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Prospective comparative study of open meshplasty (lichentenstein’s method) versus laparoscopic inguinal hernia repair

Jaykar R D¹, Kasabe P S², Aher Manoj³, Korde P A⁴

¹Associate Professor, ²Assistant Professor, ^3,4Resident, Department of General Surgery, Dr. V. M. Government Medical College,

Solapur, Maharashtra, INDIA.

Email: pkthehunk@gmail.com

Research Article

Abstract Background: Since the dawn of surgical history, hernias have been subject of interest and their treatment has evolved through distinct stages. Time has seen many advances in hernia management from truss and bandages recommended by Cooper in 18^th century to laparoscopic hernia repair till date. Cases: We present 2 years prospective comparative study of 60 patients of inguinal hernias with respect to post-operative pain, operative time, hospital stay and rate of recurrence. 30 patients undergone hernia repair by meshplasty (Lichenstein’s repair) and rest of 30 patients undergone laparoscopic hernia repair (15 by TAPP and 15 by TEP)

Keywords: lnguinal hernia, Lichenstein’s meshplasty, prolene mesh.

INTRODUCTION

The word “HERNIA” is the Greek word meaning offshoot, a budding or buldge while in LATIN it means “ rupture or tear”.² An inguinal hernia is defined as a protrusion of part of the contents of the abdomen through the inguinal region of the abdominal wall¹. 75 % of all abdominal hernias occur in the groin. Indirect: Direct = 2:1. Right sided inguinal hernias are more common than left sided with male: female ratio of 7:1³. The inguinal hernia incidence and prevalence is considerably high. Incidence rate is approximately 1 in 544⁴. The yearly cost of groin hernia repair in any country accounts major percentage of health care expenditure, so the expeditious and effective care of inguinal hernia remains an important health care issue^5. The most important advance in hernia surgery has been the development of tension free repair using mesh. Improvement in surgical technique together with the development of new prosthetic material and a better understanding of how to use them, have significantly improved outcome of the patients⁶. With advent of laparoscopy, groin hernia repair by transabdominal pre-peritoneal repair has become more comfortable repair which is simple with less tissue damage and earliest return to normal activities with negligible post-operative pain⁷.

CASE REPORT

A prospective comparative study over 60 patients of inguinal hernia was done 30 of which were treated by Lichenstein’s repair and remaining 30 were treated by laparoscopic hernia repair. Prolene mesh of size 15x 15 cm was used for unilateral laproscopic repair and 15x 8 cm for Lichenstein’s repair. For bilateral hernias in laparoscopic repair the mesh size was 30x 25cm. All the male patients in the age group of 30 to 70 years were considered in this study. Patients with very large hernia, obstructed hernia, strangulated hernia and irreducible hernias were excluded from this study. Patients were discharged after the operation as per their comfort and instructed to follow-up on 3^rd and 7^th post-operative day and again to follow n 8^th day for suture removal. Patients were followed up at every month for six months on OPD basis and then every 3 months during study period. Post-operative pain assessment was done using McGill Visual Analogue Scale. Patients were assessed for post-operative pain, operative time, hospital stay and rate of recurrence.

OBSERVATIONS

Table 1: Age Distribution

Age	No. of patients	Percentage
31-40	9	15.00
41-50	17	28.33
51-60	29	48.33
61-70	5	8.33
Total	60	100

Total of 64 hernias were repaired in 60 patients of which 4 were bilateral. Out of 60 patients 36 were right sided and 20 were left sided hernias.

Table 2: Side of the hernia in Lichenstein’s Meshplasty group

Side of hernia	No. of the patients	Percentage
Right side	18	60.00
Left side	10	33.33
Bilateral	2	6.66
Total	30	100

Table 2(a): Side of hernia in laparoscopic group

Side of hernia	No. of pateints	Percentage
Right sided	18	60.00
Left sided	10	33.33
Bilateral	2	6.67
Total	30	100

Right sided hernia were present in 18 patients, left sided hernia was in 10 patients and bilateral hernias were in 2 pateints in both the groups

Table 3: Type of hernia in Lichenstein’s Meshplasty group

Type of hernia	No. of patients	Percentage
Indirect	20	66.66
Direct (including 1	08	26.66
recurrent)
Bilateral indirect	1	03.33
Bilateral direct	1	03.33
Total	30	100

Table 3 (a): Type of hernia in laparoscopic group

Type of hernia	No. of patients	Percentage
Indirect	23	76.66
Direct	4	13.33
Bilateral	2	6.66
Recurrent	1	3.33
Total	30	100

Table 4: Type of hernia according as per Nyhus classification in Lichenstein’s Meshplasty group

Type of hernia	No. of patients	Percentage
I	18	60.66
II	3	10.00
III a direct	8	26.66
III b indirect	0	0
III c femoral	0	0
IV a direct (recurrent)	1	3.33
IV b indirect	0	0
IV c femoral	0	0
IV d (a+b+c)	0	0
Total	30	100

