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Year : 2019  |  Volume : 7  |  Issue : 4  |  Page : 148-153

Lichtenstein repair using lightweight mesh versus laparoscopic total extraperitoneal repair using polypropylene mesh in patients with inguinal hernia: A randomized study

Department of Surgery, Government Medical College and Hospital, Chandigarh, India

Date of Submission15-Jun-2019
Date of Acceptance16-Sep-2019
Date of Web Publication12-Dec-2019

Correspondence Address:
Sanjay Gupta
Department of Surgery, Government Medical College and Hospital, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ssj.ssj_27_19

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Background: With the introduction of mesh for repair of inguinal hernia, the focus of surgeons has shifted to postoperative pain and quality of life (QOL). As compared to open procedures, laparoscopic procedures have been found to be associated with less pain and faster recovery. The present study was designed to assess whether this holds true when open Lichtenstein repair is done using lightweight mesh (LWM) because, in previous studies where laparoscopic inguinal hernia repair is compared to open Lichtenstein repair, heavyweight mesh (HWM) was used for both techniques. HWM was used for total extraperitoneal (TEP) in the current study because of higher recurrence associated with LWM.
Materials and Methods: This prospective randomized study was done on 60 patients divided into two groups: the Lichtenstein group and the TEP group. Patients were followed at 1 week, 1 month, and 6 months for any postoperative complication. QOL was assessed using hernia-specific Carolinas Comfort Scale.
Results: No statistically significant difference was observed between the two groups with regard to various postoperative complications. Only one recurrence was detected at 1 month in TEP group. The mean groin pain was significantly less in TEP group at 24 h, 1 week, and 1 month (P < 0.05). The sensation of mesh was significantly less in Lichtenstein group at 24 h and 1 week (P ≤ 0.001) but comparable to TEP at 1 month and 6 months. The difference in movement limitation was not significant at any time between the two groups.
Conclusion: Except for less pain in the early postoperative period TEP does not offer any advantage and Lichtenstein repair using LWM can still be considered as the best option for inguinal hernia repair, especially in countries where resources are limited.

Keywords: Hernia, inguinal, Lichtenstein, quality of life, total extraperitoneal

How to cite this article:
Gupta S, Goyal S, Sharma R, Attri AK. Lichtenstein repair using lightweight mesh versus laparoscopic total extraperitoneal repair using polypropylene mesh in patients with inguinal hernia: A randomized study. Saudi Surg J 2019;7:148-53

How to cite this URL:
Gupta S, Goyal S, Sharma R, Attri AK. Lichtenstein repair using lightweight mesh versus laparoscopic total extraperitoneal repair using polypropylene mesh in patients with inguinal hernia: A randomized study. Saudi Surg J [serial online] 2019 [cited 2022 Dec 3];7:148-53. Available from: https://www.saudisurgj.org/text.asp?2019/7/4/148/272847

  Introduction Top

Inguinal hernia surgery is one of the most commonly performed procedure by general surgeons, but the debate on ideal technique is yet to resolve. Earlier inguinal hernia repairs were assessed on the basis of recurrence. The recurrence rate associated with nonmesh repair was up to 15%. With the introduction of mesh, this recurrence rate dropped significantly and irrespective of the technique, open or laparoscopic, reported recurrence rate with mesh is 2%–3%.[1] Although the use of mesh has decreased the recurrence rate, it is found to be associated with increased incidence of chronic groin pain, foreign body sensation, and limitation in physical activity. The incidence of chronic pain after mesh repair varies from 10%–30% to 2%–20% of these patients experience limitations in their daily activities.[2] Therefore, more recently attention has shifted to quality of life (QOL) and postoperative pain after hernia surgery repair. Different techniques using different types of meshes were thus compared to address this issue.

In patients treated with open Lichtenstein's repair, it is found that lightweight mesh (LWM) is associated with less postoperative pain with comparable recurrence rate to heavyweight mesh (HWM).[3] LWM is thin and has large pore size as compared to conventional polyester or polypropylene HWM. LWM initiates less foreign body reactions and is found to be better biocompatible as compared to HWM.

