Hindawi Publishing Corporation

Surgery Research and Practice

Volume 2016, Article ID 8041515, 4 pages
http://dx.doi.org/10.1155/2016/8041515

Clinical Study
The Comparison of Lichtenstein Procedure with and
without Mesh-Fixation for Inguinal Hernia Repair

Feyzullah Ersoz, Serdar Culcu, Yigit Duzkoylu, Hasan Bektas, Serkan Sari,
Soykan Arikan, and Mehmet Mehdi Deniz
Istanbul Education and Research Hospital, General Surgery Clinic, Istanbul, Turkey

Correspondence should be addressed to Feyzullah Ersoz; [email protected]

Received 21 February 2016; Accepted 6 April 2016

Academic Editor: Christophoros Foroulis

Copyright 2016 Feyzullah Ersoz et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Aim. Although inguinal hernia repair is the most frequently performed surgical procedure in the world, the best repair method has
not gained acceptance yet. The ideal repair must be safe, simple, and easy to perform and require minimal dissection which provides
enough exploration, maintain patients comfort in the early stage, and also be cost-effective, reducing operation costs, labor loss,
hospital stay, and recurrence. Materials and Methods. There were eighty-five patients between the ages of 18 and 75, diagnosed with
inguinal hernia in our clinic. Lichtenstein procedure for hernia repair was performed under spinal anesthesia in all patients. Forty-
two patients had the standard procedure and, in 43 patients, the polypropylene mesh was used without fixation. All patients were
examined and questioned on the 7th day of the operation in terms of pain, scrotal edema, and the presence of seroma and later on
in the 6th postoperative month in terms of paresthesia, neuropraxia, and recurrence by a single physician. Results. Operative time
and pain scores in the nonfixation group were significantly lower, without any increase in rates of recurrence. Conclusion. Based on
these findings, in Lichtenstein hernia repair method, nonfixation technique can be used safely with better results.

1. Introduction transverse muscle aponeurosis and fascia have been observed

to play an important role in the occurrence of inguinal
In spite of various techniques being introduced for inguinal hernias. The aim of the procedure should be repairing the
hernia repair with new additions, a need for new procedures transverse fascia in a tension-free style.
to decrease recurrence rates and increase patients life qual- The high rates of recurrence and testicular complications
ities is still demanded. Although results of inguinal hernia of conventional anterior repairs have led the surgeons to
operations rely mostly on the operator, a significant difference explore new techniques. The techniques that depend on
between the success rates of different techniques has not been tissue-supported suturing such as Bassini, Shouldice, Halsted,
observed. Despite the fact that inguinal hernia is a frequent and McVay have left their places substantially to tension-
entity in surgical practice, the best repair technique is not free repairs with prosthetic meshes, like Lichtenstein, Nyhus,
clear yet. mesh plug, and laparoscopic techniques. In the beginning,
Inguinal hernias are seen in 38% of the population [1], meshes were used mainly for incisional hernias, but later they
comprising 8083% of all hernias. Fifty percent of inguinal started to be popular also in inguinal repairs, constituting
hernias are indirect, 25% are direct, and 5% are femoral. over 80% of all inguinal hernia operations in the United States
Eighty-six percent of all inguinal hernias are found in men, today. Lichtenstein procedure is the most frequently used
while 84% of femoral hernias are found in women [2, 3]. method among them.
Indirect inguinal hernia is the most frequent type in both gen- The use of synthetic meshes for hernia repair was de-
ders. Incidence of strangulation and need for hospitalization scribed first by Usher et al. and performed especially for
increase with aging [4]. recurrent cases until 1984 [5]. In 1974, Lichtenstein and
The importance of the posterior wall of inguinal canal Shore introduced their technique and reported their results
in etiology and repair has been realised lately. Defects of including 1000 patients in 1989 [6]. Hereafter, Lichtenstein
2 Surgery Research and Practice

