posterior aspect of the inguinal canal remains the major objective in inguinal hernia repair. Bassini pioneered the surgical repair of inguinal hernia (he performed his first operation in 1884 and published its outcomes in 1889) [2].

Hernias can occur anywhere, but it is common in the anterior abdominal wall, in particular, the inguinal, femoral, and umbilical regions, linea alba, and sites of previous incisions. The inguinal, femoral, and umbilical hernias constitute about 75% of all cases. The inguinal region (lying between the lower abdomen and the thigh) is the weakest point in the anterior abdominal wall where hernia commonly occurs. Hernia can occur in any condition that increases the intra-abdominal pressure. In childhood, whooping cough is an important predisposing factor. In adults, powerful muscular effort of chronic cough, and straining during micturition or defecation may precipitate a hernia [3].

The definitive surgery for inguinal hernia was first described by Marcy, Joseph Lister’s student, who stressed the importance of transversalis fascia integrity and internal ring closure. He used carbolised catgut to narrow the internal ring. Eduardo Bassini, an Italian in the 19th century predicted that two reasons were responsible for the failure of the procedures performed for inguinal hernia repair (nonanatomic repair and the wide internal ring). He recommended the triple layer technique incorporating the internal oblique, transversus abdominis muscle and transversalis fascia and approximating them with the inguinal ligament [4].

For decades, it was believed that simultaneous repair of bilateral inguinal hernias could be associated with a high morbidity and recurrence rate. The introduction of tension-free repair techniques led to a change in this concept. Placement of a prosthetic mesh is needed in all types of open or laparoscopic tension-free repair. The most commonly performed open techniques include Lichtenstein’s and Stoppa’s hernioplasties. The advantages of simultaneous repair of bilateral inguinal hernia is patient satisfaction, and cost effectiveness, as the patient is subjected to one anesthesia, single hospital stay, and only one period of recovery [5].

The myopectineal orifice was first elucidated by Fruchard (a French surgeon), which consists of medial, lateral, and femoral triangles, which are potential sites for groin hernias. Stoppa and Rives (students of Fruchard), developed the preperitoneal approach to hernia repairs. The laparoscopic techniques (TAPP and TEP) follow the principle of preperitoneal mesh placement described by Stoppa. This method is not followed by many surgeons, because of the long learning curve. This may be the ideal repair for bilateral inguinal hernia and recurrent inguinal hernia [6].

Stoppa’s great prosthetic reinforcement of the visceral sac was performed in 1975. Stoppa wrapped the lower part of the parietal wall with wide mesh that covers the myopectineal orifice. This requires dissection of the preperitoneal space, cord structures, identification and reduction of the sac and placing a wide mesh between the peritoneum and anterior abdominal wall [7].

Tension-free repair standardized by Lichtenstein is still the gold standard in the management of unilateral inguinal hernia repair. Lichtenstein used mesh to strength the posterior wall of the inguinal canal and fixed it over the conjoint concept and inguinal ligament. He tailored the mesh to accommodate to the cord structures [3].

The debate on the management of bilateral inguinal hernias led us to conduct the present study, aiming to compare the Stoppa procedure with bilateral Lichtenstein tension-free hernioplasty, for the management of bilateral inguinal hernia in terms of operative time, intraoperative and postoperative complications, postoperative pain, hospital stay, return to normal daily activities, chronic groin pain, and recurrence.

  Patients and methods Top

This prospective study involved 80 male patients who attended the General Surgery Department, Faculty of Medicine, Al-Azhar University, Assiut, Egypt. Inclusion criteria were patients with primary bilateral inguinal hernias in patients aged 20–60 years. Exclusion criteria were complicated hernia (obstructed or strangulated), patients with associated intraperitoneal pathology, and abdominal wall infections. Informed consent was taken from each respondent. Patients were assigned to two groups of 40 patients each. Patients were classified by the Nyhus classification. One group underwent hernia repair by simultaneous Lichtenstein mesh hernioplasty and the other group underwent Stoppa’s repair. They underwent routine investigations, and those found fit for surgery were operated upon. The operative time (from skin incision to wound dressing) was recorded.

The primary endpoint was evaluation of chronic groin pain and hernia recurrence in both groups. The secondary endpoints were perioperative parameters (operative time, and intraoperative and postoperative complications), hospital stay, postoperative pain scoring, timing of return to normal daily activity, and follow-up details.

Lichtenstein tension-free hernioplasty [8]

The inguinal skin incision was made 0.5 inch above and parallel to the inguinal ligament from above and lateral to the pubic tubercle to below and medial to the anterior superior iliac spine. The indirect sac was dissected, ligated using Vicryl 0 (Obour, Cairo, Egypt), and sectioned. The large direct sacs were invaginated and plicated using Vicryl 0. Prolene mesh of 6×11 cm was used in all cases. The mesh was fixed in place using polypropylene 2/0. The mesh was fixed down to the inguinal ligament and up to the conjoint tendon (from the pubic tubercle to beyond the orifice of the internal ring).

