Hernia (2013) 14:357–360
DOI 10.1007/s10029-013-0663-2
ORIGINAL ARTICLE
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 2012 / Accepted: 9 April 2013 / Published online:12 May2013
©Springer-Verlag 2013
Abstract
Background The aim of this study was to assess the out-
come 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 2006
and December 2011. The duration of operations and
complica-tion 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 classifed 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 Lichten-
stein method in inguinal hernia patients.
Keywords Inguinal hernia · Moloney darn repair ·
Lichtenstein repair · Recurrence rate
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
Introduction
Inguinal hernia repairs can be performed conventionally or
laparoscopically by using different 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 2006 and December 2011.
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.
358
Our darn method was performed by suturing between the
inguinal ligament and fascia of the internal oblique muscle
fascia by using O monofilament polyprolene suture. The first
suture began at the medial site from the pubic tubercle and
continued to the site of the internal inguinal ring. After
placing the first suture, a second suture was done 1 cm for-
ward 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 floor between the
inguinal ligament and the internal oblique muscle fascia.
The meshes were provided by our institution and origi-
nated from different companies.
The duration of operations and complication and recur-
rent rates were compared between the two groups. Hema-
toma formation, seroma collection, and wound infection
were accepted as early complications, whereas chronic
pain, loss of sensation at the operation site, and the rejec-
tion 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 defined
purulent discharge or the presence of microorganisms
which were present in culture studies in any discharge.
Chronic pain was defined as the continuation of pain after
2 months which required painkillers. The ultrasonographic
examination was performed in the presence of complica-
tions such as hematoma formation, seroma collection,
Fig. 1 Picture of darn method between the inguinal ligament and the
internal oblique muscle fascia
Hernia (2013) 14:357–360
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 defined 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
findings 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 classifed 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 investi-
gation has been performed. The anterior approach, poster-
ior 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
recur-rence rates, lower complication rates, earlier return to
daily activities, and cost-effectiveness [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 difference between the two groups
considering early complications such as hema-toma
formation, seroma formation, and wound infection. Also,
there was no difference 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 findings in
Hernia (2013) 14:357–360 359

Table 1 Demographic data of the patients

n = 306 Group I (n = 176) Group II (n = 130) P-value
a
Mean age (years) § SD 53.82 § 17.37 51.96 § 16.17 NS (0.339)
b
Mean follow-up time (months) § SD 24.63 § 13.65 23.23 § 12.65 NS (0.359)
c
Mean operation time (min) § SD* 44.83 § 4.49 44.80 § 4.69 NS (0.947)
Sex (male/female) 146/30 (83%/17%) 102/28 (78.5%/21.5%) NS (0.322)
d
Side of hernia (right/left/bilateral) 73/82/21 53/55/22 NS
e
Type of hernia (indirect/direct/pantaloon) 101/58/17 73/45/12 NS
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 her- the side-loop to prevent the rupture of fibrils. They claim that
nia repair this method is superior to the original darn method. There was
n = 306 Group I Group II P-value no recurrence in their modified darn method and a
(n = 176) (n = 130) complication rate of only 1.9%. The duration of operations
were also similar between the groups in our study, as in the
Early
studies of Zeybek et al. and Kaynak et al. [6, 10].
Hematoma 2 (1.1%) 0 (0%) NS (0.223)
Recurrence seen 6 months after the surgery was evalu-
Seroma 3 (1.7%) 3 (2.3%) NS (0.707)
ated as late recurrence in our study. Although there is no
Wound infection 9 (5.1%) 7 (5.4%) NS (0.916) consensus on this issue, we believe that recurrence within 6
Late months after the operation may be due to technical insuff-
Sensory loss 1 (0.6%) 1 (0.8%) NS (0.829) ciency. There were no recurrences in our patients, as all of the
Chronic pain 1 (0.6%) 0 (0%) NS (0.389) patients had inguinal hernia as a primary disease and recurrent
Rejection 0 (0%) 3 (2.3%) 0.043 hernia and incarcerated hernias were not included. Both
NS not signiWcant; Group I: darn repair; Group II: Lichtenstein repair 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.