Among the laparoscopic repairs, total extraperitoneal (TEP) repair is preferred over transabdominal preperitoneal repair (TAPP) as the peritoneal cavity is not entered; and thus, it reduces the chances of visceral injury, adhesion formation, and development of port site hernia. In terms of mesh, recent studies have shown that LWM in TEP does offer any additional benefit over HWM as far as postoperative pain and QOL is concerned, and the recurrence rate is higher with LWM. Therefore, HWM is the preferred choice for TEP repair.[4]

In comparison to laparoscopic TEP repair, Lichtenstein is found to be inferior in terms of postoperative pain and return to normal activity. However, in most of the identified randomized controlled trials (RCTs), where Lichtenstein is compared to TEP, HWM was used for both the techniques [Table 1].[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] The present study was, therefore, designed to find whether this also holds true when Lichtenstein using LWM is compared to laparoscopic TEP repair using HWM.
Table 1: Lichtenstein versus total extraperitoneal trials

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  Materials and Methods Top

The study was conducted in the Department of General Surgery, Government Medical College, and Hospital Chandigarh from 2016 to 2018. Patients over 18 years of age undergoing elective unilateral inguinal hernia repair were included in the study. Patients with bilateral hernia, complete hernia, recurrent hernia, strangulated hernias, prior lower abdominal surgery, and prior radiation exposure to lower abdomen were excluded from the study.

A total of 60 patients were randomized into one of the two groups: the Lichtenstein group and the TEP group. Randomization was achieved through sealed envelope technique. If a patient did not agree to the procedure after randomization, he was excluded from the study. No blinding was possible owing to different nature of the two procedures. For Lichtenstein repair, poliglecaprone 25/polypropylene LWM (Ultrapro - Ethicon) was used, and for TEP, polypropylene three-dimensional mesh (Bard) was used. A detailed information sheet was entered for each patient which included the informed written consent, demographic details, relevant history pertaining to inguinal hernia, general and local physical examination, routine hematological investigations along with electrocardiograph and chest X-ray. Details regarding the type of procedure performed, type of anesthesia used, type of mesh placed, and duration of postoperative stay were also noted down.

After discharge, patients were followed at 1 week, 1 month, and 6 months. QOL in the postoperative period was assessed by the Carolinas Comfort Scale (CCS) questionnaire, which included the sensation of mesh, pain, and movement limitation with various activities.[15] This questionnaire was filled by the patients at each follow-up. A thorough local examination was performed to look for any seroma, hematoma formation. Status of the wound was examined, and staplers were removed on the 1st follow-up. During the follow-up, patients were also examined for any testicular atrophy, mesh infection, and hernia recurrence.

CCS is a hernia-specific QOL survey. It evaluates the incidence and severity of pain, activity limitation, and mesh sensation in seven different activities, as well as pain and mesh sensation at rest. CCS scores are reported on a 6-point Likert scale – 0: No symptom, 1: Mild but not bothersome symptoms, 2: Mild and bothersome symptoms, 3: Moderate and/daily symptoms, 4: Severe symptoms, and 5: Disabling Symptoms. Maximum scores of 0 (none) or 1 (minimal and not bothersome) were classified as asymptomatic, whereas scores of 2 (minimal but bothersome) or higher were considered symptomatic. To compare each QOL domain, the mean score from all activities corresponding to that domain is calculated. Then the overall mean for a domain is calculated separately for both the groups at various follow-up visits and compared.

Descriptive statistics were used. Data were expressed in terms of mean ± standard deviation. Differences between two groups were determined by Mann–Whitney test and Wilcoxon-signed ranks test. All P < 0.05 was considered statistically significant. The statistical analysis was carried out using IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. (IBM Corp., Armonk, NY).

  Results Top

There was no significant difference in patient and disease characteristics at the time of operation [Table 2]. The mean hospital stay after TEP was 1.56 (range 1–2 days). Nineteen patients were discharged on postoperative day 1 and 11 were discharged after 2nd postoperative day. The mean hospital stay after open repair was 1.46 days (range 1–2 days). Twenty-two patients were discharged on postoperative day 1 and 8 were discharged on the 2nd postoperative day. There was no significant difference in hospital stay between the two groups [Table 3].
Table 2: Baseline characteristics

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Table 3: Postoperative hospital stay

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The peritoneal breach was the only intraoperative complication that occurred in 3 (10%) patients in TEP group. Of the three patients, two were asymptomatic and were discharged at 48 h postoperatively. One patient who was discharged at 48 h came back with the symptoms of abdominal distension and inability to pass stools and flatus on the 5-postoperative day. Abdominal X rays showed multiple air-fluid levels suggesting acute intestinal obstruction [Figure 1]. He was kept nil per oral and Ryle's tube drainage, but symptoms did not relieve. On exploratory laparotomy, loop of bowel was found herniating through the peritoneal defect. No intraoperative complication was seen in the Lichtenstein group.
Figure 1: Plain X-ray of total extraperitoneal patient showing multiple air-fluid levels

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No statistically significant difference was observed between the two groups with regard to various postoperative complications such as seroma, hematoma, wound infection, and testicular atrophy at follow-up visits. However, one recurrence was detected at 1 month in TEP group.