Stoppa procedure

The technique developed by Stoppa was used [9]. Patients received spinal anesthesia with antibiotic prophylaxis. The abdomen was opened by Pfannensteil incision. Subcutaneous fat and rectus sheath were opened. Both recti separated in the midline. Dissection of the preperitoneal space was performed from the retropubic space of Retzius to the rectus abdominis muscles and epigastric vessels laterally, extending to the retroinguinal space. Spermatic cord and gonadal vessels were identified. Superior pubic rami, obturator foramens, and iliac vessels were visualized. Small direct sacs were dissected and reduced. Large sacs were ligated with a purse-string suture and removed. Indirect sacs were divided, the proximal part was sutured, and the distal part was left in-situ attached to the cord. If indirect hernia was sliding, dissection of the sac from the cord structures was performed. Parietalization of the spermatic cord and gonadal vessels was performed by dissection of their peritoneal attachment. The chevron-shaped polypropylene mesh of size 30×30 cm was placed over the peritoneum and fixed inferiorly to the pubic symphysis, Cooper’s ligament and superiorly to the arcuate line. The wound was closed in layers with a drain.

Postoperative period

Patients were assessed for intraoperative difficulties, blood loss, and early postoperative pain using the visual analogue scale, and the need for postoperative analgesia. Minor complications including neurovascular injury, scrotal hematoma, retention of urine, seroma formation, cord edema, wound infection, and testicular pain were noted. Major complications such as bladder and bowel injury were looked for. The sutures were removed after 1 week, and the patients were discharged.


Patients were followed up every month for the first 3 months and then after 3 months in the outpatient clinic to look for recurrence. Patients were totally followed up for a period of 1 year.

Statistical analysis

Statistical analysis was performed using the statistical package for the social sciences, version 20.0 software (SPSS Inc., Chicago, Illinois, USA). Significance level was set at P value of less than 0.05. Qualitative data were described using number and percent. Quantitative data were described using range (minimum and maximum), mean, SD, and median. Comparison between different groups in terms of categorical variables was performed using the χ2-test.

  Results Top

The present study included 80 male patients with primary bilateral inguinal hernias who were divided into two groups. Group A included 40 patients who underwent bilateral Lichtenstein tension-free hernioplasty. Group B included 40 patients who underwent Stoppa repair. As regards preoperative data [age, smoking, comorbidities, BMI, and type of hernia ([Figure 1])], there were no statistically significant differences between both groups ([Table 1]).
Figure 1 Distribution of hernia.

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Table 1 Preoperative assessment

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The operative time was significantly shorter in group B patients (Stoppa repair); it ranged between 64 and 94 min, with a mean of 84.0±8.6 min, whereas in group A (bilateral Lichtenstein tension-free hernioplasty), it ranged between 72 and 114 min, with a mean of 96.4±6.2 min (P<0.001). There were no intraoperative complications (visceral or vascular injury) in either group. As regards postoperative complications (wound seroma and hematoma, urine retention, wound infection, and scrotal swelling), chronic groin pain, postoperative hospital stay, and return to work, there were no statistically significant differences ([Table 2]). No recurrence occurred in any patient after 1 year of follow-up in either group.
Table 2 Operative and postoperative parameters

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As regards postoperative pain scoring measured by visual analogue scale at 12 h postoperatively, there were statistically significant differences between both groups in favor of group B patients, but there was no statistically significant difference between both groups in pain at 24 h and 7 days postoperatively ([Table 3]).
Table 3 Postoperative pain in both groups

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  Discussion Top

Inguinal hernia has a maximum incidence of between 30 and 60 years. Studies carried out by Fernandiz and Tartas showed that the mean age of presentation was 52.7 years [9]. In the present study, mean age of presentation was 41.8±4.8 years in group A, and 43.4±6.2 years in group B, which is younger than the mean age reported by the Fernandiz and Tartas study. This may be due to the fact that most of the patients in the present study were laborers. In the present study, all the patients studied were male individuals.

The study carried out by Maghsoudi and Paarvand [10] had 100% men in their study. Most of their patients had risk factors for the development of hernia, the most common being smoking (76.6%), obesity (10%), chronic obstructive pulmonary disease (20%) and benign prostatic hypertrophy (20%), which is comparable to the outcome of the present study.

For decades, it was thought that concomitant repair of bilateral inguinal hernias should not be performed, because this may result in increased postoperative complications (pain, wound complications, and recurrences). Today, it is well known that synchronous repair of bilateral hernia is feasible and effective.

