Comparison of Lichtenstein inguinal hernia repair with the tension-free Desarda technique: a clinical audit and review of the literature

Introduction

The history of hernias is as old as the history of surgery, with the first repairs dating to 1559. ¹ Inguinal hernias rank among the commonest of all hernias and surgery is the only definitive treatment. In understanding the pathological process of the development of a hernia, anatomical considerations have largely been concentrated on, and the emphasis is thus on restoring anatomical integrity, mostly (in the context of inguinal hernia) by reinforcing the posterior wall of the inguinal canal. This was originally achieved by bringing the tissues of the posterior wall together and has been appropriately described as a tissue repair. Bassini originally described this method in 1889; it is still used today with some modifications. ¹ In 1987 Lichtenstein described reinforcement of the posterior wall using a mesh, described as the mesh repair. ¹ Today this method is widely used and is often touted as the gold standard, probably owing to its ease of application, resultant tension free repairs and lower recurrence rates. ² However, considerations such as postoperative morbidity affecting the quality of life, the cost to the healthcare system, sepsis rates and understanding of the physiological contributions to the pathological process of hernia occurrences are equally important. ³ In an attempt to address these issues, particularly in rural hospitals, Desarda developed a physiological method of tissue repair that results in a tension-free reinforcement of the posterior wall without the use of a mesh. ⁴ In this review, we compare the aspects of open hernia techniques undertaken in a single unit experience in a local hospital in a middle-income country.

Patients and Methods

In this retrospective clinical audit of elective repair of inguinal hernia, a chart review was carried out from a single surgical unit at King Edward VIII Hospital, a state facility in Durban, South Africa. Approval to conduct this study was obtained from the hospital manager and the Biomedical Research Ethics Committee (BREC) of the University of KwaZulu-Natal. A manual search of outpatient, inpatient and theatre records of patients aged 13 years and older who underwent inguinal hernia repair from October 2012 to April 2014 was undertaken. Demographics such as age, sex and type of hernia were assessed. Theatre records were assessed for type of hernia repair and duration of operative time. The Lichtenstein repair described in patients’ theatre notes remained unchanged and were consistent with standard descriptions. A polypropylene mesh was sutured laterally to the inner shelf of the inguinal ligament and medially to the conjoint tendon posterior to the cord and structures. The Desarda repair was performed as originally described; a flap of the external oblique aponeurosis was used to create a tension-free repair between the inner shelf of the inguinal ligament and the conjoint tendon posterior to the cord. ⁴ In the original description, after excision of the sac, Desarda described that a strip of the external oblique aponeurosis (EOA) be partially separated from its medial leaf, keeping its continuity intact at either end. This undetached strip of EOA is then sutured to the inguinal ligament laterally and the conjoint tendon medially, behind the spermatic cord, to form a new posterior wall. Unlike mesh repairs, the strip of EOA that replaces the mesh is more physiological and when put under tension when straining by abdominal wall muscular contraction, creates lateral tension while contraction of the internal oblique/conjoined muscle creates tension above and laterally, making the EOA strip a shield to prevent any herniation. This fascial strip also gives additional strength to the weakened internal oblique and transverse abdominis muscle.

Operative time was measured from the time of skin incision to skin closure. Inpatient records were assessed for duration of hospitalisation and postoperative complications such as pain, sepsis and haematoma formation. The days of hospitalisation was counted from the day of operation to the day of discharge. No pain scores were documented in the notes. However, patients experiencing pain that required additional analgesia was documented.

Outpatient records were assessed for up to 1 year following the operation for recurrence. Patients were followed up at 2 weeks and at 2, 6 and 12 months postoperatively. Patients with dual pathology (inguinal hernia plus another surgical pathology), previous inguinal hernia repairs, bilateral repairs and patients that were lost to follow-up within 1 year of the hernia repair were excluded from the study. Results were captured on a Microsoft Excel spread sheet and all variables were compared to different hernia repair methods. IBM SPSS version 22 was used for data analysis. Non-parametric Mann–Whitney tests were used to compare length of hospital stay between two independent groups. Fisher’s exact tests were used to compare binary variables between two groups. All tests were two-sided at a significance level of 0.05. Univariate binary logistic regression analysis was used to assess risk factors for recurrence. Odds ratios and 95% confidence intervals were reported.

Results

A total of 65 patients had elective inguinal hernia repairs from October 2012 to April 2014. Excluded were two patients with dual pathologies (inguinal and umbilical hernias), nine with bilateral inguinal hernia repairs and 19 lost to follow-up. Thirty-five participants therefore met the inclusion criteria for the study. All patients were men. The mean age was 47.3 years (age range, 16–82 years). A total of 23 patients (66%) underwent a Lichtenstein repair and 12 (34%) a Desarda repair. There were 18 direct and 17 indirect hernias. The senior registrar or junior consultant attached to the unit operated on all patients. All Lichtenstein mesh repairs were administered a prophylactic antibiotic in theatre prior to the administration of the anaesthetic. All patients were given simple oral analgesia in the form of paracetamol and a non-steroidal anti-inflammatory drug.