Quality of life

QOL was assessed using CCS. Of 30 patients included in TEP using HWM, 2 were excluded from the study as 1 patient developed intestinal obstruction on 5th postoperative day and underwent emergency laparotomy and the other had hernia recurrence at 1 month. Further, one patient in Lichtenstein using LWM did not respond after 1 month and one patient in TEP using HWM did not responded at 6-month period. Only 23 patients who underwent TEP and 22 patients who underwent Lichtenstein repair could respond to “sensation of mesh” questionnaire as others were unable to understand what is being asked.

The mean groin pain at any point of time was less in TEP group than Liechtenstein group. The difference was significant at 24 h and 1 week and 1 month. The sensation of mesh was less in Lichtenstein using LWM as compared to TEP using HWM. This was statistically significant at 24 h and 1 week postoperatively. Movement limitation in TEP using HWM was less than Lichtenstein using LWM. This was not statistically significant at any time. The overall QOL was better in TEP using HWM than Lichtenstein using LWM. This was statistically significant only at 1-week postoperative period [Table 4] and [Figure 2].
Table 4: Carolinas Comfort Scale outcome

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Figure 2: Overall quality of life on Carolinas Comfort Scale

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  Discussion Top

Tension-free mesh repair is now the standard technique for adult inguinal hernia. The recurrence rate after mesh repair is as low as 0.3%–2.2%. As a result, nowadays, the area of interest in hernia surgery has shifted to postoperative pain and QOL. With the introduction of TEP and TAPP for repair of inguinal hernias, various studies have revealed that laparoscopic repairs are associated with less postoperative pain and complications as compared to open procedures. However, at the same time, there are reports in the literature which have questioned the superiority of minimally invasive procedures over open procedures. A recent meta-analysis of thirteen RCTs, including 3279 patients, comparing Lichtenstein and TEP in the treatment of inguinal hernias concluded that there is insufficient evidence to determine the greater effectiveness between TEP and Lichtenstein mesh techniques.[16]

The present study was designed to provide further insight into this area of research and to contribute a little to existing literature. The aim of this was to compare the best available open hernia repair technique with the best available laparoscopic technique. LWM was used for Lichtenstein repair, as LWM is associated with less chronic pain, groin stiffness, and foreign body sensation as compared to HWM. For TEP, HWM was used because various studies have found that LWM increases recurrence rate. Recently concluded RCT (TULP trial), in which lightweight (Ultrapro) was compared to heavyweight (Prolene), also found that use of LWM in laparoscopic inguinal repair is associated with statistically higher recurrence rate and does not offer any additional benefit in terms of postoperative pain.[4]

In our study, both the groups were comparable in terms of the patient demographics and no significant difference in the intraoperative complications was observed between two groups. The peritoneal breach was the only intraoperative complication that was encountered in TEP group. Subsequently, one of these patients presented with intestinal obstruction due to herniation of loop of bowel through peritoneal rent. A similar experience was reported by Andersson et al. in their study, where one patient who underwent TEP hernia repair presented with small bowel obstruction 3 days after surgery due to herniation.[8] Complex anatomy and presence of vital structures in the preperitoneal space predispose TEP to serious complications such as vascular injury, urinary bladder, or intestinal perforation. However, with gain in experience the incidence of these complications can be brought down significantly and comparable to open hernia repair. Gokalp et al. in their study found that there was no significant difference in terms of incidence of intraoperative complications in the two groups.[7] Lau et al. found similar results with only a few minor complications occurring in either surgical group. No major complication such as visceral injury or intestinal obstruction occurred.[9] Various postoperative complications such as urinary retention, constipation, seroma formation, hematoma, and wound infection were similar among both the groups. This is comparable to the results of various other RCTs.