The guidelines of the European Hernia Society recommend one-stage procedure (laparoscopic or Lichtenstein) for the management of bilateral inguinal hernias [11]. The Stoppa technique is an alternative method for repair of bilateral inguinal hernia, but only for experienced surgeons with this procedure [12],[13]. This led us to perform this study to compare the Stoppa procedure with the Lichtenstein technique for surgery of bilateral inguinal hernias.

Giant prosthetic reinforcement of the visceral sac or Stoppa procedure is a preperitoneal approach for bilateral inguinal hernias. This procedure entails wide dissection of the preperitoneal space. The classical Stoppa’s repair is performed by wrapping the lower part of the parietal peritoneum with a large chevron-shaped polypropylene mesh. Pelissier et al. [14] suggested that all recurrences occur through the myopectineal orifice; hence, a mesh covering only this area is effective, as performed in the Rives procedure.

A recent clinical trial assessed the outcome of bilateral inguinal hernia repair in patients undergoing conventional Stoppa repair with a single mesh and without staple fixation and laparoscopic total extraperitoneal repair. This study concluded that the laparoscopic approach causes less trauma but has longer operative time. Quality of life during convalescence was equal in both techniques [15]. In simultaneous bilateral inguinal hernia repairs, Lichtenstein and laparoscopic repairs are the ones commonly used. The Lichtenstein technique proved to have increased risk of mesh inguinodynia. The laparoscopic technique needs special equipment and training.

Sharma et al. [16], performed a study to determine clinical outcome and cost effectiveness of open preperitoneal mesh insertion in comparison with Lichtenstein mesh repair in primary bilateral inguinal hernia. They interpreted that inguinodynia in Lichtenstein repair is more as compared with open preperitoneal repair. They attributed it to dissection in the inguinal canal and mesh fixation. In the open preperitoneal technique, the mesh is placed in the preperitoneal plane and gets fixed in place by intra-abdominal pressure. Both have similar recurrence rates. They concluded that open preperitoneal approach is a safe, most efficient and cost-effective alternative to Lichtenstein mesh repair. Askar et al. [17], conducted a prospective randomized study for repair of bilateral inguinal hernia in 40 patients comparing the Stoppa technique with simultaneous bilateral Lichtenstein technique. They concluded that the Stoppa repair was a reliable technique for bilateral inguinal hernia, consuming less operative time, reduced postoperative pain, early return to routine activity, low recurrence rate and good patient satisfaction level. These results are comparable to the outcome of the present study.

Sajid et al. [18], in a meta-analysis of published controlled trials, compared laparoscopic versus open preperitoneal prosthetic repair in inguinal hernia. They evaluated 1286 patients of 10 randomized trials and calculated that laparoscopic preperitoneal hernia repair takes longer operative time and has less postoperative pain, as compared with the open preperitoneal approach. Both the open and laparoscopic preperitoneal hernia repairs were statistically equivocal in terms of postoperative complications, recurrence and chronic inguinal pain. Ates et al. [19] suggested the use of the Stoppa procedure whenever conversion is required in laparoscopic total extraperitoneal hernia repair in the event of technical difficulties. This procedure is advantageous especially in bilateral inguinal hernia repair, as its mesh reinforcement is carried out in the same plane and avoids entering into the peritoneal cavity.

The open new simplified totally extraperitoneal (ONSTEP) repair of inguinal hernia is a new technique using mesh in the preperitoneal space by open surgery [20]. Andresen et al. [21], in a recent review of open preperitoneal techniques of nine different techniques made a search on databases. In this database search, 67 studies describing nine different methods, such as Kugel, TREPP, TIPP, ONSTEP, Horton, Nyhus, Vgohavy, Read and Stoppa, were found. They analyzed the results in reference to pain, recurrence and complications in 1 month follow-up. They concluded that preperitoneal techniques with placement of mesh by open surgery seemed to be promising, as compared with standard anterior techniques [22].

Maghsoudi et al. [23], carried out a study on 234 patients with 420 inguinal hernias, of which 186 were bilateral and 49 were unilateral. Of these, recurrent hernia was present in 154 cases. The Stoppa preperitoneal technique using a wide polyester mesh was used for repair of these hernias. Mean operative time was 45 min, and mean hospital stay was 2.2 days. There were occasional complications. On follow-up, the recurrence rate was 0.71%, which is very low per hernia repaired.

Operating time is the time gap between incision and last skin suture. In the Wantz series, operating time of Stoppa was much shorter than laparoscopic repair and bilateral Lichtenstein repair performed bilaterally. Operating time was not greatly increased even in cases of bilateral hernias and recurrent hernias. No major complications were found in the present study. No cases of major bleeding or bladder injury occurred. No conversion to other methods of repair was undertaken. No cases of mesh infections were reported. There were five cases of scrota edema, and five cases of chronic groin pain were reported. No cases of ischaemic orchitis was reported. No recurrence was reported in both groups after 1 year of follow-up. Recurrences reported in previous studies that occurred early in the first year were caused by mesh of lesser size, displacement of mesh, or wrong technique [24].

