Evidence - Lichtenstein Repair of Inguinal Hernia - general and visceral surgery

Compared to sutured open herniorraphy in adults (particularly the Shouldice procedure), in surgical repair of (unilateral and bilateral) inguinal hernia by the Lichtenstein technique the following differences have been reported:

• Lower recurrence rate (↑↑ [6; 8; 11; 12; 15; 21])
• Probably somewhat shorter operating time (↑↑ [6; 12; 15; 20; 21])
• Perhaps somewhat less postoperative pain, in the long run apparently comparable pain (↑↑ [3; 11; 13; 18; 20-22])
• Perhaps somewhat speedier recovery (↑↑ [3; 6; 18; 21])
• Comparable rate of infection (↑↑ 21)
• May be performed under local anesthetics (↑↑ 11)
• More expensive because of cost of mesh (↑ 18)
• For comparison of the Lichtenstein repair with other procedures please see there: Inguinal herniorraphy with Rutkow plug, TAPP and TEP.

The comparison fociused on heavy and light-weight meshes (100 g/cm² and 30g/cm² respectively). Outcome of the light-weight meshes:

• Less foreign body sensation in the groin (↑ [5; 19])
• Trend of less chronic groin pain (↑ [5; 19])
• Comparable recurrence rates (↑ 5)

In addition, several mesh materials were studied. The comparison of Prolene®, Vypro II®, Premilene® and Surgisis® resulted in the following:

• No significant differences in the perioperative course (↑↑ [1; 4; 17])

Sutures, sealants, skin staples and spiral tacks used in mesh fixation were also studied. The outcome was as follows:

• After mesh fixation by sealant perhaps somewhat less postoperative pain (↑ [9; 10; 16])
• With staples and tacks somewhat shorter operating time (↑ [7; 14])
• Comparable recurrence rates overall (↑ [7; 9; 10; 14; 16])

Routine prophylactic antibiotic protocol in Lichtenstein repair resulting in:

• Evidently no reduction in the rate of wound infection (↑ 2)

