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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 158-162

Comparative study of laparoscopic mesh repair and lichtenstein's open mesh repair for inguinal hernia


Department of Surgery, Lourdes Hospital, Kochi, Kerala, India

Date of Submission28-Jul-2020
Date of Acceptance13-Aug-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Dr. Sooraj Sankar
Department of General Surgery, Lourdes Hospital, Pachalam, Kochi - 682 012, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_4_20

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  Abstract 


Background: Hernias are among the oldest known afflictions of humankind, and surgical repair of the inguinal hernia is one of the most common general surgery procedure performed today. Despite the high incidence, the technical aspects of hernia repair continue to evolve. We conducted a unicentric prospective study to compare the outcome of laparoscopic mesh repair and open Litchtenstein's mesh repair. Methods: We included a total of 80 cases who were diagnosed to have uncomplicated inguinal hernia and underwent surgical management electively for the same. They were randomized into both open or laparoscopic repair groups and results compared. Results: Among the 2 groups, the laparoscopic repair group had significantly low early post operative pain, low complication rate, early return to work and better cosmetic outcome. However, late post operative pain and duration of hospital stay did not show any significant difference between the two groups. Conclusion: Laparoscopic hernia repair offer significant advantages in terms of early post operative pain, early return to work and better cosmetics. But, in 2020, it still accounts for the minority of hernia repairs performed in India because of increased operative times, increased costs, and a longer learning curve. In addition are concerns about the need to use general anesthesia for laparoscopic operations. To summarize, there is no universal repair for groin hernia and no two surgeons will disagree to agree on that point.

Keywords: Hernia, Lichtenstein, transabdominal preperitoneal


How to cite this article:
Sankar S, Iype V, Abraham SJ. Comparative study of laparoscopic mesh repair and lichtenstein's open mesh repair for inguinal hernia. Kerala Surg J 2020;26:158-62

How to cite this URL:
Sankar S, Iype V, Abraham SJ. Comparative study of laparoscopic mesh repair and lichtenstein's open mesh repair for inguinal hernia. Kerala Surg J [serial online] 2020 [cited 2020 Nov 30];26:158-62. Available from: http://www.keralasurgj.com/text.asp?2020/26/2/158/300242




  Introduction Top


Hernias are among the oldest known afflictions of humankind, and surgical repair of the inguinal hernia is one of the most common general surgery procedures performed today. Despite the high incidence, the technical aspects of hernia repair continue to evolve. This evolution has paralleled technological developments in the field. The most significant advances to impact inguinal hernia repair have been the addition of prosthetic materials to conventional repairs and the introduction of laparoscopy to general surgical procedures.

Failure of these early techniques of hernia repair was based on inadequate knowledge of groin anatomy and poor understanding of the natural history of hernia formation. Then came the era of tension-free repairs.

With the advent of minimally invasive surgery, inguinal hernia repair underwent its most recent transformation. Laparoscopic inguinal hernia repair has added to the armamentarium of the general surgeon, gaining its popularity by providing a technique that lessens post-operative pain and improves recovery. Furthermore, an array of prosthetic materials have and are been introduced to further lower recurrence rates and provide the patient with the utmost quality of life.

This study aims at comparing the outcome of both Lichtenstein's mesh repair and laparoscopic mesh repair for inguinal hernia in terms of multiple parameters, namely operative time, post-operative pain, duration of hospital stay, post-operative complications, time taken to resume his/her routine work and scar appearance.


  Materials and Methods Top


We performed a unicentric, prospective descriptive-analytical study from October 2017 to September 2018. The sample size of 80 was determined by the formula, n > Z2 × PQ/d2, where, n → sample size, P → rate of prevalence, Q → 1 − P and D → error of estimation. By taking P as 4.88% and with a confidence interval of 95%, the minimum sample size as per the above formula worked out to be 72 and has been conveniently taken as 80. Simple random sampling was used. The demographic profile of both groups, including age, sex and occupation distribution, was also studied. The distribution of specific characteristics of inguinal hernia, including side (right, left) and the anatomical type (direct, indirect), were included in the study and compared to standard published literature and conclusions drawn. Statistical tests included t-test for comparing continuous variables and the Chi-square test for comparing categorical variables.

Patients diagnosed to had uncomplicated inguinal hernia of either sex and underwent surgical management electively for the same were included. Patients with complications such as obstruction, incarceration and strangulation, who had undergone lower abdominal surgery previously, recurrent inguinal hernia, emergency hernia repair, pre-operative urinary retention issues, psychiatric illness, those <18 years, and unwilling patients were excluded. Data were collected using a pro forma for full history, clinical examination, routine pre-operative investigations such as complete blood count, blood sugar level, serum creatinine, chest X-ray, electrocardiogram, etc., The patients were randomised according to their serial number to undergo open mesh repair or laparoscopic hernia mesh repair (totally extraperitoneal, transabdominal preperitoneal [TAPP]). Single dose of pre-operative prophylactic antibiotics was given to all patients. Post-operatively, patients were given analgesia as oral paracetamol based on body weight and pain scoring (visual analogue scale [VAS]).

