Desarda versus Lichenstein technique for primary inguinal hernia treatment: one year results of a randomised clinical trial

INTRODUCTION

Inguinal hernias remain a surgical problem due to its increased frequency and complications accounting for 27% incidence in males and 3% incidence in females.¹ Until 2009, there were no guidelines for hernia management when European Hernia Society (EHS) published its recommendation based on analysis of literature and several clinical trials. In the EHS guideline, mesh-based techniques Lichenstein’s was particularly recommended for the treatment of symptomatic inguinal hernia.² Shouldice method of tissue repair has also been accepted. Considering the amount of advancement and several techniques involved in the treatment of inguinal hernia repair, several questions can be asked as; is Shouldice technique the only method of non-mesh method of repair that yields good results and is any other tissue-based repair of hernia effective if done correctly?

In course of time, several problems of mesh repair have been reported like foreign body sensation, scrotal edema, increased chances of infection further complicating the hospital stay. Complications like mesh migration, intense inflammatory response around the mesh leading to infection can further complicate subsequent operations.^3,4

In addition to this, sexual function is also been reported to have been affected in mesh inguinal hernia repair.

Keeping in view of the above complications involved intra-operative/post-operative, it is observed to assert of techniques having less foreign body reactions like tissue repair. It was until 2001 when Desarda technique was initially done leading to same results in surgical outcome and hence forth the search for tissue repair for inguinal hernia has become popular. This current study compares the clinical outcome of mesh based (Lichenstein’s) repair to tissue (Desarda) repair in a randomised clinical trial.

There have been several studies earlier which compared the efficacy of both the surgical techniques i.e., Desarda’s tissue repair and Lichenstein’s mesh repair and the outcomes were equable in terms of post-operative and long-term outcomes of the patient. The objective of the current study is to test the hypothesis that the Desarda repair is as effective as the standard Lichtenstein procedure, allowing successful hernia repair without mesh in terms of wound site infection, seroma formation, foreign body sensation, disturbances in sexual activity, return to daily activity, office work and recurrence in the long run.

The aim of the present study was to test the hypothesis that the Desarda repair is as effective as the standard Lichtenstein procedure, allowing successful hernia repair without mesh.

METHODS

It was a prospective randomised case control study done for a period of one year (1^st October 2015 to 2016). It was conducted in the Department of General Surgery, Silchar Medical College and Hospital, Assam. A total of 42 participants (40 males and 2 females) were included in this study and were divided into two groups - Desarda’s tissue repair comprising of 19 participants in group 1 and Lichenstein’s mesh repair comprising of 23 participants in group 2.

Inclusion criteria included male and female participants above 25 years of age, assessment of proper condition of the external oblique aponeurosis and the presence of bilateral inguinal hernia operated on a single side by same group of surgeons. Presence of divided, tiny and weak external oblique aponeurosis, recurrent and complicated hernia, age <20 years, presence of scar in inguinal region and ASA score >3 in participants were excluded from the study. Informed consent was taken from the patient and their party and surgery was performed under spinal anaesthesia.

A 7.5×15 cm polypropylene mesh was used as per the dimension of the patient’s inguinal floor. The mesh was sutured to the ligament of Poupart using a non-absorbable continuous 2/0 suture (prolene) and secured cranially using same suture (Figure 1). The Desarda’s repair was performed as it was originally described in 2001.^5,6

Interrupted non-absorbable suture (2/0 prolene) was used to secure the aponeurotic strip to the inguinal ligament laterally, and the strip was secured to the internal oblique muscle medially with same suture (Figure 2). All intraoperative variables were recorded and compared. Patients were encouraged to resume normal activities as soon as possible. Recurrences and other complications were recorded. Pain was measured using a visual analog scale (VAS), which ranged from 0 (no pain) to 10 (maximum, unbearable pain). Return to normal activity was described as the patient’s ability to perform elementary activities like walking, bathing etc, usual activities at home i.e., preparing food, cleaning house (home activity); and returning to all previously performing work activity.

Patients were followed up and the outcomes were compared on 7^th, 30^th day and at 6^th and 12^th months with a minimum follow up of 12 months after the surgery. They were discharged on the 3^rd post-operative day when they were fit and comfortable.

Statistical analysis was conducted with the help of microsoft excel and SPSS software for windows. Variables were presented as mean and standard deviation for quantitative and percentages for qualitative or as deemed appropriate.