For ongoing trials see: www.isrctn.com

1. Ansaloni L, Catena F, D’Alessandro L. Prospective randomized, double-blind, controlled trial comparing Lichtenstein’s repair of inguinal hernia with polypropylene mesh versus Surgisis gold soft tissue graft: preliminary results. Acta Biomed Ateneo Parmense 2003; 74 Suppl 2: 10-4.
2. Aufenacker TJ, van Geldere D, van Mesdag T, Bossers AN, Dekker B, Scheijde E, van Nieuwenhuizen R, Hiemstra E, Maduro JH, Juttmann JW, Hofstede D, van der Linden CT, Gouma DJ, Simons MP. The role of antibiotic prophylaxis in prevention of wound infection after Lichtenstein open mesh repair of primary inguinal hernia: a multicenter double-blind randomized controlled trial. Ann Surg 2004; 240: 955-61.
3. Barth RJ, Jr., Burchard KW, Tosteson A, Sutton JE, Jr., Colacchio TA, Henriques HF, Howard R, Steadman S. Short-term outcome after mesh or shouldice herniorrhaphy: a randomized, prospective study. Surgery 1998; 123: 121-6.
4. Bringman S, Heikkinen TJ, Wollert S, Osterberg J, Smedberg S, Granlund H, Ramel S, Fellander G, Anderberg B. Early results of a single-blinded, randomized, controlled, Internet-based multicenter trial comparing Prolene and Vypro II mesh in Lichtenstein hernioplasty. Hernia 2004; 8: 127-34.
5. Bringman S, Wollert S, Osterberg J, Smedberg S, Granlund H, Heikkinen TJ. Three-year results of a randomized clinical trial of lightweight or standard polypropylene mesh in Lichtenstein repair of primary inguinal hernia. Br J Surg 2006; 93: 1056-9.
6. Danielsson P, Isacson S, Hansen MV. Randomised study of Lichtenstein compared with Shouldice inguinal hernia repair by surgeons in training. Eur J Surg 1999; 165: 49-53.
7. Douglas JM, Young WN, Jones DB. Lichtenstein inguinal herniorrhaphy using sutures versus tacks. Hernia 2002; 6: 99-101.
8. Friis E, Lindahl F. The tension-free hernioplasty in a randomized trial. Am J Surg 1996; 172: 315-9.
9. Helbling C, Schlumpf R. Sutureless Lichtenstein: first results of a prospective randomised clinical trial. Hernia 2003; 7: 80-4.
10. Hidalgo M, Castillo MJ, Eymar JL, Hidalgo A. Lichtenstein inguinal hernioplasty: sutures versus glue. Hernia 2005; 9: 242-4.
11. Kux M, Fuchsjäger N, Feichter A. Lichtenstein-Patch versus Shouldice-Technik bei primären Leistenhernien mit hoher Rezidivgefährdung. Chirurg 1994; 65: 59-63.
12. McGillicuddy JE. Prospective randomized comparison of the Shouldice and Lichtenstein hernia repair procedures. Arch Surg 1998; 133: 974-8.
13. Miedema BW, Ibrahim SM, Davis BD, Koivunen DG. A prospective trial of primary inguinal hernia repair by surgical trainees. Hernia 2004; 8: 28-32.
14. Mills IW, McDermott IM, Ratliff DA. Prospective randomized controlled trial to compare skin staples and polypropylene for securing the mesh in inguinal hernia repair. Br J Surg 1998; 85: 790-2.
15. Nordin P, Bartelmess P, Jansson C, Svensson C, Edlund G. Randomized trial of Lichtenstein versus Shouldice hernia repair in general surgical practice. Br J Surg 2002; 89: 45-9.
16. Nowobilski W, Dobosz M, Wojciechowicz T, Mionskowska L. Lichtenstein inguinal hernioplasty using butyl-2-cyanoacrylate versus sutures. Preliminary experience of a prospective randomized trial. Eur Surg Res 2004; 36: 367-70.
17. Paajanen H. A single-surgeon randomized trial comparing three composite meshes on chronic pain after Lichtenstein hernia repair in local anesthesia. Hernia 2007; 11: 335-9.
18. Porrero JL, Bonachia O, López-Buenadicha A, Sanjuanbenito A, Sánchez-Cabezudo C. Reparación de la hernia inguinal primária: Lichtenstein frente a Shouldice. Estúdio prospectivo y aleatorizado sobre el dolór y los costes hospitalarios. Cir Esp 2005; 77: 75-8.
19. Post S, Weiss B, Willer M, Neufang T, Lorenz D. Randomized clinical trial of lightweight composite mesh for Lichtenstein inguinal hernia repair. Br J Surg 2004; 91: 44-8.
20. Prior MJ, Williams EV, Shukla HS, Phillips S, Vig S, Lewis M. Prospective randomized controlled trial comparing Lichtenstein with modified Bassini repair of inguinal hernia. J R Coll Surg Edinb 1998; 43: 82-6.
21. Scott NW, McCormack K, Graham P, Go PM, Ross SJ, Grant AM, on behalf of the EU Hernia Trialists Collaboration. Open mesh versus non-mesh for repair of femoral and inguinal hernia. Cochrane Database Syst Rev 2002: CD002197.
22. Vatansev C, Belviranli M, Aksoy F, Tuncer S, Sahin M, Karahan O. The effects of different hernia repair methods on postoperative pain medication and CRP levels. Surg Laparosc Endosc Percutan Tech 2002; 12: 243-6.

European Hernia Society guidelines on the treatment of inguinal hernia in adult patients

1. Köckerling F, Schug-Pass C. Tailored approach in inguinal hernia repair – decision tree based on the guidelines. Front Surg. 2014 Jun 20;1:20.

2. Pisanu A, Podda M, Saba A, Porceddu G, Uccheddu A. Meta-analysis and review of prospective randomized trials comparing laparoscopic and Lichtenstein techniques in recurrent inguinal hernia repair. Hernia. 2015 Jun;19(3):355-66.

3. Antoniou SA, Pointner R, Granderath FA. Current treatment concepts for groin hernia. Langenbecks Arch Surg. 2014 Jun;399(5):553-8. doi:
10.1007/s00423-014-1212-8.

4. Bracale U, Melillo P, Pignata G, Di Salvo E, Rovani M, Merola G, Pecchia L. Which is the best laparoscopic approach for inguinal hernia repair: TEP or TAPP? A systematic review of the literature with a network meta-analysis. Surg Endosc. 2012 Dec;26(12):3355-66.