The median age in the Desarda group was 34 years compared to 52 years for the Lichtenstein group. There was a statistical difference in the duration of surgery and days of hospitalisation. The median operative time of the Lichtenstein was 70 min and the Desarda was 50 min, P value = 0.025 (Table 1). There was a significant association between type of repair and stay. The median hospital stay of the Lichtenstein was 2 days and the Desarda was 1 day, P value = 0.003 (Table 1). The median age may have influenced operative stay as older patients may take a longer time to recover. Postoperative wound sepsis, haematoma and pain were observed as postoperative complications. There was no association between type of repair and complications (P = 0.986) (Table 2). Hernia recurrence was evaluated after a total follow-up time of 1 year. There were no recurrences within this time frame in both groups. Therefore, there was limited statistical power to show any significant associations. More research with a larger sample size and longer follow-up is needed to show any trends in recurrence.

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Table 1.

Differences in duration of surgery and length of hospital stay. The difference in duration of surgery P = 0.025. The difference in hospital stay P = 0.003.

		Duration of surgery (min)			Length of hospital stay (days)
		Median	Percentile 25	Percentile 75	Median	Percentile 25	Percentile 75
Type of repair	Lichtenstein mesh	70	60	90	2	2	3
	Desarda	50	40	63	1	1	2

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Table 2.

The association between type of repair and complications (pain, haematoma, sepsis), P = 0.986.

	Complications
Type of repair (n)	Pain	Recurrence	Haematoma	Wound sepsis
Desarda (12)	3	0	1	0
Lichtenstein (23)	5	0	2	1

Discussion

Prior to the European Hernia Society (EHS) recommendations of 2009, ² guidelines regarding hernia repairs were lacking. The EHS guidelines have provided clarity and direction to many facets of hernia repair, particularly to the choice of repair (Table 3). ² While laparoscopic repair has been advocated on account of a quicker postoperative recovery, less pain and possibly lower recurrence rates, there seems to be consensus that primary unilateral hernias be performed by the open approach. Nonetheless the approach chosen is largely dependent on technology available, patient preference, and expertise and experience of the operating surgeon.^2,5

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Table 3.

European Hernia Society (EHS) 2009 hernia repair recommendations for male adults (>18 years). ²

Type of hernia	Recommended repair
Primary unilateral	Lichtenstein mesh repair or endoscopic repair (if expertise available)
Primary bilateral	Lichtenstein mesh repair or endoscopic repair (if expertise available)
Recurrent – previous anterior repair	Pre-peritoneal mesh repair or endoscopic repair (if expertise available)
Recurrent – previous posterior repair	Lichtenstein mesh repair

Recurrence rates are the crucial determinant of the effectiveness of hernia repair. Tension-free methods, such as mesh repairs, have been shown to be superior to primary repair approximating tissues.^6,7 For this reason, the Lichtenstein mesh repair is now touted as the gold standard of open repair.^2,5,8 A endoscopic technique inevitably necessitates using a mesh.

However, infective complications associated with using mesh require at best long treatment with antibiotics, or at worst difficult and damaging removal of the mesh leaving a defect far worse than initially present. Infective complications may occur late and are obviously more serious in immunocompromised patients, who are of significant proportion in South Africa. Furthermore, other mesh-related complications include mesh migration, ‘meshoma’ (contraction, migration or bunching up of a prosthetic mesh), nerve entrapment and intestinal fistula formation may ensue. ⁹

To this end, Desarda, prompted by the inconsistent availability of mesh in low-income countries, developed a technique to avoid the use of a mesh, thus avoiding mesh-related complications. He described this method in 2001. Following its original report, the Desarda technique has been compared to the Lichtenstein tension-free mesh repair and has been consistently shown, particularly in poor-resource settings, to have a better outcome with regard to complications and re-explorations for sepsis, quicker return to normal work, ¹⁰ a significantly shorter operative time ¹¹ and early resumption of normal gait and freedom from pain. ¹² Some have therefore concluded that the Desarda repair has the potential to become the new gold standard particularly in low- and middle-income countries. ¹³

Consequently, we endeavoured to compare this genuine tension-free tissue repair with the Lichtenstein method.

In our study, comparing the Desarda method with the Lichtenstein repair, results are consistent with those of larger randomised international trials reported from settings not dissimilar to ours. The Desarda method appears to save costs due to shorter hospital stays, reduced operating times and the avoidance of the use of a mesh.

There are certain limitations in our study. Patient numbers fall short of being significant. In resource-depleted facilities such as ours, elective inguinal hernia repair is increasingly not given priority status, notwithstanding the cost-effectiveness and efficacy of early repair. Furthermore, it has been reported that in low- and middle-income countries, approximately 65% of inguinal hernias are repaired as emergencies. ¹⁴ In such situations, of course, the use of a mesh may be even more hazardous with respect to sepsis.

Follow-up review was not uniform or comprehensive; this is always difficult in low- or non-earning populations, once patients deem themselves recovered following their surgery. Importantly, the reliability of a hernia repair may need at least a 10-year follow-up to determine the viability and strength of the repair performed.

We did not compare the Desarda technique with the nylon darn tension-free tissue repair popularised by Moloney ¹⁵ and validated by Callum et al.; ¹⁶ this repair similarly compares favourably with the Lichtenstein technique.^17,18

Conclusion

Though prospective randomised double-blind studies are needed to clinch the argument, we conclude that in resource-depleted settings, an open tension-free inguinal hernia repair, appears to be equivalent in reliability to the Lichtenstein mesh repair, but is more suitable in terms of its safety, reproducibility and probably its cost-effectiveness.