Table 4 (a): Type of hernia as per Nyhus classification in laparoscopic group

Type of hernia	No. of patients	Percentage
I	20	66.67
II	4	13.33
III a direct	5	16.66
III b indirect	0	0
III c femoral	0	0
IV a direct (recurrent)	1	3.33
IV b indirect	0	0
IV c femoral	0	0
IV d (a+b+c)	0	0
Total	30	100

Table 5: Post-operative pain Visual Analogue Score (VAS) of patients operated by Lichenstein Meshplasty method

VAS	No. patients	Percentage
1-2	9	30.00
3-4	17	56.33
5-6	4	13.33
7-8	0	0
9-10	0	0
Total	30	100

Table 5 (a): Visual Analogue Score of patients operated by laparoscopic method in present study

VAS	No. patients	Percentage
1-2	19	63.33
3-4	10	33.33
5-6	1	3.33
7-8	0	0
9-10	0	0
Total	30	100

Hence pain was significantly higher in open hernia repair group than the laparoscopic repair group.

Table 6: Post-operative hospital stay Distribution of post-operative hospital stay in both groups

Post-operative	Lichenstein’s		Laparoscopic Repair
Hospital Stay	Meshplasty Group		Group
Post-operative	No.of	Percentage	No. of	Percentage
day(POD)	patients	of patients	patients	of patients
POD 1	-	-	-	-
POD 2	-	-	-	-
POD 3	-	-	20	66.66
POD 4	-	-	5	16.66
POD 5	24	80	4	13.33
POD 6	4	13.33	1	3.33
POD 7	2	6.66	-	-

Laparoscopic group received general anesthesia and Lichenstein meshplasty group received spinal anesthesia for which patients were watched for first 2 POD. No patient in our study was discharged within 48 hrs. In Lichenstein. Meshplasty group 24 patients i.e.80% of the patients were discharged on POD 5, 4 patients on POD 6 (13.33%) and 2 patients on POD 6 (6.66%). In laparoscopic group 20 pateints were discharged on POD 3 (66.66%) and 5 patients on POD 4(16.66%) and 4 pateints on POD 6(3.33%).

Table 7: Operative time required in Lichenstein Meshplasty and Laparoscopic group

Operative time	Lichenstein’s		Laparoscopic Repair
	Meshplasty Group		Group
Time in mins	No.of	Percentage	No. of	Percentage
	patients	of patients	patients	of patients
40-45	7	23.33	2	6.66
46-50	5	16.66	1	3.33
51-55	13	43.33	13	43.33
56-60	1	3.33	5	16.66
61-65	1	3.33	4	13.33
66-70	1	3.33	2	6.66
71-75	2	6.66	2	6.66
76-80	0	0	1	3.33

Thus average operative time for LIchenstein’s Meshplasty group was 54.16 mins while for Laparoscopic repair was 57.16 mins. Thus mean operative time for laparoscopic repair was more than that of Lichenstein’s Meshplasty.

Table 8: Recurrence of hernia

Lichenstein’s Meshplasty Group		Laparoscopic Repair Group
No.of patients	Percentage of	No. of patients	Percentage of
	Patients		patients
1	3.33	1	3.33

Thus there were similar hernia recurrence rate after Lichenstein’s meshplasty and Laparoscopic repair in our study which was 1/33 i.e. 3.33%. One patient in open meshplasty and one in laparoscopic repair developed inferior epigastric bleed which was controlled by ligation of vessel intra-operatively. One of the patient in open meshplasty and no patient in laparoscopic repair had intra-operatively ilioinguinal nerve injury. There was no patient who suffered with the complication like vas deference injury, bowel injury and bladder injury. One patient in open meshplasty developed scrotal hematoma which was treated by scrotal support, analgesics and antibiotics. Retention of urine was present in both groups, one in open meshplasty and one in laparoscopic repair group which was treated by urinary catheterization which was removed next morning. Two patients in open meshplasty and one in laparoscopic repair group developed wound infection i.e. surgical site infection and port site infection respectively. It was treated by removing one suture and drainage of pus and daily dressing and higher antibiotics. One patient from open meshplasty and one patient from laparoscopic repair developed recurrence on follow-up. One patient in laparoscopic repair (TAPP) was converted to open meshplasty due to adhesions.

RESULT AND DISSCUSSION

In present study all the patients included were male patients. 91 patients belong to age group of 30-50 years. This age group constituted major working population of the country, so surgical outcomes of these patients significantly influences the economy and health care delivery system of our country. in this study there were total 60 patients with inguinal hernia, 30 patients were operated by Lichenstein’s meshplasty and remaining 30 are operated by laparoscopic repair that is 15 patients by TAPP and 15 patients by TEP method. In our study 60% patients had right sided inguinal hernia and 33.33% patient had left sided inguinal hernia and 6.66% patients had bilateral inguinal hernia. According to Nyhus classification 63.33% of inguinal hernias were type I, 11.66% were of type II, 21.66% were of type IIIa and 3.33% was of type IVa.