In terms of hospital stay, one can presume that laparoscopic procedures shorten the hospital stay. However, nowadays, even open hernia repairs are done on daycare basis in most of the centers. We also observed that the patient who underwent Lichtenstein repair using LWM repair had a comparable length of hospital stay (1.46 days) to TEP using HWM (1.56 days), with no statistical difference.

To assess QOL after mesh hernioplasty, hernia-specific instrument, i.e., CCS is found to be a useful tool to effectively understand how surgical repair with mesh will affect patient QOL. It was developed by physician and researchers from Carolina laparoscopic and advanced surgery program, to monitor QOL in patients undergoing hernia repair. It measures the severity of pain, mesh sensation, and movement limitations during various day-to-day activities. In our study, almost all patients could make the components of CCS, except that 13 patients (25%) were unable to make out the difference between pain and sensation of mesh. Various other studies have also shown that CCS is feasible, easy to use with high acceptance rate in patients undergoing hernia repair with mesh.[17]

The overall reported incidence of chronic pain after herniorrhaphy is 12%; 18% in patients who undergo open surgery and 6% in patients who are treated laparoscopically.[18] The International Association for the Study of Pain has defined this chronic pain as pain lasting for longer than 3-month postoperatively.[19] The EU Hernia Trialists Collaboration review of 2003 patients treated by laparoscopic or open mesh repair showed that a significantly smaller number of laparoscopically treated patients developed a chronic pain state.[20] The Cochrane review on laparoscopic versus open inguinal hernia repairs reviewed 41 published reports of eligible trials that involved 7,161 participants and showed that there was less persistent pain (290/2,101 vs. 459/2,399) in the laparoscopic groups.[21] In our study, the mean groin pain was less in TEP using HWM as compared to Lichtenstein using LWM, at 24 h, 1 week, and 1 month postoperatively, and it was statistically significant. However, chronic pain was comparable in both the groups at 6 months' period. This could be attributed to the fact that LW mesh used in Lichtenstein was associated with less scar tissue formation and less chronic inflammatory reaction. Consequently, the advantages of laparoscopic surgery on chronic pain were nullified by the usage of LWM in Lichtenstein group.

The sensation of mesh was significantly low in Lichtenstein group using LWM as compared to TEP using HWM in the immediate postoperative period (24 h and at 1 week). The sensation of mesh at 1-month and 6-month period was less in Liechtenstein group using LWM as compared to TEP using HWM but not statistically significant. A plausible explanation to this fact could be that due to decreased groin pain in TEP group, patients focused more on the sensation of mesh whereas in Lichtenstein group due to more pain, patients paid less attention to foreign body sensation in early postoperative period. At 1 month and 6 months, when pain had reduced in both the groups, the sensation of mesh was comparable in both the groups. The difference in movement limitation with TEP group using HWM and Lichtenstein using LWM was not statistically significant at any time. This is contrast to other studies which reported more sensibility disorder and movement restriction following Lichtenstein repair with polypropylene mesh.[22]

It was thus observed that apart for less pain in the early postoperative period, TEP does not offer any additional benefit over Lichtenstein repair using LWM. Moreover, TEP is associated with certain disadvantages. The operative time and cost involved with TEP is significantly higher as compared to Lichtenstein repair.[7] Furthermore, there is a long learning curve for TEP as compared to Lichtenstein repair. The reported learning curve for TEP is between 30 and 250 surgeries. Neumayer et al. found higher recurrence rate (>10%) for surgeons who have performed less than 250 procedures.[23] Therefore, authors are of the opinion that Lichtenstein repair using LWM is good option for repair of uncomplicated inguinal hernia, particularly in developing nations where resources are limited.

