Comparison of Lichtenstein's tension free mesh repair with GPRVS-Stoppa's repair for bilateral inguinal hernia.
Inguinal hernia is one of the most common surgical problem that presents to a surgeon in his outpatient department, making hernia repair one of the most common operations performed by general surgeons. Hernia repair is one of the cornerstones of a general surgery practice.
The word "Hernia" is derived from the Latin word for rupture. A hernia [1,2] is defined as a protrusion of a viscus or a part of viscus through an abnormal opening in the walls of its containing cavity. 
Since the mid 1980's dramatic progress has been made in the evolution of hernia surgery, [4,5,6] by the increasing use of prosthetic mesh. There are various methods in the placement of prosthetic mesh in hernioplasty. 
The concept of avoiding tension by onlay mesh repair was championed by Lichtenstein. Lichtenstein theorised that by using a mesh prosthesis to bridge the hernia defect rather than closing it with sutures tension is avoided, ostensibly resulting in a less painful operation. Now Lichtenstein's tension free mesh repair  is considered as Gold standard for hernia surgery.
The preperitoneal space [9,10] can also be used for repair of an inguinal hernia, because of the mechanical advantage gained from prosthesis placement behind the abdominal wall. Giant Prosthetic Reinforcement of the Visceral Sac is one of the technique in the field of hernia surgery introduced by Stoppa RE in 1989. In this innovative technique, Stoppa used polyester Dacron for bilateral preperitoneal prosthetic hernia repair.
In this study, I have used prosthetic mesh of prolene for the repair of bilateral inguinal hernia by Stoppa's technique and have compared the morbidity and results of various Lichtenstein's repair with that of Stoppa's technique.
Aim of Study
To compare the advantages and disadvantages of GPRVSStoppa's hernia repair with Lichtenstein's repair for bilateral hernia, which includes-
* Operating time.
* Postoperative complications.
* Duration of hospital stay.
* Days taken to return to normal activity.
* Days taken to return for work.
* Early recurrence.
* Chronic groin pain.
Comparative observational study.
Duration of Study
12 Months (February 2014 to February 2015).
The average number of patients being admitted in one surgical unit for elective bilateral hernia repair per year was fifty. Hence, the sample size was selected as fifty.
1. Patients admitted in the Department of General Surgery in Govt. T.D. Medical College Hospital diagnosed to have bilateral inguinal hernia giving consent to participate in the study were included.
2. Patients admitted with recurrent inguinal hernia following surgical repair.
1. Irreducible or obstructed hernia.
2. Congenital inguinal hernia.
All patients who presented with uncomplicated bilateral direct inguinal hernia were included in the study. Patients are allocated to two groups. Patients were allocated to two groups randomly; patients admitted on Wednesday were allocated to the Stoppa group and patients admitted on Fridays were allocated to the Lichtenstein's group. The inclusion into the study was done after explaining the purpose and procedure of the study and after obtaining informed consent from the patients. The two groups of patients were comparable in age, body weight index, comorbidities, size and type of hernia. Informed consent was obtained from patients.
Preoperative investigations include Hb, TC, DC, platelet count, ESR, chest and abdomen x-ray, RBS, S. Electrolytes, ECG, viral markers.
All patients are empirically started on broad-spectrum antibiotic cefotaxime 1 gm at induction of anaesthesia followed by definitive surgery either Lichtenstein or GPRVS-Stoppa's hernia repair. Mesh used in both methods of repair is polypropylene mesh. Due to non-availability of Dacron mesh in our centre, we have used prolene mesh for repair.
Operating time for primary hernia and recurrent hernia was compared in this study. During post-operative period the incidence of haematoma, wound infection, sinus formations and rejection of mesh were compared in both groups of patients.
Duration of hospital stay, days taken for return to normal activity and return to work were also compared in each group. In all cases on review, we have examined for early recurrence of hernia formation.
Statistical methods and analysis.
Data was consolidated and organised into graphs and tables using Microsoft Excel.
Qualitative variables were compared using Chi square test and Fisher exact test.
Quantitative variables were compared using unpaired t-test.
Observation and Analysis
Total number of cases studied- 50.
26 cases underwent Lichtenstein's Hernia repair.
24 cases underwent GPRVS repair.
All were males.
With Lichtenstein 5/26 (19.23%) developed haematoma, whereas only 2/24 (8.33%) developed haematoma in GPRVS group. (P > 0.005 using Fisher Exact statistic).
Immediate Postoperative Pain
* Scoring of postoperative pain.
* Numerical scale.
* 0--no pain.
* 10--Maximum possible pain.
* Severe pain is defined as score of more than five.
* Mean visual analogue scale pain in Lichtenstein is 3.74.
* Mean visual analogue scale pain in GPRVS is 4.79.
There is no statistically significant difference in immediate postoperative pain.
[x.sup.2] = 1.845, df = 1, p = 0.174
P-value > 0.05.
No statistically significant difference in incidence of surgical site infection in either groups.
