British Journal of Medicine & Medical Research

21(9): 1-8, 2017; Article no.BJMMR.32834

ISSN: 2231-0614, NLM ID: 101570965

A Comparative Study between Laparoscopic Hernia

Repair and Open Lichtenstein Mesh Repair
Arth H. Shah1, Jignesh B. Rathod2 and Vipul D. Yagnik3*
1
Resident Plastic Surgery, B. J. Medical College, Civil Hospital Campus, Ahmedabad, Gujarat, India.
2
Department of Surgery, Pramukhswami Medical College, Shree Krishna Hospital, Karamsad, India.
3
Ronak Endo-Laparoscopy and General Surgical Hospital, Patan, Gujarat, India.

Authors’ contributions

This work was carried out in collaboration between all authors. Author AHS designed the study,
performed the statistical analysis, wrote the protocol and wrote the first draft of the manuscript.
Authors JBR and VDY managed the analyses of the study. Author VDY managed the literature
searches and critically analyze the study. All authors read and approved the final manuscript.

Article Information

DOI: 10.9734/BJMMR/2017/32834
Editor(s):
(1) Syed Faisal Zaidi, Department of Basic Medical Sciences, College of Medicine, King Saud Bin Abdulaziz University-HS,
National Guard Health Affairs, King Abdulaziz Medical City, Kingdom of Saudi Arabia.
Reviewers:
(1) Juan Carlos Martín del Olmo, Medina del Campo Hospital, Valladolid, Spain.
(2) Mushtaq Chalkoo, Govt. Medical College, Srinagar, Kashmir, India.
(3) Jianming Zhu, Shanghai University of Traditional Chinese Medicine, China.
(4) Nagendra Kumar Kaushik, Kwangwoon University, South Korea.
Complete Peer review History: http://www.sciencedomain.org/review-history/19188

Received 18th March 2017

th
Original Research Article Accepted 10 May 2017
Published 25th May 2017

ABSTRACT

Background: A prospective comparative study of open inguinal hernia mesh repair with
laparoscopic inguinal hernia mesh repair was performed in a tertiary care centre in a rural setup.
This study was conducted with an objective to compare the effectiveness of each procedure and
complications if any.
Methods: 50 cases of an inguinal hernia admitted in the tertiary care centre rural area were
selected by nonprobability (purposive) sampling method. All patients with uncomplicated hernia
treated by open or laparoscopic method were included. The age /sex, incidence, mode of
presentation, surgical treatment and postoperative complications were all evaluated and compared
with standard published literature.
Results: Postoperative wound infection developed in 4 cases of open hernioplasty and 1 case in
laparoscopic surgery. Hematoma and seroma at the operated site were found in 2 cases of open

_____________________________________________________________________________________________________

*Corresponding author: E-mail: [email protected];

 Shah et al.; BJMMR, 21(9): 1-8, 2017; Article no.BJMMR.32834

hernioplasty. The duration of hospitalization was 3.23 days in case of open hernioplasty while 3.5
days in a laparoscopic hernia. The mean duration of procedure was 71.5 min in open surgery while
84.25 min in laparoscopic group.
Conclusion: There was the less post-operative complication in the laparoscopic group.
Laparoscopic hernioplasty has a comparable result with an open procedure.

Keywords: Inguinal hernia; total extraperitoneal (TEP); lichtenstein tension free hernioplasty;
complications.

1. INTRODUCTION Exclusion Criteria

Inguinal hernia repair is one of the most Complicated hernia, bilateral hernia. Associated
frequently performed operations in general groin condition like hydrocele, varicocele, etc.
surgery. The standard method for hernia repair Recurrence and previous surgery with mesh in
had changed little over a hundred years. the same region. Patients in American Society of
Introduction of synthetic mesh had changed the Anaesthesiologists (ASA) class IV (i.e., those
scenario. It can be placed either by open or who had systemic disease that is a constant
laparoscopic techniques. Laparoscopic hernia threat to life) or Class V (i.e., those who were
repair was first reported by L Ger and colleagues unlikely to survive e for 24 hours, with or without
in 1990 [1]. However, it has not gained much operation), immunocompromised patients with
acceptance till date due to its serious vascular Malignancy.
and visceral complications.
Choice of Procedure
In our Institutions, Inguinal hernia repair is one of
the common surgeries performed regularly. The The procedure was based on the personal
main aims of the study are: preference of the patient, general condition and
associated cost of the procedure.
1. To compare the outcome of both open and
Preoperative Treatment Included
laparoscopic inguinal mesh repair,
patient’s duration of stay, complications
that occur between open inguinal hernia • Optimization of precipitating factors
mesh repair and laparoscopic hernia mesh The type of anesthesia used was spinal
repair and to arrive at a conclusion. anesthesia for open cases and general
2. To evaluate the limitations of laparoscopic anesthesia for laparoscopic hernia mesh repair.
inguinal hernia mesh repair.
3. To compare the time taken for the surgery A single dose of preoperative broad spectrum
between open and laparoscopic inguinal antibiotic given. NSAIDs was given post-
hernia repair. operative for two days and later as and when
required.
2. METHODOLOGY
TEP and open Lichtenstein tension-free
The present study is a prospective study of 50 hernioplasty:
cases of an inguinal hernia admitted in tertiary
care centre during the study period of September TEP (Total Extraperitoneal Repair):
2012 to August 2013. This study was approved
by human research ethics committee. Written In this method after reducing the hernia contents,
and informed consent was taken from the the mesh is placed laparoscopically.
patients. All the laparoscopic TEP operation was
performed by a single surgeon. Open Lichtenstein tension-free hernioplasty is
done above the fascia tranversalis after putting
50 cases for the purpose of the survey were an incision in the inguinal region and mesh is
selected by the nonprobability (purposive) fixed.
sampling method.
The technique of TEP:
Inclusion Criteria
A 10-mm sub umbilical incision was made. A
Adults above 18 years age, Unilateral, Primary transverse incision was then made on the
inguinal hernia. anterior rectus sheath. Stay sutures taken over

