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 Table of Contents  
Year : 2017  |  Volume : 22  |  Issue : 2  |  Page : 93-98

Lichtenstein hernia repair versus totally extraperitoneal hernia repair: Randomized control study in rural area

1 Department of Surgery, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
2 Department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India

Date of Web Publication15-Sep-2017

Correspondence Address:
Aditi Agrawal
B/607, Lok Tirth, Marve Road, Malad West, Mumbai - 400 064, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmgims.jmgims_47_15

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Introduction: Lichtenstein technique is an age-old accepted technique of inguinal hernia repair. However, we have compared it with laparoscopic totally extraperitoneal hernia repair in terms of clinical outcome, quality of life, safety, and effectiveness. Materials and Methods: One-hundred and fifty patients were randomized to TEP group (75 patients – Group 1) or Lichtenstein repair group (75 patients – Group 2); pre-, peri-, and post-operative factors were then recorded. Results: Preoperative factors were similar in both the groups. Chronic pain was more prevalent in Lichtenstein repair than TEP group. Recurrence rates were similar in both the groups. Patients in laparoscopic group returned to work much earlier than open group resulting in more economic savings and decrease in loss of working days. TEP was a expensive procedure.Conclusions: The laparoscopic technique with mesh in the treatment of inguinal hernia in our rural setup is still complimentary to open mesh repair and not an alternative, irrespective of several important clinical aspects, with concomitant improvement in patient satisfaction in terms of early return to work.

Keywords: Clinical outcome, inguinal hernia, laparoscopy, quality of life, TEP repair

How to cite this article:
Sawarkar P, Agrawal A, Zade R, Mehera B, Gupta D. Lichtenstein hernia repair versus totally extraperitoneal hernia repair: Randomized control study in rural area. J Mahatma Gandhi Inst Med Sci 2017;22:93-8

How to cite this URL:
Sawarkar P, Agrawal A, Zade R, Mehera B, Gupta D. Lichtenstein hernia repair versus totally extraperitoneal hernia repair: Randomized control study in rural area. J Mahatma Gandhi Inst Med Sci [serial online] 2017 [cited 2018 Dec 17];22:93-8. Available from: http://www.jmgims.co.in/text.asp?2017/22/2/93/214761

  Introduction Top

Tension-free mesh techniques for inguinal hernia repair have become popular during the last decade as results with various types of conventional sutured repairs are poor. The Lichtenstein technique has become the standard approach for open repair as it is easy to learn and has low recurrence rates in the hands of the expert and the average surgeon.[1],[2] Laparoscopic tension-free hernia repair is a minimally invasive procedure and has advantages over open techniques with less postoperative pain and shorter convalescence and sick leave periods.[3] Inguinal hernia at times is the first surgery performed by surgical resident and is the most common surgery. However, still, no consensus on the technique of repair of hernia has been concluded, so we did a comparative study of open Lichtenstein repair and laparoscopic totally extraperitoneal (TEP) repair.

  Materials and Methods Top

Men aged 15–80 years with a primary inguinal hernia were eligible for the inclusion. Exclusion criteria were recurrent hernia, obstructed, irreducible, strangulated, bilateral hernia, and previous lower abdominal surgery, for example, pfannenstiel, lower midline, and other abdominal incisions below the umbilicus on the side of the hernia. Patients not consenting/not willing for follow-up and an American Society of Anesthesiologists grade higher than III were not included in the study. Consent was obtained from parents in case of men <18 years of age (minor). After informed consent, 150 patients were alternatively randomized to TEPP (75 patients – Group 1) or Lichtenstein repair (75 patients – Group 2). A randomized prospective study was carried out at Mahatma Gandhi Institute of Medical Sciences, Sewagram, from January 2009 to January 2011 after ethics committee approval was obtained. The operations were planned as day care cases, and patients in both the groups were instructed to resume their normal daily activities and return to work as soon as possible, irrespective of the operative technique used. Both the operations were performed by the same operating team. Consort diagram of the study is depicted in Flowchart 1.

