Hernia (2010) 14:357360 DOI 10.

1007/s10029-010-0663-2

O R I G I N A L A R T I CL E

Lichtenstein or darn procedure in inguinal hernia repair: a prospective randomized comparative study
H. F. Kucuk H. E. Sikar N. Kurt H. Uzun M. Eser F. Tutal Y. Tuncer

Received: 19 August 2009 / Accepted: 9 April 2010 / Published online: 12 May 2010 Springer-Verlag 2010

Abstract Background The aim of this study was to assess the outcome of patients with inguinal hernia where the Moloney darn or Lichtenstein procedure was used as the surgical choice. Method A herniorrhaphy procedure was performed in a total of 306 patients at our clinic between January 2003 and December 2008. The duration of operations and complication and recurrent rates were compared between the two groups. Hematoma formation, seroma collection, and wound infection were accepted as early complications, whereas chronic pain, loss of sensation at the operation site, and the rejection of mesh were accepted as late complications. Results Considering early complications as hematoma formation, the accumulation of seroma and wound infection ratios were similar in the two groups. Loss of sensation at the operation site and chronic pain, which were classiWed as late complications, were similar in the groups. However, in considering rejection, there were three rejections in the group where mesh was used. Conclusion The darn repair method is simple, safe, and has similar recurrence rates when compared to the Lichtenstein method in inguinal hernia patients. Keywords Inguinal hernia Moloney darn repair Lichtenstein repair Recurrence rate

Introduction Inguinal hernia repairs can be performed conventionally or laparoscopically by using diVerent methods. The purposes of these methods are obtaining lower recurrent rates, better pain-free postoperative periods, and shorter convalescence periods [1]. The recurrence rate of traditional sutured hernia repair techniques is reported to be between 0.7 and 9.3% [2]. On the other hand, the recurrence rate of tension-free mesh repair is less than 1% [3]. The darn repair, originally described by Moloney [4], is another tension-free repair method. Mesh repair either conventionally or laparoscopically is more popular than the tension-free method, but it is more expensive and can cause many complications that cause removal of the mesh as a result [1]. In this study, we compared the results of the Lichtenstein procedure with the darn repair technique.

Materials and methods This prospective comparative study was performed at our surgical clinic between January 2003 and December 2008. The study included 306 patients with inguinal hernia, which were divided into two groups. Group I included 176 patients and darn repair was performed. Group II included 130 patients and Lichtenstein procedure was performed as the hernia repair method. The patients had inguinal hernia as a primary disease and recurrent hernia and incarcerated hernias were not included. Patients were randomly chosen. Informed consent from all of the patients was obtained. The operations were performed by four surgeons who were experienced in hernia repair or were performed under the control of these surgeons.

H. F. Kucuk (&) H. E. Sikar N. Kurt H. Uzun M. Eser F. Tutal Y. Tuncer Kartal Research and Education Hospital, Petrol-is mh. Sh. Dursun Bakan Sk. Hilal Sit. A Blok D:21, 34862 Kartal, Istanbul, Turkey e-mail: hasan.kucuk@sbkeah.gov.tr

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Our darn method was performed by suturing between the inguinal ligament and fascia of the internal oblique muscle fascia by using O monoWlament polyprolene suture. The Wrst suture began at the medial site from the pubic tubercle and continued to the site of the internal inguinal ring. After placing the Wrst suture, a second suture was done 1 cm forward and was continued between the inguinal ligament and the internal oblique muscle fascia (Fig. 1). The sensory nerves were preserved in all cases with gentle tissue handling, gentle dissection, meticulous hemostasis, and avoidance of extensive thermal injury. We used a 7.5 15-cm polypropylene mesh in Group II. The mesh was positioned on the inguinal Xoor between the inguinal ligament and the internal oblique muscle fascia. The meshes were provided by our institution and originated from diVerent companies. The duration of operations and complication and recurrent rates were compared between the two groups. Hematoma formation, seroma collection, and wound infection were accepted as early complications, whereas chronic pain, loss of sensation at the operation site, and the rejection of mesh and recurrence 6 months after the operation were accepted as late complications. Rejection was accepted in the presence of redness of the operative site and discharge from the wound and the absence of bacterial growth in culturing studies. Before obtaining the results of culturing studies, a sultamicillin 750 mg tablet twice a day was prescribed for 10 days. The patients were observed for about 2 months. In the secondary operation, the mesh was not attached to surrounding tissue, as it was excluded from the body and was removed. Wound infection was deWned purulent discharge or the presence of microorganisms which were present in culture studies in any discharge. Chronic pain was deWned as the continuation of pain after 2 months which required painkillers. The ultrasonographic examination was performed in the presence of complications such as hematoma formation, seroma collection,

wound infection, or suspicion of recurrence during physical examination. The data were collected postoperatively after the 1st week, 1st, 3rd, 6th, and 12th month, and 2nd and 3rd year, or at any time which the patients needed admission due to any of the problems deWned above. The data were assessed with SPSS 10.0. The statistical analyses were done using the unpaired t-test and the Chi-square test.