Data included occupation, operating time, the requirement of post-operative analgesia, post-operative complications such as haematoma and urinary retention in their immediate post-operative period, surgical site infection and opinion about scar appearance (using Patient and Observer Scar Assessment Scale [POSAS] score). Patients were routinely discharged on the next day when they were haemodynamically stable and relatively asymptomatic, except when any complications such as haematoma, high-grade fever, severe pain or urinary retention occurred.

They were reviewed at 2 weeks, 1, 3 and 6 months post-operatively, when the late post-operative complications and scar appearance were assessed.


  Results Top


The age group profile shows that most patients (59 out of 80) were between 25 and 60 years of age in both study groups. Eighteen (45%) in the age group of 25–40 in laparoscopic repair and 17 (42.5%) in the age group of 40–60 in open repair. The most number of patients admitted were in the age group of 40–60 years (40%). Twenty-seven patients (33.8%) were in 25–40 years age group and 14 patients (17.5%) were >60 years of age. There was no statistically significant difference in age between the two groups [Figure 1].
Figure 1: Bar graph showing age distribution in the study group γ2 = 6.98; P = 0.072 (P > 0.05)

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The highest incidence of inguinal hernia was seen in males (95%). Majority of the cases were involved in an occupation demanding moderate-to-heavy strenuous physical activities. Thirty-six (45%) of patients were doing Job Type 1 (Strenuous work), including manual labourer/porter/mason/agriculturist, 26 (32.5%) had Job Type II (Moderate work), including shopkeeper/teacher/driver/small scale businessman/desk workers and only 18 (22.5%) had Job Type III (Light work) including retired/unemployed/student/homemaker. Sixty five (81.25%) of the cases had a right-sided inguinal hernia and 15 (18.75%) were left sided. No case of bilateral inguinal hernia was noted in the study. Of the total cases, 56 (70%) of the cases had an indirect inguinal hernia and the rest 24 (30%) had a direct one. The mean operation time of laparoscopic TAPP repair was 73.45 min with standard deviation (SD) of ± 11.686 and that of open Lichtenstein repair was 30.88 min with SD of ± 5.534, with P < 0.05 being statistically significant, showing that laparoscopic repair was lengthier than open repair. The post-operative pain was recorded at 12 h, 24 h, 48 h, 72 h and 7 days after operation by using VAS pain scoring system [Table 1]. The mean pain score in the laparoscopic group was significantly less than the Lichtenstein group for the first 48 h after surgery (P < 0.05). However, post 48 h, though the pain score was less for the laparoscopic group than open repair group, it was not statistically significant (P > 0.05).
Table 1: Comparison of post-operative pain (using Visual Analogue Scale)

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The mean post-operative analgesic (tablet paracetamol 1 g) consumption in the first 48 h after surgery was 4.83 ± 1.196 in the laparoscopic repair group as compared to 6.30 ± 1.454 in the open repair group. This was statistically significant with P = 0.000. In 3–7 days period post-operatively, the mean analgesic consumed was 11.6 ± 2.216 for the laparoscopic repair group and 12.53 ± 2.465 [Table 2]. Although the analgesic requirement in laparoscopic repair group was less than open repair group, it was not statistically significant (P > 0.05).
Table 2: Comparison of post-operative analgesia requirement in study groups mean (±standard deviation) tablet paracetamol 1 g received from day 1 to 7 post-operatively

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The mean duration of hospital stay after a laparoscopic hernia repair was observed to be 1.150 ± 0.36 days and 1.175 ± 0.44 days following open mesh repair, with the P value being not statistically significant [Table 3]. Of the 40 cases who underwent laparoscopic repair, 34 cases (85%) were discharged within 1 day and the remaining 6 cases were discharged within 2 days. Among the open repair group, 34 cases were discharged within 1 day, 5 cases were discharged within 2 days and the remaining 1 case within 3 days [Figure 2].
Table 3: Duration of post-operative stay in the two groups

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Figure 2: Comparison of return to work in both the groups

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Among the 40 cases that underwent open mesh repair, 29 cases had no complications related to surgery, 3 cases required urethral catheterisation for urinary retention, 4 cases suffered chronic pain, 3 cases had wound-related complications and 1 had wound infection. The total complication rate of the open group was 27.5%. Among the 40 cases that underwent laparoscopic repair, 35 cases had no complication, 3 cases required urethral catheterisation for urinary retention and 2 cases had wound-related complications, total complication rate for this group being 12.5% [Table 4].
Table 4: Post-operative complications in the two groups

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The mean duration to get back to work in the open repair group was 16.28 ± 3.63 days, whereas in the laparoscopic group, the mean was 9.55 ± 4.443 days (P value was extremely significant), suggesting that return to normal daily activities and work is much earlier following a laparoscopic procedure for inguinal hernia repair.