RESULTS

A total of 42 participants for both Desarda’s and Lichenstein’s group were included, of which 19 participants comprised Desarda's (group 1) and 23 participants comprised the LIchenstein's (group 2) (Table 1 and 2). Mean age was 37.32±7.2 years in Desarda’s and 35.42±8.7 years in Lichenstein’s. There was no significant difference in age and comorbid conditions in both the groups (p>0.05).

There was no statistical difference in duration of surgery between the two groups (p>0.05). Mean VAS score was 1.32±0.70 in Desarda’s and 4.52±0.97 in Lichenstein’s. The difference was significant (p<0.02). The mean incidence of seroma formation was 1.28±0.50 days in Desarda’s and was 4.72±0.79 days in Lichenstein’s. The difference was extremely significant (p<0.03) (Table 3).

The mean duration of return to basic activity was 16.74±6.40 days in Desarda’s and 14.34±5.33 days in Lichenstein’s. This difference was significant (p<0.195). The mean duration of return to activity was 4.74±1.24 days in Desarda’s and 7.00±3.90 days in Lichenstein’s (Table 4). This difference was significant (p<0.020).

The mean cost involved in Desarda was Rs 711.05±2.67 in Desarda’s and was Rs. 2420.65±4.83 in Lichenstein’s. It was extremely significant (p<0.001) (Table 6). The mean duration of hospital stay was 2.21±0.53 days in Desarda’s and 2.65±1.46 days in Lichenstein (p<0.220) (Table 7).

DISCUSSION

Inguinal hernia is one of the commonly encountered surgically treated condition. Several techniques have been developed for its repair. Although Desarda’s repair is a tissue based inguinal hernia repair technique, several objections have already been raised.^5,6 It has been established as one of the successful methods of repair of inguinal hernia by using undetached strip of external oblique aponeurois muscle. This technique is original and satisfies the principles of ‘no-tension’ presented by Lichenstein’s and is different from the historical explanation given by McArthur and Andrewson Zimmerman.^7,8

Lichenstein remains one of the modern methods of mesh repair of inguinal hernia and is widely used. Apart from the mesh being costly, other complications like SSI, mesh displacement, foreign body sensation, seroma formation is often seen more in hands of unexperienced surgeons.

In our study, there were no statistically significant differences between the patients enrolled to the Desarda and Lichtenstein groups. The percentage of other early and late complications was comparable. The higher ratio of seromas after use of the Lichtenstein method can be explained by the influence of the synthetic mesh on surrounding tissues. This is consistent with other studies and the known influence of polypropylene on tissue.^9,10 There was a single recurrence seen in Desarda’s group. Similar findings were reported by Desarda on 860 patients over a follow up period of more than seven years.¹¹

Mean VAS score on 3^rd post-operative day was 1.32 in Desarda’s technique and 4.52 in Lichtenstein’s technique. Similar study by Mitura et al compared Desarda’s and Lichtenstein’s technique and reported mean VAS score on 3^rd post-operative day to be 3.3 and 3.8 in Desarda’s and Lichtenstein’s technique respectively.¹² In our study the mean hospital stay was 2.21 days and 2.65 days in Desarda and Lichtenstein group respectively. Similar study by Mitura et al reported that patients operated by Desarda’s technique were discharged on 4^th day and those operated by Lichtenstein’s technique were discharged on 5^th post-operative day.¹² The mean time to return to basic physical activity in was 4.74 and 7.00 days in Desarda’s and Lichenstein’s group respectively. Similarly, study conducted by Desarda et al reported that the mean time to return to work in the Desarda’s technique was 8.48 days while it was 12.46 days in the Lichtenstein’s group.¹³

CONCLUSION

There was no significant difference in the clinical outcome of both the techniques. Frequency of complication was almost similar in both the groups. The cost of treatment was significantly high in Lichenstein’s technique when compared to Desarda’s repair. Desarda is an economical, indigenous and innovative technique with equivalent results to Lichenstein’s demanding less technicality.

ACKNOWLEDGEMENTS

I would like to recognise the invaluable contribution of Dr Pinak Pani Dhar in this study starting from the conceptualisation to technique to guiding me in making this article is invaluable. I would also like to give a special mention to the head of my department, Dr Amitava Ghosh whose support and guidance was indispensable in completion of this study. I would also give credits to my senior in the department Dr Raman Shankar whose idea, layout and the valuable feedback has been indispensable in the study. I would also like to express my gratitude towards my fiance Mr Soumya Ranjan Moharana whose support has been instrumental in such trying times. I would also like to acknowledge the professionalism shown by our collegues at IJS.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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