procedure with synthetic mesh became accepted as an ideal Table 1: Age and BMI data of the groups.
method for primary inguinal hernias.
The aim of our study is to compare the results of the tech- Group 1 Group 2
: 42 : 43
nique with and without mesh-fixation, in terms of operative
time, postoperative pain, complications, and recurrence rates. Age 54.5 12 50.33 12.13 1.88 0.063
BMI 26.14 3.29 25.3 3.21 1.19 0.236
2. Materials and Methods
Following the approval of the Ethics Committee, 85 patients Table 2: Distribution of region and type.
between the ages of 18 and 75 that had been referred to Group 1 Group 2
our clinic between June 2009 and June 2010, diagnosed
Right 24 57.10% 21 48.80% 2 : 0.58
with inguinal hernia, were evaluated prospectively in our Region
randomized study. Recurrent cases, femoral and bilateral Left 18 42.90% 22 51.20% = 0.443
hernias, and patients with the history of collagen tissue Indirect 23 54.80% 27 62.80%
diseases and immunosuppressive medications were excluded Type Direct 14 33.30% 12 27.90% 2 : 0.57
from the study. All the participants were informed about the Indirect + direct 5 11.90% 4 9.30% = 0.751
study and, following their signed informed consent, the trial
was performed in accordance with Helsinki report of clinical
trials. Table 3: Comparison of operative time, hospital stay, and VAS score
All the patients were admitted to hospital one day before between the groups.
the surgery. The operation area was shaved and cleaned on Group 1 Group 2
the operation day. The patients were given 1st-generation
: 42 : 43
cephalosporin at the time of anesthesia induction for prophy-
Operative time 0.001
laxis. Oral intake was started on the 4th postoperative hour. 49.4 13.17 32.37 7.96 7.24
(minutes)
Uncomplicated cases were discharged on the 1st postopera-
Hospital stay
tive day. 1.29 0.46 1.14 0.35 1.66 0.101
(days)
All the patients underwent Lichtenstein inguinal hernia
VAS 5.88 2.06 3.88 1.78 4.79 0.001
repair under spinal anesthesia. Forty-two of the patients were
operated on with standard procedure (Group 1), while the
synthetic mesh was fixed only around the inguinal cord at the
border of the internal ring with one 2-0 prolene suture in 43 The mean operative time was found to be significantly
patients (Group 2). The rest of the mesh was laid under fascia shorter in group 2 ( = 0.001). Duration of hospital stay did
without any fixations on neither inguinal ligament nor any not reveal any significance between the groups ( = 0.101).
part of tendon conjoint. Mean VAS score was significantly higher in group 1 ( =
Visual analog scale (VAS) was used to evaluate the 0.001) (Table 3).
pain severity of the patients on the 1st postoperative day. The differences in the rates of seroma formation, scrotal
According to this scale, the patients were asked to scale edema, and recurrence were not found to be statistically
their current pain intensity or pain intensity in the last 24 significant between the groups, and the values were
hours, and the severity of the pain was scored between 0 0.972, 0.976, and 0.997, respectively. Rates of paresthesia and
and 10 by the patient. All the participants were examined on neuropraxia were not found to be statistically significant
the 7th postoperative day for seroma formation and scrotal between the groups, and the values were 0.625 and 0.543,
edema and then later on in the 6th month for paresthesia, respectively (Table 4).
neuropraxia, and recurrence by a single clinician. Statistical
analysis was performed with Number Cruncher Statistical 4. Discussion
System (NCSS, 2007 Statistical Software, Utah, USA). In
addition to the descriptive statistical methods, independent Despite the fact that inguinal hernia repair is the most
-test was used to compare the groups; chi-square test and frequent procedure in surgical practice and lots of repair
odds ratio with the confidence interval of 95% were used for types have been described, efforts to find new techniques have
qualitative data. A value under 0.05 was accepted to be not come to an end, yet. The main factor underlying these
statistically significant. searches is to decrease the rates of recurrence. Additionally,
applicability, complication rates, hospital stay, labor loss,
3. Results and overall cost-effectiveness of the techniques have been
questioned in the recent years. In these studies, tension-free
The mean age and BMI were not found to be statistically repair with synthetic mesh has been reported to be superior
significant between the groups, and the values were 0.063 to other modalities, in both open and laparoscopic surgery
and 0.236, respectively (Table 1). [710].
Region and type of the hernias of the patients were The main problem of the conventional hernia repair
compared and the values were 0.443 and 0.751, respectively, techniques is the tension on the suture tract, which can be
showing no statistical significance (Table 2). decreased by a relaxation incision but not avoided completely.
Surgery Research and Practice 3

Table 4: Comparison of seroma, scrotal edema, recurrence, paresthesia, and neuropraxia between the groups.

Group 1 Group 2 OR 95%

2
+ 4 9.50% 4 9.30% : 0.001 1.02
Seroma
38 90.50% 39 90.70% = 0.972 0.234.4
+ 3 7.10% 3 7.00% 2 : 0.002 1.02
Scrotal edema
39 92.90% 40 93.00% = 0.976 0.195.39
+ 1 2.40% 1 2.30% 2 : 0.0001 1.02
Recurrence
41 97.60% 42 97.70% = 0.997 0.066.94
+ 3 7.10% 2 4.70% 2 : 0.024 1.6
Paresthesia
39 92.90% 41 95.30% = 0.625 0.259.95
+ 2 4.80% 1 2.30% 2 : 0.370 2.1
Neuropraxia
40 95.20% 42 97.70% = 0.543 0.1824

The primary etiologic factor of the insufficiency of hernior- postoperative complications, and recurrence rates indicates
rhaphy is to suture two tissues which do not meet with each the safety of the procedure.
other in normal anatomy, in a tense manner, which is also
adverse to general surgical principles. Because of the tension, 5. Conclusion
sutures tear the tissues and cause necrosis. Conversely, mesh
repairs do not cause tension on the suture tract, enable a In our study, we performed Lichtenstein procedure with
repair without changing the normal anatomic configuration, and without mesh-fixation in two groups and compared
and result in decreased recurrence rates. Additionally, the the results prospectively in terms of patient demographics,
technique is simple and more effective and causes less pain. postoperative complications, hospital stay, operative time,
Tension-free method also enables performing bilateral hernia and effects on life quality. Operative time was found to be
repair [11]. statistically shorter, and postoperative pain score was found
For over a century, the success of inguinal hernia repairs to be statistically lower in the study group.
is evaluated with their recurrence rates. In a study including Today, new techniques are being explored and introduced
1098 patients by Kark et al., Lichtenstein procedure was frequently in inguinal hernia surgery. Lichtenstein repair,
reported to have a recurrence rate of 0.1% [12]. Bellone et which is accepted to be gold standard in open surgery, may be
al. found the same rate following their tension-free repair performed safely and effectively with better results, without
as 0.8% in 119 patients [13]. McGillicuddy compared Licht- mesh-fixation, although further studies with larger control
enstein and Shouldice techniques and found the recurrence and study groups are necessary for certain results.
rates as 0.2% and 1%, respectively [14]. Koninger found
recurrences rates of 0.3% following a tension-free repair [15]. Competing Interests
Amid et al. studied 4000 patients and followed them up for 5
years and found the recurrence rates as 0.1% in their clinical The authors declare that they have no competing interests.
trials [1621].
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