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anterior rectus sheath. A 10-mm Cannula without once the adhesions are lysed, or hernial sac is
trocar was then introduced subumbical incision in reduced, the anatomical landmarks like Cooper’s
the preperitoneal space. A 10-mm 30° telescope ligament, ilio pubic tract, became visible. The sac
was used. Blunt dissection was performed with was completely dissected from the cord
the telescope. The other two working ports were structures (Image 2) and reduced. The lateral
placed. First, a 5-mm port is positioned about 2 boundary of the dissection was the anterior
cm above the pubic symphysis and second, 10 superior iliac spine. Identified triangle of doom
mm port was placed midway between the two (Image 3) and the triangle of pain. We did not
ports in the midline. Dissections in preperitoneal perform any dissection in the triangle of doom
space were performed by dividing the loose as it contains the external iliac vessels. Mesh
areolar tissue with the help of sharp and blunt was introduced through the 10-mm sub
dissection. The first landmark is the pubic bone umbilical port. We used 15×11 cm polypropylene
which appears as white glistening structure in the mesh. The mesh was placed over the space to
midline was identified (Image 1). The hernia sac cover the all the possible hernia sites. Mesh
and Inferior Epigastric vessels were also was fixed to the Cooper’s ligament by tacker
identified.parietilization of sac performed and (Image 4).

Image 1. Pubic bone with cooper’s ligament

Image 2. Hernial Sac

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Choice of procedures Discharge

The procedure was based on the patients wish, Patients is discharged once fit and called on
the general patient condition, and associated regular follow-up for one week, two weeks and at
cost of the laparoscopic and open procedure. the end of month.

Postoperative care and complications: post- Statistical Methods used

operative complications like bleeding, wound
infection, seroma, Orchitis and urinary retention Descriptive, Crosstabs, Chi-square and
were carefully monitored. Independent – samples T-test.

Image 3. Triangle of doom

Image 4. Mesh is fixed with tacker

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3. RESULTS to less sample size of laparoscopic inguinal

hernioplasty patients (n=20).
In our study, we analyzed total 50 patients, of
whom 30 were operated using open technique Further, the p-value is not significant between the
and 20 posted for laparoscopic inguinal two groups.
hernioplasty.
3.3 Duration of Hospital Stay
In our study the minimum age at which
occurrence of a hernia was 21 years and the The mean length of the hospital was found to be
eldest being at 80 years. All the patients in the 3.23 days for the open hernioplasty. Compared
study were men. to the laparoscopic hernia group, which was
around 3.5 days but the p-value is insignificant.
Of all the patients analyzed 42% presented with
left sided groin swelling and rest 58% with right 4. DISCUSSION
sided groin swelling.
4.1 Age and Sex
In our study, we found that right inguinal hernia
was more common 58% of the study group Last 5year data from the Danish national hospital
presented with right inguinal swelling. register were included. All groin hernia repaired
during last five years were identified. Study
74% of the patients presented within the first population covered n = 5,639,885 persons
year of onset of complaints while 26% presented including 2,799,105 males and 2,840,780
after one year. females [2]. Within this population, 88.6% males
and 11.4% females. Inguinal hernias comprised
Hypertension was the most common associated 97% of groin hernia repairs (90.2% males, 9.8%
illness with eight people suffering from it, females) [2]. Patients between 0–5 years and
Diabetes mellitus was seen in 4 people. 75–80 years constituted the two dominant groups
for inguinal hernia repair [2]. There is a bimodal
Right direct hernia was observed in 18 cases peak with the highest incidence in older age
being the most frequent type while left indirect group. In our study, 11 cases were in 15-44 age
the least prevalent. group and 16 cases in >65 age group. Gupta et
al. reported an incidence of 96% males while
3.1 Duration of Surgery Charles et al. reported 93.2% of all the cases to
be males [3,4]. Our findings are corresponding
In our study, we found that the mean time taken with the literature. The age incidence of our study
for open inguinal hernia repair (hernioplasty) was matches with the above study. The sex incidence
about 71.5 minutes compared to the average of our study does not correlate with the other
duration of 84.25 minutes taken for laparoscopic studies; it may be due to the shy nature of the
inguinal hernia repair. Indian women that it may not have presented to
us. The male preponderance is due to strenuous
3.2 Post-operative Complications activity.