All the patients in each group were asked to give their opinion about the appearance of scar. It was assessed using the POSAS, which consists of two parts: a patient scale and an observer scale. Both scales consist of six items, each are scored numerically from 1 to 10. The sum altogether will give the “total score” of the POSAS, which will be averaged to a 10-point score, with 10 indicating the worst imaginable scar and 1 corresponds to the situation of normal skin [Figure 3]. The mean POSAS score for the laparoscopic repair group was 3.038 (SD ± 1.034) and that of the open repair group was 3.525 (SD ± 1.0739) with a statistically significant P = 0.042 (P < 0.05), which indicates that laparoscopic hernia repair had a significantly better cosmetic outcome than open hernia repair [Figure 3].
Figure 3: Comparison of patient's opinion about scar

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  Discussion Top


Maximum cases with inguinal hernia were 25–40 years, similar to the other studies, 45–64 years,[1] 40–59 years [2] and 47–52.[3] Ninety-five percent of our patients were male, similar to other studies, 90% of males,[1] 97% of males [3] and 100% of males.[4] Forty-five percent of our cases were heavy workers, 32.5% of cases had moderate work and 22.5% cases had light work, similar to other studies.[4],[5],[6],[7] About 81.25% of the cases presented with a right-sided inguinal hernia, comparable to other studies.[4],[6],[7] Seventy percent presented with an indirect hernia, comparable to other studies.[8],[9]

The mean operating time in the laparoscopic group was 73.45 min and in the open mesh repair group, 30.88 min with a significant P value, similar to other studies,[10],[11],[12] highlighting the steep learning curve in laparoscopic hernia repair.

Post-operative pain in the first 48 h was significantly low in laparoscopic repair as compared to open repair (P = 0.000). The pain scores at 72 h and 7th day were less in the laparoscopic repair group but did not reach significant levels (P = 0.669). The results are comparable to other reports.[13],[14]

The mean post-operative analgesic consumption in the first 48 h after surgery was statistically significantly lesser (P = 0.000) in the laparoscopic surgery group. This is comparable to other reports,[14] whereas Paganini et al.[15] did not find any significant difference. However, in 3–7 days period, though the analgesic requirement in the laparoscopic repair group was less than open repair group, it was not statistically significant comparable to the result of Heikkinen et al.,[14] whereas Paganini AM et al.,[16] did not find any significant difference.

The mean duration of hospital stay after a laparoscopic hernia repair was slightly lesser but was not statistically significant. Other reports [16],[17],[18],[19] also observed similar insignificant difference; the total complication rate of the open group was 27.5% against 12.5% in the laparoscopic group. This was comparable to other studies.[17],[18] However, Neumayer et al., reported a higher rate of complications in the laparoscopic-surgery group.[19]

In our study, the mean duration to get back to work in the open repair group was significantly more than that in the laparoscopic group. This was similar to other studies.[17],[19]

The mean POSAS score for the laparoscopic repair group was 3.038 (SD ± 1.034) and that of the open repair group was 3.525 (SD ± 1.0739) with a statistically significant P value of 0.042 (P < 0.05), which indicated that laparoscopic hernia repair had a significantly better cosmetic outcome than open hernia repair.

The mean POSAS score for the laparoscopic repair group was significantly lesser (P < 0.05), which indicated that laparoscopic hernia repair had a significantly better cosmetic outcome than open hernia repair. However, Schrenk et al.[20] did not find any significant difference in the patient's opinion about surgery.