Rejection of Mesh
None of the cases developed rejection of mesh with either Lichtenstein or GPRVS technique.
Chronic Groin Pain
Chronic groin pain is that pain, which lasts for more than 3 months.
That pain which lasts for more than 1 month after the usual time that is required for an insult to heal.
P > 0.05
This difference was found to be statistically insignificant.
None of the cases developed early recurrence with GPRVS technique, whereas with Lichtenstein technique one patient developed recurrence. (P-value > 0.05).
There is no statistically significant difference in hospital stay in both groups.
T-value: 3.015; P-value: 0.0041.
There is statistically significant difference in number of days taken for return to normal activity between the two groups. GPRVS took more days for returning to normal activity compared to Lichtenstein hernia repair.
T-value: 3.532; P- value: 0.0009.
There is statistically significant difference in number of days taken for return to work between the two groups. Lichtenstein took more days for returning to work compared to GPRVS hernia repair.
In analysing the variables, Chi-Square test was used. A P-value of less than 0.05 will be considered to be statistically significant and a P value of more than 0.05 will not be found to be statistically significant.
The present study was designed primarily to provide an answer to the question of whether preperitoneal prosthetic placement is better tolerated in bilateral inguinal hernia than subaponeurotic positioning. Secondary end points were other early and late complications; there was no statistically significant difference between two study groups in terms of demographic or type of hernia.
Out of the total 50, 26 patients underwent Lichtenstein repair and 24 patients underwent GPRVS repair. All the patients were males. Average age of patients were 53.7 in GPRVS series and 58.9 in Lichtenstein series.
Even though Stoppa introduced the giant prosthetic reinforcement of visceral sac with polyester Dacron mesh, we used prolene mesh for GPRVS repair because of non-availability of Dacron mesh in our centre. The prolene mesh of correct shape and size was placed in preperitoneal space.
The average duration of illness were 1.8 years in GPRVS and 2 years in Lichtenstein. Both groups are comparable on duration of illness; 18 patients in Lichtenstein group were smokers and 15 patients in GPRVS group were smokers. The relationship between smoking and hernia formation as well as recurrence was first reported in 1981 and further research has identified proteolytic enzymes that may degrade the connective tissue components. In our study the average time for surgery was comparable in both groups, but in recurrent inguinal hernia GPRVS duration of operating time, postoperative complications and recurrence rate were significantly less as compared to Lichtenstein repair.
There were 2 haematomas in GPRVS and 5 in Lichtenstein hernia repair. All haematomas were managed conservatively. The higher incidence in Lichtenstein may be due to increased dissection and mesh fixing sutures in the more vascular subaponeurotic plane compared to relatively avascular preperitoneal space. No statistically significant difference between immediate postoperative pain in two groups. The increased immediate postoperative pain in Lichtenstein group can be attributed to more dissection and sutures in the subaponeurotic neurovascular plane. There were no serious surgical site infection in either group, which required removal of mesh.
There were 3 cases of chronic groin pain reported in Lichtenstein group compared to none in GPRVS. This difference was found to be statistically insignificant. Increased incidence of chronic groin pain in Lichtenstein group may be due to the increased dissection in subaponeurotic neurovascular plane and also due to constant contact and impingement of the nerves with the mesh. The ilioinguinal and the iliohypogastric nerves are generally injured during the elevation of the external oblique fascial flaps for fixation of mesh, while the genitofemoral nerve is most likely to be injured during the isolation of the cord and stripping of the cremasteric muscle fibres in Lichtenstein repair. While taking the bites for fixing the polypropylene mesh, the nerves may be injured accounting for the increased incidence of inguinal pain.
There is no obvious difference in recurrence rates and there was no significant difference in duration of hospital days, but number of days taken to return to normal activities is more for Stoppa's repair and for return to previous work is more for Lichtenstein repair. Thus, the present study along with previous data indicates that there is no just one right way to cure inguinal herniation. At present time, both deep and superficial prosthetic placements are satisfactory and each technique carries its own advantages and disadvantages to both patient and surgeon.
* Giant prosthetic reinforcement of the visceral sacStoppa's repair is a good alternative to Lichtenstein's repair for primary bilateral inguinal hernia.
* Giant prosthetic reinforcement of the visceral sac is far superior to Lichtenstein repair for recurrent inguinal hernia.
* Time taken to return to normal activity is more for Stoppa's repair and time taken to return to normal activity and chronic groin pain is more for Lichtenstein's hernia repair.
* This work represents the combined effort of a large number of individuals and it is my pleasure to acknowledge those concerned without whom this work would have been impossible.
* I am extremely grateful to Dr. R. V. Ramlal, Associate Professor, Department of General Surgery, Govt. T. D. Medical College, Alappuzha for the support and invaluable suggestions provided at various stages of the study and for all the efforts in facilitating the smooth conduct of the study.