Results The number of patients in group I was 176 and there were 130 patients in group II. The mean age, follow-up time, operation time, sex distribution, side of hernia, and type of hernia between groups were similar. The demographic Wndings are shown in Table 1. Considering early complications such as hematoma formation, accumulation of seroma, and wound infection, the ratios were similar in the two groups. Loss of sensation at the operation site and chronic pain, which were classiWed as late complications, were also similar in the groups. However, in considering rejection, there were three rejections in the group in which mesh was used. The rejection times were 6, 7, and 13 months after the operations, respectively. Complications after inguinal hernia operation are shown in Table 2.

Discussion Many types of operative management have been described in the repair of inguinal hernias and much clinical investigation has been performed. The anterior approach, posterior approach, laparoscopic, and open operations have been research. Anterior repair methods are the most common and tension-free repairs are now standard procedures. The aims of all these types of operations are to obtain lower recurrence rates, lower complication rates, earlier return to daily activities, and cost-eVectiveness [1]. Tension in a repair method is the principal cause of recurrence [5]. Using mesh as a prosthetic material has been described by Lichtenstein in the repair of inguinal hernia and is a tension-free method and has become very popular [6]. The darn method using nylon suture described by Moloney is also a tension-free method. We compared the complication and the recurrence rates of both repair procedures in this study. There was no diVerence between the two groups considering early complications such as hematoma formation, seroma formation, and wound infection. Also, there was no diVerence when considering late complications such as sensory loss at the operation site and chronic pain. Rejection was detected in three of our patients where the Lichtenstein method was used. The Wndings in

Fig. 1 Picture of darn method between the inguinal ligament and the internal oblique muscle fascia

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Hernia (2010) 14:357360 Table 1 Demographic data of the patients n = 306 Mean age (years) SD Mean follow-up time (months) SD Mean operation time (min) SD* Sex (male/female) Side of hernia (right/left/bilateral) Type of hernia (indirect/direct/pantaloon) Group I (n = 176) 53.82 17.37 24.63 13.65 44.83 4.49 146/30 (83%/17%) 73/82/21 101/58/17 Group II (n = 130) 51.96 16.17 23.23 12.65 44.80 4.69 102/28 (78.5%/21.5%) 53/55/22 73/45/12 P-value

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NS (0.339)a NS (0.359)b NS (0.947)c NS (0.322) NSd NSe

NS not signiWcant; Group I: darn repair; Group II: Lichtenstein repair * Two surgeons performed bilateral hernia repair at the same time a t = 0.957 b t = 0.918 c t = 0.066 d P = 0.901/0.456/0.214 e P = 0.830/0.761/0.899 Table 2 Early and late postoperative complications after inguinal hernia repair n = 306 Group I (n = 176) Group II (n = 130) P-value

Early Hematoma Seroma Wound infection Late Sensory loss Chronic pain Rejection 1 (0.6%) 1 (0.6%) 0 (0%) 1 (0.8%) 0 (0%) 3 (2.3%) NS (0.829) NS (0.389) 0.043 2 (1.1%) 3 (1.7%) 9 (5.1%) 0 (0%) 3 (2.3%) 7 (5.4%) NS (0.223) NS (0.707) NS (0.916)

NS not signiWcant; Group I: darn repair; Group II: Lichtenstein repair

these patients were similar to the Wndings in the study of Hofbauer et al. [7]. The rejection can be due to chronic foreign body reactions of the prosthesis used in the surgery. Wang et al. [8] suggested that host versus mesh reaction is the cause of rejection. Koukourou et al. [9] compared polyprolene mesh with the nylon darn hernia repair method and they observed an early complication rate of 28% in the mesh group versus 33% in the darn group and, also, the late complication rates were 15 and 20% in mesh and darn groups, respectively; there was no statistically signiWcant diVerence between the groups. The recurrence rates were similar after 1 year, being 4%. The mean follow-up times were 24.63 13.65 and 23.23 12.65 months in the darn group and Lichtenstein group, respectively, in our study and there was no recurrence in the groups. Kaynak et al. [10] compared the Lichtenstein hernioplasty and Moloney darn repair methods and concluded that there was no diVerence in the early complication rates and recurrence rates between the two groups. Zeybek et al. [6] used a diVerent modiWed darn method and used supporting sutures through

the side-loop to prevent the rupture of Wbrils. They claim that this method is superior to the original darn method. There was no recurrence in their modiWed darn method and a complication rate of only 1.9%. The duration of operations were also similar between the groups in our study, as in the studies of Zeybek et al. and Kaynak et al. [6, 10]. Recurrence seen 6 months after the surgery was evaluated as late recurrence in our study. Although there is no consensus on this issue, we believe that recurrence within 6 months after the operation may be due to technical insuYciency. There were no recurrences in our patients, as all of the patients had inguinal hernia as a primary disease and recurrent hernia and incarcerated hernias were not included. Both methods were also tension-free. Gentle and meticulous surgery is another reason for decreased recurrence. On the other hand, our mean follow-up time was around 24 months. Bisgaard et al. [11] followed primary Lichtenstein mesh and sutured inguinal repair patients for 8 years and observed that cumulative recurrence was increasing in the mesh group until 5 years postoperatively. In conclusion, the Moloney darn repair method is simple, safe, and has similar recurrence rates when compared to the Lichtenstein method in inguinal hernia patients. On the other hand, in the Lichtenstein method, there is risk of rejection of the mesh which requires its removal as result. Although there are a limited number of similar studies comparing the above-mentioned methods, the Moloney darn repair method can be used in the treatment of primary inguinal hernia.

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