Operative procedure for laparoscopic (totally extraperitoneal) hernia repair

The patient was placed in supine position with arms by the side after administration of general anesthesia. The surgeon was positioned on the opposite side of hernia, with the assistant (camera operator) positioned on the other side. To create the preperitoneal space, a 2 cm infraumbilical transverse incision was made in the midline of the fascia.

The rectus muscle was bluntly separated, and a small tunnel was made in the direction of pubis between the rectus muscle and peritoneum. Using a finger, blunt dissection was performed to open preperitoneal space. A handmade balloon was then inserted into the space and blunt dissection done. A 12 mm blunt tip trocar was inserted and secured to the skin for stabilization. Insufflation with carbon dioxide (CO2) to 14 mmHg was then obtained. An operating 10 mm 30° telescope was inserted for visualization of the preperitoneal space. The second 5 mm trocar was placed approximately two fingerbreadth above the pubic symphysis, and other 5 mm trocar was inserted between the two trocars in the midline. Blunt dissection of the preperitoneal space was performed through both 5 mm trocar.

To identify the standard anatomic boundaries, the dissection began at the level of pubis, and then continued along the Cooper's ligament to the femoral canal, after which the epigastric vessels were identified and continued laterally to identify the iliopubic tract. At this point, the type of defect became readily visible. All potential sites (direct, indirect, femoral, and obturator) were dissected free, exposing the myopectineal orifice of Fruchaud. A 15 cm × 15 cm polypropylene mesh was used and trimmed according to the need. The mesh was introduced through the 10 mm trocar, unrolled in the preperitoneal space, and positioned to cover the entire space from symphysis pubis in the midline to the anterior superior iliac spine laterally.

The mesh was fixed with two tackers, one on the pubic arch and another on the anterior superior iliac spine. After ensuring hemostasis, trocars were removed under vision. The extraperitoneal space was then emptied of CO2 with gentle pressure applied on lower abdomen. Finally, the infraumbilical fascial defect was repaired, and the skin incisions were closed.

The open operation was performed according to the Lichtenstein technique.[1] After dividing the cremaster muscle, the hernia sac was opened to permit digital examination of the femoral canal for the presence of a coinciding femoral hernia. The sac was then either resected or invaginated. A polypropylene mesh measuring 7.5 by 12 cm was anchored with a running 2/0 polypropylene suture overlapping the pubic tubercle by 1–2 cm. Laterally, a slit in the mesh permitted passage of the spermatic cord and the ilioinguinal nerve.

All patients were given intravenous antibiotics ceftriaxone + sulbactam 1.5 g preoperatively and single dose postoperatively. The analgesics (diclofenac sodium 50 mg) 12 hourly was given for 1 day postoperatively and then repeated if complaint of pain was persistent.

Patients were discharged after 24 h. On discharge, patients were advised normal diet and were asked to return to work or their normal routine activity as soon as possible. Intraoperative time for surgery was noted. In the postoperative period, patients were assessed complications such as hematoma, seroma formation, wound infection, and wound dehiscence. Patients were followed up at 1 week, 1 month, and 6 months by surgical resident doctors. Patients who did not visit outpatient department for follow-up were contacted through phone and a questionnaire was filled (phone number which was collected during the hospital stay). Thirty-four (15 in TEP group and 19 in Lichtenstein group) patients were followed up with the help of questionnaire on phone. Questionnaire is depicted in Appendix 1.[Additional file 1]

The outcome was measured in both the group of patients as the time taken for operation, incidence of intraoperative and postoperative complications, severity of pain at postoperative day 1, 1 week, 1 month, and 6 months, after operation, return to work, and cost effectiveness of laparoscopic (TEP) inguinal hernia repair.