In the present study, spinal anesthesia was used in all operations, to avoid any bias in items of postoperative pain scoring. The present study’s outcome was consistent with results of Malazgirt et al. [25] in duration of surgery, as the Stoppa technique took less time than the bilateral Lichtenstein method. The Gustavo et al. [26] study evaluated simultaneous bilateral inguinal hernia repair by the Lichtenstein technique and found a mean operative time of 113±19.33 min, which was significantly longer than the operative time (mean) of the bilateral Lichtenstein technique in the present study (96.4±6.2 min). Gustavo et al. [26] included recurrent and complicated hernias in their study; this may explain the prolonged operative time in their study. Fernandez-Lobato et al. [9] evaluated the Stoppa procedure in a large-scale study for management of bilateral inguinal hernia. Their trial included 210 patients who underwent bilateral inguinal hernia repair in 9 years. They recorded that the operative time decreased significantly from 105 min in the first 12 months to less than 61 min in 2001, with 73% of the cases operated in less than 60 min and 62% in 2003 (P<0.0001). Stoppa and colleagues achieved an operative time of 51 min (mean). This duration was also shorter than that required in the bilateral Lichtenstein technique. In the present study, the mean operative time for Stoppa repair was 84.0±8.6 min, which is longer than what was reported by Stoppa.

In the present study, there was no significant difference in postoperative hospital stay between both groups, which is compatible with the Malazgirt et al. study [25]. Sasso et al. [26] recorded postoperative hospital stay of 1.55±0.83 days in patients who underwent bilateral Lichtenstein operation (most of their cases spent 1 day in the hospital).

Malazgirt et al. [25] reported no significant difference between Stoppa repair and bilateral Lichtenstein repair with regard to postoperative complications. Li et al. [27] carried out a meta-analysis concerning outcomes of 2860 cases from two comparative studies and 10 randomized-controlled trials for comparison between Lichtenstein and preperitoneal repair of bilateral inguinal hernia and recorded that there was no statistical difference between both techniques in postoperative complications.

Results of the present study were equivalent to those of Malazgirt et al. [25] and Fernandez et al. [9], as no significant difference was found between both groups in postoperative complications. In the current study, with regard to return to normal daily activities, there was no difference between both techniques; the mean was 16.00±4.60 and 20.00±3.80 days for group A and B, respectively. Our results were comparable to those of Malazgirt et al. [25], who reported that the time needed to return to casual daily activities was 18 and 17 days, following Stoppa and Lichtenstein, respectively.

Malazgirt et al. [25] observed a single recurrence after Stoppa (1/22 patients) and none after bilateral Lichtenstein technique. Gustavo et al. [26] found single recurrence in 59 patients who underwent bilateral Lichtenstein repair (after follow-up of 2 years). Kark et al. [28] recorded 1% recurrence following Lichtenstein repair from 199 cases. Amid et al. [29] published a 0.1% recurrence rate among 1000 cases. Hidalgo et al. [30] found no recurrences in 55 patients after Lichtenstein repair. The result of our study concerning recurrence after Lichtenstein was in agreement with many series [25],[26],[28],[29],[30], as no recurrence was detected through 1 year of postoperative follow-up. Fernandez-Lobato et al. [9] reported three recurrent cases from 210 repairs following Stoppa for bilateral inguinal hernias. Two emerged in the first 30 patients and one in the remaining 140 patients. Total recurrences were 3/210 patients (1.4%) and 3/420 hernias (0.7%) (P<0.001). They explained recurrence because of the use of a small mesh; it did not cover the inguinal region correctly. Carmen et al. [31] reported single recurrence of 124 cases per repaired inguinal hernia (1%) or single recurrence in 64 patients (2%) following Stoppa operation after 24 months of follow-up. There was no recorded recurrence following Stoppa repair in the present study after 1 year of follow-up. Our results as regards recurrence of inguinal hernia after Stoppa technique were similar to those of other studies [9],[31].

  Conclusion Top

Simultaneous repair of bilateral inguinal hernia is safe and effective, as it is associated with better patient satisfaction, lower cost and the patient is subjected to only one hospital admission, anesthesia and needs only one period of recovery without an increase in morbidity or the recurrence rate. Stoppa’s method of hernia repair is a good alternative to bilateral Lichtenstein’s repair for the treatment of bilateral inguinal hernia with comparative operative and postoperative complications. Stoppa’s repair can also be completed in a relatively shorter duration, and hence could be the method of choice, especially in high-risk patients with bilateral inguinal hernia. Moreover, Stoppa’s repair should be routinely incorporated in any healthcare system dealing with hernia patients and in the professional learning curriculum of junior surgeons.

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Conflicts of interest

There are no conflicts of interest.

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