* I am extremely thankful to Dr. N. R. Sajikumar, Additional Professor, Department of General Surgery, Govt. T. D. Medical College, Alappuzha for his zealful and motivating words in conducting this study.
* I express my sincere thanks to Dr. P. Mohandas, Additional Professor, Department of General Surgery, Govt. T. D Medical College, Alappuzha for his valuable advice and support.
* I express my sincere thanks to Dr. Y. Shajahan, Additional Professor, Department of General Surgery, Govt. T. D. Medical College, Alappuzha for his valuable advice and support.
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 Kux M. Anatomy of the groin: a view from the surgeon. In: Fitzgibbons RJ, Greenberg AG. eds. Nyhus and Condon's Hernia. 5th edn. Philadelphia: Lippincolt Williams & Wilkins 2002:45-53.
 Condon RE. The anatomy of the inguinal region and its relation to groin hernia. In: Nyhus LM, Harkins HN. eds. Hernia. 3rd edn. Philadelphia: JB Lippincott 1989.
 Condon RE. The anatomy of the inguinal region and its relation to groin hernia. In: Nyhus LM, Harkins HN. eds. Hernia. 4th edn. Philadelphia: JB Lippincott 1995.
 Lichtenstein IL, Shulman AG, Amid PK, et al. The tension free hernioplasty. Am J Surg 1989; 157(2):188-93.
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Abdul Latheef A (1), R. V. Ramlal (2), Ansar P (3)
(1) Professor and HOD, Department of Surgery, TD Medical College, Alappuzha.
(2) Associate Professor, Department of Surgery, TD Medical College, Alappuzha.
(3) Senior Resident, Department of Surgery, TD Medical College, Alappuzha.
Financial or Other, Competing Interest: None.
Submission 23-02-2016, Peer Review 19-03-2017, Acceptance 25-03-2017, Published 30-03-2017.
Dr. Abdul Latheef A, Professor and HOD, Department of Surgery, TD Medical College, Alapuzha. E-mail: email@example.com
Caption: Figure 5. Early Recurrence
Caption: Figure 6. Duration of Hospital Stay
Table 1. Total Number of Cases N % Lichtenstein 26 52 GPRVS 24 48 Total 50 100 Table 2. Operating Time Types of Mean Operating SD T-value P-value Surgery Time (Minutes) Lichtenstein 103.1 7.4 1.448 0.1540 GPRVS 99.8 8.7 Table 3. Operating Time for Recurrent Hernia Types of Surgery Mean Operating Time (Minutes) Lichtenstein 125.4 GPRVS 104.4 Table 4. Haematoma Haematoma Lichtenstein GPRVS Total N % N % N % Yes 5 19.2 2 8.3 7 14 No 21 80.8 22 91.7 43 86 Total 26 100 24 100 50 100 Table 5. Surgical Site Infection SSI GPRVS Lichtenstein Total N % N % N % Yes 0 0 2 7.7 2 4.1 No 24 100 24 92.3 48 95.9 Total 24 100 26 100 50 100 Table 6. Chronic Groin Pain Chronic Pain GPRVS Lichtenstein Total N % N % N % YES 0 0 3 11.5 3 6.1 NO 24 100 23 88.5 47 93.9 TOTAL 24 100 26 100 50 100 Table 7. Early Recurrence Recurrence GPRVS Lichtenstein Total N % N % N % Yes 0 0 1 3.8 1 2 No 24 100 25 96.2 49 98 Total 24 100 26 100 50 100 Table 8. Duration of Hospital Stay Types of Mean Duration of SD T-value P-value Surgery Hospital Stay Lichtenstein 5.78 6 0.6850 0.4967 GPRVS 7.04 7 Table 9. Number of Days taken for Return to Normal Activity Types of Number of Days taken for T- P- Surgery Return to Normal Activity value value Lichtenstein 9 3.015 0.0041 GPRVS 12 Table 10. Number of Days taken for Work Types of Number of Days T-value P-value Surgery taken for Work Lichtenstein 42 3.532 0.0009 GPRVS 38 Figure 1. Haematoma Absent Present Lichtenstein 80.77% 19.23% GPRVS 91.67%x 8.33% Note: Table made from bar graph. Figure 2. Immediate Postoperative Pain Mean visual analogue scale Lichtenstein 3.74 GPRVS 4.69 Note: Table made from bar graph. Figure 3. Surgical Site Infection Present Absent GPRVS 0 24 Lichtenstein 2 24 Note: Table made from bar graph. Figure 4. Chronic Groin Pain present absent GPRVS 0 24 Lichtenstein 3 23 Note: Table made from bar graph. Figure 7. Number of Days taken for Return to Normal Activity Lichtenste 9 GPRVS 12 Note: Table made from bar graph. Figure 8. Number of Days taken for Work Lie hen stein 42 GPRVS 38 Note: Table made from bar graph.
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|Title Annotation:||Original Research Article|
|Author:||Abdul, Latheef A.; Ramlal, R.V.; Ansar, P.|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Mar 30, 2017|
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