  Results Top

Patient characteristics in both the groups are depicted in [Table 1]. Operative time was divided into four categories: <60 min, 61–90 min, 91–120 min, and >120 min. The mean duration for open hernia repair in open category (Lichtenstein repair) was 70 min and for laparoscopic category was 81.3 min, with significant P= 0.001. [Table 2] depicts comparison of complications - intraoperative and postoperative among the two modalities of hernia repair.
Table 1: Patient characteristics

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Table 2: Complications: Intraoperative and postoperative

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There was recurrence in 2 patients (1.3%) from 150 patients and was equally distributed among both the groups. Postoperative pain is depicted in [Table 3]. The percentage of mild pain at postoperative day 1 was found to be more (62.6%) in laparoscopic group as compared to 13.3% in open group, which was found to be statistically significant (P < 0.001). Moderate pain at postoperative day 1 was found more in open group (73.3%) as compared to 29.4% in laparoscopic surgery which was found to be statistically significant (P < 0.001). In open surgery group, severe pain was found 13.4% in comparison with 8% in laparoscopic surgery, which was not found to be statistically significant (P = 0.29).
Table 3: Pain felt by patients at different interval before and after operation

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  Discussion Top

Lichtenstein technique of inguinal hernia repair is regarded as a gold standard [4] and laparoscopic technique of hernia surgery attempting similar claims underwent controversies with conflicting results.[5] This was primarily because of the fact that the society and the surgeons perspective varied widely from not only country to country but also among the regions within the same country. Hence, “the battle for the bulge still continues.”

One-hundred and fifty patients underwent hernia repair during the study. The mean duration for open hernia repair was 70 min and for laparoscopic was 81.3 min, with significant P= 0.001 which is in contrast to a clinical trial by Colak et al.[6] To achieve an average operative time of <1 h for TEPP of unilateral hernia, involved surgeons surmounted the steep learning curve for TEPP.[7] Despite the fact that TEPP was a new procedure for the surgeon and the study was conducted during the learning phase, the results were comparable to the established open Lichtenstein hernia technique as reported by other studies worldwide.[8],[9] Initially, the time taken by the surgeon was more owing to unfamiliarity of preperitoneal anatomy and extra carefulness for newly introduced surgery for better results.

The high rate of intraoperative complications in laparoscopic group was because of single most common complication of pneumoperitoneum which occurred exclusively in laparoscopic hernia repair group. Out of total 29 (38.6%) patients, 24 (32%) patients of laparoscopic hernia repair had pneumoperitoneum in comparison with other study where 39.4% patients [9] and 40%–47%[7],[10] and all were managed by insertion of Veress needle and removal of the gas. The tendency of pneumoperitoneum decreased with increase in surgical experience.

[Table 4] depicts comparative analysis of complications occurring in various studies. Vas injury was present in three patients (4.0%) in open category. In laparoscopic group, one patient had complete transaction as the patient was old and Vas was strongly adherent to hernia sac. The postoperative complication was in 15 patients (20.0%) of open group as compared to 10 patients (13.4%) in laparoscopic group (P = 0.27) in contrast to other trials which show more complications in open hernia repair group [16],[17],[18] or more in laparoscopic group.[19]
Table 4: Comparison of postoperative complication rates in laparoscopic and open repairs

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Two patients (2.6%) in open group developed testicular pain and one patient was found to have orchitis at 5 days postoperatively. Two patients (2.6%) in laparoscopic group developed scrotal swelling. Wound infection was present only in open repair in three patients (4.0%). Wound dehiscence was present in only in open repair in two patients (2.6%).

Four patients (5.3%) in open group developed urinary complaints - two patients developed burning micturition and two had retention of urine. Two patients (2.6%) in laparoscopic repair developed urinary complaints as complaint of retention of urine.

In our study, longer duration of stay was noted as most of our patients were from rural area and the cost of travel was high. In other studies, patients were discharged on the same day of operation [8],[9],[17] and hospital stay of >7 days was associated with some type of complications. Maximum stay was noted in open group in patients with wound dehiscence.