Post-operative pain

Patients were assessed for post-operative pain on day 1, 3 and7 and the maximum score for given patient was taken into account

Table 1: Comparison of VAS in patient operated by Lichenstein’s meshplasty and Laparoscopic hernia repair in the present study and M.S.Wilson study

Post-operative visual	Lichenstein’s		Laparoscopic Repair
analogue scale	Meshplasty Group		Group
	Wilson	Present	Wilson	Present
	study	Study	study	study
Mean VAS score	3	3.36	3	2.6

The mean VAS of Lichenstein’s meshplasty in our study was 3.36. This was comparable to the mean VAS of M.S. Wilson study which was 3. The mean VAS of laparoscopic hernia repair in our study was 2.6 which was comparable to that of M.S. Wilson study which has VAS 3. Post-operative pain was higher in Lichenstein’s meshplasty group than Laparoscopic hernia repair group.

Table 2: Operative time the important issue of the operative time depends on surgeon experience, infrastructure and team work

Study group	Lichenstein’s Meshplasty Group		Laparoscopic Repair Group
	Wright D.M study	Present study	Wright D.M study	Present Study
Mean operative time(mins)	45	53.66	58	57.16

Study group	Lichenstein’s		Laparoscopic Repair
	Meshplasty Group		Group
	Wright D.M. study	Present study	Wright D.M. Study	Present Study
Mean operative time	45	53.66	58	57.16
(mins)

The mean operative time in our study for Lichenstein’s meshplasty was 53.66 mins, for Laparoscopic hernia repair was 57.16 mins. It is comparable with operative time for Lichenstein’s meshplasty which was 45mins and Laparoscopic hernia repair which was 58 mins in Wright D.M. et. al. study. It is clear that mean operative time for Laparoscopic hernia repair was more relatively more than open hernia repair and is statistically significant. On the contrary mean operative time for bilateral hernia was less with laparoscopic hernia repair than open hernia repair. In our study operative time for Lichenstein’s meshplasty was more than Wright D.M. study because most of open surgery in our study were done in teaching institute.

Table 3: Post-operative hospital stay

Post-operative	Lichenstein’s		Laparoscopic Repair
hospital stay	Meshplasty Group		Group
	Wilson study	Present Study	Wilson Study	Present Study
Mean stay in days	2	5.26	1	3.53

The mean hospital stay in Lichenstein’s meshplasty was 5.26 days and in Laparoscopic group was 3.53 days in our study. Mean hospital stay in Lichenstein’s meshplasty was 2 days and laparoscopic group was 1 day in M.S. Wilson study group. From this we can assess that laparoscopic hernia repair group had less post-operative stay than open hernia repair in our study.

Table 4: Recurrence in hernia

Recurrence in our study				Recurrence in Douek et. al study
Lichenstein’s Meshplasty Group		Laparoscopic Repair Group		Lichenstein’s Meshplasty Group		Laparoscopic Repair Group
No. of	%	No. of	%	No. of	%	No. of	%
Patients		Patients		patients		patients
1	3.33	1	3.33	1	3.33	1	3.33

Thus there are similar recurrence rate after Lichenstein’s meshplasty and Laparoscopic hernia repair. In our study it was 1/33 i.e. 3.33% which was similar to that of Douek et. al study.

CONCLUSION

Our comparative study of Lichenstein’s meshplasty and laparoscopic hernia repair revealed following :

Mean operative time was more in laparoscopic hernia repair than Lichenstein’s meshplasty repair.
In laparoscopic group there was less post-operative pain as compared with Lichenstein’s meshplasty on post-operative day 1, 3 and 7.
Post-operative stay in laparoscopic groups was less than Lichenstein’s meshplasty. Thus in conclusion, both Lichenstein’s meshplasty and laparoscopic (TAPP/TEP) hernia repair has advantages and disadvantages for patients. Depending on local resource and infrastructure and expertise, both methods can be used and recommended for inguinal as well as for recurrent and bilateral hernias.
Laparoscopic repairs seems to be the better choice if feasible for bilateral hernia repair because it is less painful and more cosmetic with less hospital stay as compared to open bilateral Lichenstein’s meshplasty repair.
Lichenstein’s meshplasty done meticulously with good technique still proves to be the good option for laparoscopic repair if laparoscopic repair cannot be done due to any reason.
Recurrent hernia repair to be done laparoscopically is difficult and technically demanding procedure. Lichenstein’s meshplasty could be the option for recurrent hernia repair. Laparoscopy is the better option for recurrent inguinal hernia repair.

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