  Conclusion Top


There is no universal repair for groin hernia and no two surgeons will disagree to agree on that point. The availability of such an array of surgical techniques in the treatment of groin hernias is bound to confuse the younger surgeon. All techniques will have hard proponents as well as opponents. This is where the practice of evidence-based medicine is very crucial and one should have a close watch on the long-term follow-up results of any particular newer procedures. Till then, one may practice a time-honoured and a good surgical technique, which has the least recurrence rate that is handed over to them by their seniors, taking into account the cost factor, which is still important in the developing country like ours and with the noble thought that the patient is not a guinea pig.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surg Clin North Am 2003;83:1045-51.  Back to cited text no. 1
    
2.
Ruhl CE, Everhart JE. Risk factors for inguinal hernia among adults in the US population. Am J Epidemiol 2007;165:1154-61.  Back to cited text no. 2
    
3.
Kurzer M, Belshan PA, Kark AE. The lichtensten repair. Surg Clin North Am 1998;78:1025-46.  Back to cited text no. 3
    
4.
Shyam DC, Rapsang AG. Inguinal hernias in patients of 50 years and above. Pattern and outcome. Rev Col Bras Cir 2013;40:374-9.  Back to cited text no. 4
    
5.
Bay-Nielsen M, Thomsen H, Andersen FH, Bendix JH, Sørensen OK, Skovgaard N, et al. Convalescence after inguinal herniorrhaphy. Br J Surg 2004;91:362-7.  Back to cited text no. 5
    
6.
Naeem M, Khan SM, Qayyum A, Jan WA, Jehanzeb M, Mehmood K. Recurrence of inguinal hernia mesh repair. JPMI 2009;23:254-7.  Back to cited text no. 6
    
7.
Sanjay P, Woodward A. Single strenuous event: Does it predispose to inguinal herniation? Hernia 2007;11:493-6.  Back to cited text no. 7
    
8.
Palanivelu C. Result of hand sutured laparoscopic hernioplasty: An effective method of repair. Indian Journal of Surgery. 2000;62:339-41.  Back to cited text no. 8
    
9.
Predrag M, Kolinovic M. “Surgical management of abdominal wall hernias in adults epidemiological aspects and our experiences.” Priory Med J 2013. Retrieved from https://www.priory.com/surgery/hernia_abdominal.htm.  Back to cited text no. 9
    
10.
Zieren J, Zieren HU, Jacobi CA, Wenger FA, Müller JM. Prospective randomized study comparing laparoscopic and open tension-free inguinal hernia repair with Shouldice's operation. Am J Surg 1998;175:330-3.  Back to cited text no. 10
    
11.
Johansson B, Hallerbäck B, Glise H, Anesten B, Smedberg S, Román J. Laparoscopic mesh versus open preperitoneal mesh versus conventional technique for inguinal hernia repair: A randomized multicenter trial (SCUR Hernia Repair Study). Ann Surg 1999;230:225-31.  Back to cited text no. 11
    
12.
Lal P, Kajla RK, Chander J, Saha R, Ramteke VK. Randomized controlled study of laparoscopic total extraperitoneal versus open Lichtenstein inguinal hernia repair. Surg Endosc 2003;17:850-6.  Back to cited text no. 12
    
13.
Anadol ZA, Ersoy E, Taneri F, Tekin E. Outcome and cost comparison of laparoscopic transabdominal preperitoneal hernia repair versus open Lichtenstein technique. J Laparoendosc Adv Surg Tech A 2004;14:159-63.  Back to cited text no. 13
    
14.
Heikkinen T, Haukipuro K, Leppälä J, Hulkko A. Total costs of laparoscopic and lichtenstein inguinal hernia repairs: A randomized prospective study. Surg Laparosc Endosc 1997;7:1-5.  Back to cited text no. 14
    
15.
Paganini AM, Lezoche E, Carle F, Carlei F, Favretti F, Feliciotti F, et al. A randomized, controlled, clinical study of laparoscopic vs open tension-free inguinal hernia repair. Surg Endosc 1998;12:979-86.  Back to cited text no. 15
    
16.
Eklund A, Carlsson P, Rosenblad A, Montgomery A, Bergkvist L, Rudberg C, et al. Long-term cost-minimization analysis comparing laparoscopic with open (Lichtenstein) inguinal hernia repair. Br J Surg 2010;97:765-71.  Back to cited text no. 16
    
17.
Bhandarkar DS, Shankar M, Udwadia TE. Laparoscopic surgery for inguinal hernia: Current status and controversies. J Minim Access Surg 2006;2:178-86.  Back to cited text no. 17
    
18.
Erhan Y, Erhan E, Aydede H, Mercan M, Tok D. Chronic pain after Lichtenstein and preperitoneal (posterior) hernia repair. Can J Surg 2008;51:383-7.  Back to cited text no. 18
    
19.
Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R Jr., Dunlop D, Gibbs J, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004;350:1819-27.  Back to cited text no. 19
    
20.
Schrenk P, Woisetschläger R, Rieger R, Wayand W. Prospective randomized trial comparing postoperative pain and return to physical activity after transabdominal preperitoneal, total preperitoneal or Shouldice technique for inguinal hernia repair. Br J Surg 1996;83:1563-6.  Back to cited text no. 20
    


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