The cost of surgery was significantly higher for laparoscopic hernia repair (for open Rs. 3233 and for laparoscopic Rs. 6508 with P< 0.001) which is in accordance with other studies.[9],[20] This is because all laparoscopic procedures are done in general anesthesia and use of large size of mesh (6” × 6”) which is expensive. The postoperative quality of life was definitely better for patient operated laparoscopically. This is calculated as a postoperative pain felt by patients in different intervals. The severity of pain determined by a scale, i.e., ten point numeric rating scale consisting of four grades as determined in other studies (none - 0, mild - 1–3, moderate - 4–6, and severe - 7–10). Visual analog pain scale was not used by us.

On the 1st postoperative day, 13.4% patients in open (Lichtenstein) group had severe pain as compared to 8.0% patients of in laparoscopic group, which is satisfactory (P = 0.29) but not significant, but other studies confer that follow-up till 7 days postoperatively indicates that laparoscopic hernia repair causes less pain than open repair, assessed by analgesic use and pain score.[16],[17],[18] The severity of pain after operation at 1 week was significantly less in laparoscopic group than in open group. Only 9.3% patient had moderate pain in laparoscopic surgery as compared to 36.0% in open surgery, which found to be significant (P < 0.001). Severe pain was present only in two patients (2.6%) of open group, and no patient in laparoscopic group had severe pain at 1 week after surgery.

At 1 month after surgery, 49.3% patients reported that they did not have pain in laparoscopic surgery as compared only 10.6% in open surgery, which was found to be significant (P = 0.0006). At 1 month and at 6 months after surgery, no patients in either group had severe pain, and no patient had even moderate degree of pain at 6 month interval. This finding well correlated with previous study done by Courtney et al.[22]

The maximum duration of time taken to return to work was 30 days in laparoscopic surgery as compared to 35 days in open surgery. The mean duration of time taken for return to work was 14 days in open repair and 11 days in laparoscopic repair (P = 0.002 which is statistically significant). This translates into a significant economic savings to the society because of fewer working days lost.

This was clearly seen in the manual working laborer undergoing laparoscopic operations. When we compared return to work with working conditions, we found that those who work as a heavy manual laborers return to work late due to sole fear of recurrence as compared to those who engaged in light manual or desk work in spite they would tell by us to return to work when they feel comfortable as early as possible. It is the mindset which decides return to work more than the physical fitness and capability of an individual to return to work.

This together with the fact that the TEPP group in general had a shorter period of sick leaves indicates that convalescence period directly related to degree of surgical trauma.

Our study has a few limitations-we have only taken unilateral primary hernia and hence the role of laparoscopy in bilateral and recurrent hernia cannot be assessed. Our sample size is also small.