these patients were similar to the findings in the study of
Bisgaard et al. [11] followed primary Lichtenstein mesh and
Hofbauer et al. [7]. The rejection can be due to chronic for-
sutured inguinal repair patients for 8 years and observed that
eign body reactions of the prosthesis used in the surgery.
cumulative recurrence was increasing in the mesh group until
Wang et al. [8] suggested that host versus mesh reaction is the
5 years postoperatively. In conclusion, the Moloney darn
cause of rejection. Koukourou et al. [9] compared poly-
repair method is simple, safe, and has similar recurrence rates
prolene mesh with the nylon darn hernia repair method and
when compared to the Lichtenstein method in inguinal hernia
they observed an early complication rate of 28% in the mesh
patients. On the other hand, in the Lichten-stein method, there
group versus 33% in the darn group and, also, the late
is risk of rejection of the mesh which requires its removal as
complication rates were 15 and 20% in mesh and darn groups,
result. Although there are a limited number of similar studies
respectively; there was no statistically significant difference
comparing the above-mentioned methods, the Moloney darn
between the groups. The recurrence rates were similar after 1
repair method can be used in the treatment of primary inguinal
year, being 4%. The mean follow-up times were 24.63 § 13.65
hernia.
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 References
that there was no difference in the early complication rates
and recurrence rates between the two groups. Zeybek et al. [6] 1. Malangoni MA, Rosen MJ (2011) Hernias. In: Towsend CM Jr,
Beauchamp RD, Evers BM, Mattox KL (eds) Sabiston textbook
used a different modified darn method and used supporting of surgery: the biological basis of modern surgical practice, 18th
sutures through edn. Saunders/Elsevier, Philadelphia, pp 1155–1179
360
2. Rulli F, Percudani M, Muzi M, Tucci G, Sianesi M (1998) From
Bassini to tension-free mesh hernia repair. Review of 1409 con-
secutive cases. G Chir 19:285–289
3. Lichtenstein IL, Shulman AG, Amid PK, Montllor MM (1989)
The tension-free hernioplasty. Am J Surg 157(2):188–193
4. Moloney GE (1958) Results of nylon-darn repairs of herniae.
Lan-cet 1:273–278
5. Wantz GE (1999) Abdominal wall hernias. In: Schwartz SI (ed)
Principles of surgery, 7th edn. McGraw-Hill, New York, p 1585
6. Zeybek N, Tas H, Peker Y, Yildiz F, Akdeniz A, Tufan T (2008)
Comparison of modiWed darn repair and Lichtenstein repair of
pri-mary inguinal hernias. J Surg Res 146:225–229
7. Hofbauer C, Andersen PV, Juul P, Qvist N (1998) Late mesh
rejec-tion as a complication to transabdominal preperitoneal
laparo-scopic hernia repair. Surg Endosc 12:1164–1165
Hernia (2013) 14:357–360
8. Wang AC, Lee LY, Lin CT, Chen JR (2004) A histologic and
immunohistochemical analysis of defective vaginal healing after
continence taping procedures: a prospective case-controlled pilot
study. Am J Obstet Gynecol 191:1868–1874
9. Koukourou A, Lyon W, Rice J, Wattchow DA (2001)
Prospective randomized trial of polypropylene mesh compared
with nylon darn in inguinal hernia repair. Br J Surg 88:931–934
10. Kaynak B, Celik F, Guner A, Guler K, Kaya MA, Celik M (2007)
Moloney darn repair versus Lichtenstein mesh hernioplasty for open
inguinal hernia repair. Surg Today 37:958–960
11. Bisgaard T, Bay-Nielsen M, Christensen IJ, Kehlet H (2007)
Risk of recurrence 5 years or more after primary Lichtenstein
mesh and sutured inguinal hernia repair. Br J Surg 94:1038–1040
Copyright of Hernia is the property of Springer Science & Business Media B.V. and its content may not be
copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.