  Conclusion Top

The results of Lichtenstein technique for repair of inguinal hernia using LWM are comparable to laparoscopic TEP repair. Apart from less pain in the early postoperative period TEP repair do not offer any other benefit. However, large multicentered randomized trials are needed to further substantiate this fact, as a number of cases in the present study were small.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Schouten N, van Dalen T, Smakman N, Elias SG, Clevers GJ, Verleisdonk EJ, et al. The effect of ultrapro or prolene mesh on postoperative pain and well-being following endoscopic totally extraperitoneal (TEP) hernia repair (TULP): Study protocol for a randomized controlled trial. Trials 2012;13:76.  Back to cited text no. 2
Sajid MS, Leaver C, Baig MK, Sains P. Systematic review and meta-analysis of the use of lightweight versus heavyweight mesh in open inguinal hernia repair. Br J Surg 2012;99:29-37.  Back to cited text no. 3
Burgmans JP, Voorbrood CE, Simmermacher RK, Schouten N, Smakman N, Clevers G, et al. Long-term results of a randomized double-blinded prospective trial of a lightweight (Ultrapro) versus a heavyweight mesh (Prolene) in laparoscopic total extraperitoneal inguinal hernia repair (TULP-trial). Ann Surg 2016;263:862-6.  Back to cited text no. 4
Heikkinen TJ, Haukipuro K, Koivukangas P, Hulkko A. A prospective randomized outcome and cost comparison of totally extraperitoneal endoscopic hernioplasty versus Lichtenstein hernia operation among employed patients. Surg Laparosc Endosc 1998;8:338-44.  Back to cited text no. 5
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Gokalp A, Inal M, Maralcan G, Baskonus I. A prospective randomized study of Lichtenstein open tension-free versus laparoscopic totally extraperitoneal techniques for inguinal hernia repair. Acta Chir Belg 2003;103:502-6.  Back to cited text no. 7
Andersson B, Hallén M, Leveau P, Bergenfelz A, Westerdahl J. Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: A prospective randomized controlled trial. Surgery 2003;133:464-72.  Back to cited text no. 8
Lau H, Patil NG, Yuen WK. Day-case endoscopic totally extraperitoneal inguinal hernioplasty versus open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males: A randomized trial. Surg Endosc 2006;20:76-81.  Back to cited text no. 9
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. 10
Vidović D, Kirac I, Glavan E, Filipović-Cugura J, Ledinsky M, Bekavac-Beslin M. Laparoscopic totally extraperitoneal hernia repair versus open Lichtenstein hernia repair: Results and complications. J Laparoendosc Adv Surg Tech A 2007;17:585-90.  Back to cited text no. 11
Langeveld HR, van't Riet M, Weidema WF, Stassen LP, Steyerberg EW, Lange J, et al. Total extraperitoneal inguinal hernia repair compared with Lichtenstein the LEVEL-trial: A randomized controlled trial. Ann Surg 2010;251:819-24.  Back to cited text no. 12
Wang WJ, Chen JZ, Fang Q, Li JF, Jin PF, Li ZT, et al. Comparison of the effects of laparoscopic hernia repair and Lichtenstein tension-free hernia repair. J Laparoendosc Adv Surg Tech A 2013;23:301-5.  Back to cited text no. 13
Dhankhar DS, Sharma N, Mishra T, Kaur N, Singh S, Gupta S. Totally extraperitoneal repair under general anesthesia versus Lichtenstein repair under local anesthesia for unilateral inguinal hernia: A prospective randomized controlled trial. Surg Endosc 2014;28:996-1002.  Back to cited text no. 14
Yeo AE, Berney CR. Carolinas comfort scale for mesh repair of inguinal hernia. ANZ J Surg 2012;82:285-6.  Back to cited text no. 15
Bobo Z, Nan W, Qin Q, Tao W, Jianguo L, Xianli H, et al. Meta-analysis of randomized controlled trials comparing Lichtenstein and totally extraperitoneal laparoscopic hernioplasty in treatment of inguinal hernias. J Surg Res 2014;192:409-20.  Back to cited text no. 16
Jalil O, Rowlands C, Ruddle A, Hassn A, Morcous P. Medium-term recurrence and quality of life assessment using the hernia-specific carolinas comfort scale following laparoscopic inguinal hernia repair. J Laparoendosc Adv Surg Tech A 2015;25:477-80.  Back to cited text no. 17
Aasvang E, Kehlet H. Chronic postoperative pain: The case of inguinal herniorrhaphy. Br J Anaesth 2005;95:69-76.  Back to cited text no. 18
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EU Hernia Trialists Collaboration. Repair of groin hernia with synthetic mesh: Meta-analysis of randomized controlled trials. Ann Surg 2002;235:322-32.  Back to cited text no. 20
McCormack K, Scott NW, Go PM, Ross S, Grant AM; EU Hernia Trialists Collaboration. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2003;(1):CD001785.  Back to cited text no. 21
Eker HH, Langeveld HR, Klitsie PJ, van't Riet M, Stassen LP, Weidema WF, et al. Randomized clinical trial of total extraperitoneal inguinal hernioplasty vs. Lichtenstein repair: A long-term follow-up study. Arch Surg 2012;147:256-60.  Back to cited text no. 22
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. 23


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

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