We feel that laparoscopic TEP mesh hernia repair is safe and effective in the treatment of primary unilateral inguinal hernia, but still a complimentary choice and not alternative to open Lichtenstein hernia repair surgery in our rural setup for unilateral primary inguinal hernia.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Amid PK, Shulman AG, Lichtenstein IL. Open “tension-free” repair of inguinal hernias: The Lichtenstein technique. Eur J Surg 1996;162:447-53.  Back to cited text no. 1
Davies N, Thomas M, McIlroy B, Kingsnorth AN. Early results with the Lichtenstein tension-free hernia repair. Br J Surg 1994;81:1478-9.  Back to cited text no. 2
Berndsen F, Arvidsson D, Enander LK, Leijonmarck CE, Wingren U, Rudberg C, et al. Postoperative convalescence after inguinal hernia surgery: Prospective randomized multicenter study of laparoscopic versus shouldice inguinal hernia repair in 1042 patients. Hernia 2002;6:56-61.  Back to cited text no. 3
Nordin P, Haapaniemi S, van der Linden W, Nilsson E. Choice of anesthesia and risk of reoperation for recurrence in groin hernia repair. Ann Surg 2004;240:187-92.  Back to cited text no. 4
Wright D, Paterson C, Scott N, Hair A, O'Dwyer P. Five-year follow-up of patients undergoing laparoscopic or open groin hernia repair: A randomised con trolled trial. Ann Surg 2002;235:333-7.  Back to cited text no. 5
Colak T, Akca T, Kanik A, Aydin S. Randomized clinical trial comparing laparoscopic totally extraperitoneal approach with open mesh repair in inguinal hernia. Surg Laparosc Endosc Percutan Tech 2003;13:191-195.  Back to cited text no. 6
Lau H, Patil NG, Yuen WK. Day case endoscopic totally extra peritoneal inguinal hernioplasty versus open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males. Surg Endosc 2006;20:76-81.  Back to cited text no. 7
Juul P, Christensen K. Randomized clinical trial of laparoscopic versus open inguinal hernia repair. Br J Surg 1999;86:316-9.  Back to cited text no. 8
Eklund A, Rudberg C, Smedberg S, Enander LK, Leijonmarck CE, Osterberg J, et al. Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair. Br J Surg 2006;93:1060-8.  Back to cited text no. 9
Montogomery A. TEP for superfor specialist, not for general surgeon? In: Schumpelick V, Nyhus LM, editors. Meshes: Benefits and Risks. Berline: Springer; 2004. p. 379-87.  Back to cited text no. 10
Laparoscopic versus open repair of groin hernia: A randomised comparison. The MRC Laparoscopic Groin Hernia Trial Group. Lancet 1999;354:185-90.  Back to cited text no. 11
Grant AM, Scott NW, O'Dwyer PJ; MRC Laparoscopic Groin Hernia Trial Group. Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia. Br J Surg 2004;91:1570-4.  Back to cited text no. 12
Bringman S, Ramel S, Heikkinen TJ, Englund T, Westman B, Anderberg B. Tension-free inguinal hernia repair: TEP versus mesh-plug versus Lichtenstein: A prospective randomized controlled trial. Ann Surg 2003;237:142-7.  Back to cited text no. 13
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. 14
Wake BL, McCormack K, Fraser C, Vale L, Perez J, Grant AM. Transabdominal pre-peritoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair. Cochrane Database Syst Rev 2005;(1):CD004703.  Back to cited text no. 15
Stoker DL, Spiegelhalter DJ, Singh R, Wellwood JM. Laparoscopic versus open inguinal hernia repair: Randomised prospective trial. Lancet 1994;343:1243-5.  Back to cited text no. 16
Wellwood J, Sculpher MJ, Stoker D, Nicholls GJ, Geddes C, Whitehead A, et al. Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: Outcome and cost. BMJ 1998;317:103-10.  Back to cited text no. 17
Champault GG, Rizk N, Catheline JM, Turner R, Boutelier P. Inguinal hernia repair: Totally preperitoneal laparoscopic approach versus Stoppa operation: Randomized trial of 100 cases. Surg Laparosc Endosc 1997;7:445-50.  Back to cited text no. 18
Lawrence K, McWhinnie D, Goodwin A, Doll H, Gordon A, Gray A, et al. Randomised controlled trial of laparoscopic versus open repair of inguinal hernia: Early results. BMJ 1995;311:981-5.  Back to cited text no. 19
Singh V, De U. Laparoscopic mesh versus open mesh repair of inguinal hernia. An experience from West Bengal, India. The Internet J Surg 2008;20:Number 1.  Back to cited text no. 20
Liem MS, van der Graaf Y, van Steensel CJ, Boelhouwer RU, Clevers GJ, Meijer WS, et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N Engl J Med 1997;336:1541-7.  Back to cited text no. 21
Courtney CA, Duffy K, Serpell MG, O'Dwyer PJ. Outcome of patients with severe chronic pain following repair of groin hernia. Br J Surg 2002;89:1310-4.  Back to cited text no. 22


  [Table 1], [Table 2], [Table 3], [Table 4]


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