3 (10%) cases of urinary retention in open The right sided hernia is more common in the
hernioplasty as compared to 1(5%) in literature. In Bisher Saeed A et al. evaluated
laparoscopic hernioplasty. Wound infection seen inguinal hernias and found that 70.8% were right
in 4 (13.33%) cases in an open group as sided, 33.3% were left sided, 45.8% were indirect
compared to 1 (5%) in laparoscopically operated inguinal hernias, and 58.3% were direct inguinal
cases. Orchitis was more prevalent in the hernias [5]. Alam et study also found the
laparoscopic hernioplasty patient with incidence incidence of a right-sided hernia is more common
among 3 (15%) cases as compared to 1 (3.33%) [6]. In our study also right sided inguinal hernia is
in open group. 2 (6.67%) cases of seroma were more common. Right side dominance is because
found in the hernioplasty group whereas none in of later descent of right testis [7].
laparoscopic repair group.
In the present study 30 cases, each underwent
Overall postoperative complications were fewer Lichtenstein repair while 20 cases underwent
in laparoscopic hernia repairs when compared to TEP. The procedure was chosen based on
the open hernia repair group which may be due patient’s choice, need and financial status.

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Table 1. Duration of the surgery

Laparoscopic repair Open hernia repair P value

Mean Duration of 84.25(19.35) 71.5 (16.56) 0.016
Surgery(S.D.)

Table 2. Post-operative complications

Complications Laparoscopic repair (n=20) Open Hernia repair (n=30) P Value

Urinary Retention 1(5%) 3(10%) 0.641
Wound Infection 1(5%) 4(13.33%) 0.636
Orchitis 3(15%) 1 (3.33%) 0.289
Hematoma/Seroma 0 (0%) 2 (6.67%) 0.510
Injuries to Speramtic
Cord, Vessels and 0(0%) 0 ------------
Bowel

Table 3. Duration of stay (no. of days)

Laparoscopic repair Open hernia repair P value

Mean Duration of 3.50 (1.1) 3.23(0.89) 0.352
Stay (S.d)

The mean duration for hernioplasty in our study [8]. A systemic review by Cochrane collaboration
was 71.5 min. Time for laparoscopic inguinal showed trans abdominal preperitoneal (TAP)
hernia repair (TEP) was 84.25 min. Reviewing was associated increased risk of a port-site
Cochrane database, K McCormak et al. [8] also hernia and visceral organ injury and also
found that duration of operation was longer in the concluded that there are insufficient data to
laparoscopic groups (WMD 14.81 minutes, 95% prove the relative effectiveness of the TEP and
CI 13.98 to 15.64; p<0001). TAP repair for inguinal hernia [9]. During
laparoscopy most common vascular injuries
4.2 Postoperative Complications involving the Inferior Epigastric and spermatic
vessels [8]. The external iliac, profunda and
In our study the postoperative complications like obturator vessels are at also the risk, and
hematoma/ seroma and wound infection, urinary previous lower abdominal surgery is a risk factor
retention were comparatively lower in the [10]. Vidovic et al. [11]. Reported a higher rate of
laparoscopic hernia repair group 0%, 5%, 5% urinary retention following TEP which was
compared to that of the hernioplasty group successfully managed by per urethral
6.67%, 13.33% and 10% respectively. As hernia catheterization. In our study, urinary retention
surgery is a clean operation, it does not require was more common in open hernia group
routine antibiotic prophylaxis. However, as we probably because of spinal anesthesia and
are practicing in a rural area with overcrowded patients with older age group might have
population and reduced local and general associated benign prostatic hyperplasia. The
hygiene in villages, we made a policy to overall rate of vascular injury during laparoscopic
administer the pre-operative single dose of repairs was 0.09% as against no reported cases
antibiotic. Even in the presence of antibiotic during open operations [9]. In the present study,
prophylaxis, we had a little higher wound we did not encounter any case of vascular injury
infection rate probably because of poor personal probably because of small sample size (n=20).
local and general hygiene by the patients. In our study, we found the higher rate of Orchitis
following TEP is possibly because of
The incidence of Orchitis was higher in the extensive dissection during TEP leads to
laparoscopic group at 15% as compared to thrombosis of vascular plexus or foreign body
3.33% in open group. Cochrane review also reaction to mesh.
suggests that operative complications were
uncommon for both techniques but more In our study, we found that the mean period of
frequent in the laparoscopic group for visceral hospitalization was slightly higher 3.5 days in
(Overall 8/2315 versus 1/2599) and vascular case of laparoscopic hernia repair with 3.23 days
(Overall 7/2498 versus 5/2758) injuries in cases of hernioplasty but not statistically

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significant. The post-operative days spent in the COMPETING INTERESTS

hospital were almost comparable in both groups.
Cochrane review also state that length of hospital Authors have declared that no competing
stay did not differ between open and laparoscopy interests exist.
groups (WMD -0.04 days, 95% CI -0.08 to 0.00;
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