A comparative study to evaluate the outcome between open posterior preperitoneal versus open anterior tension free hernioplasty in cases of recurrent inguinal hernia
Keywords:Recurrent inguinal hernia, Open posterior pre peritoneal approach, Open anterior tension free approach, Hernioplasty
Background: The ideal method for repair of inguinal hernia would cause minimal discomfort to the patient, both during the surgical procedure and in the postoperative course. It would be technically simple to perform and easy to learn, would have a low rate of complications and recurrence, and would require only a short period of convalescence. However, the most effective method in any given patient is not clearly defined and consequently surgery for recurrent inguinal hernia after mesh repair is usually a difficult operation due to the disadvantage of re-operating through dense fibrotic scar tissue around the mesh with the risk of testicular damage and a large number of local hematoma. To avoid the disadvantage of re-operating through scar tissue and dense fibrotic scar tissue around the mesh, the open posterior pre peritoneal mesh repair was popularized by Nyhus as a good alternative for recurrent inguinal hernias. In previous study, Saber and co-workers reported that open pre peritoneal hernia repair offers many advantages over the trans inguinal repair for recurrent hernia. This approach gives results far superior to those of the commonly used anterior approach.
Methods: Patients in this study were divided consecutively in two main groups: A and B. Group A patients were subjected to open posterior preperitoneal approach, those of group B were subjected to transinguinal anterior tension-free repair. All of our patients were gentlemen with total number was 60 patients; 30 for each group, their ages ranged between 42 and 65 years. The study duration was from January 2009 to January 2011 in department of general surgery, B.J Medical college and civil hospital, Ahmedabad, India.
Results: There was no statistical difference between the two groups regarding patients' age and body mass index. Age ranged between 42 and 65 years with a mean age as 53.5 years. The mean operative time in group A was 71.3 min±25.2 (40-120). In group B, the mean value was 94.5 min±28.5 (60-150). The mean hospital stay was 1- 3 days (2.1 ± 0.8) in group A and 2-6 days (3.7 ± 1.5) in group B. In the other hand, the mean time to return work was 8.2±1.15 (7-10) days in group A while in group B was 11.2 ± 2.3 (7-15) . Therefore, the mean time off from work in group A was 10.3 ± 1.95 days and in group B was 14.9±3.8 (P < 0.05).Chronic postoperative pain was observed in 4 patients in group A (13.33%) , in 9 patients in group B (30%).
Conclusions: In recurrent inguinal hernia, the open posterior approaches are more effective in term of operative outcome. The open pre peritoneal hernia repair offers many advantages. It is inexpensive, has a low recurrence rate, and allows the surgeon to cover all potential defects with one piece of mesh. Postoperative recovery is short and postoperative pain is minimal. This approach gives results far superior to those of the commonly used anterior approach.
Read RC. The development of inguinal herniorrhaphy. Surg Clin North Am. 1984;64(2):185-96.
Eubanks WS. Hernia. In: Sabiston Textbook of Surgery 16e. 16 edn. Edited by CMT. Philadelphia, Pennsylvania. W.B. Saunders Company. 2001;198.
Patino J. A history of the treatment of hernia. In: Hernia 5th edn. Edited by NyhusLM CR. Philadelphia: Lippincott; 2002:17-28.
Amid PK. Groin hernia repair: open techniques. World J Surg. 2005;29(8):1046-51.
Lau WY. History of treatment of groin hernia. World J Surg. 2002;26(6):748-59.
Saber A, Ellabban GM, Gad M, Elsayem K. Open pre peritoneal versus anterior approach for recurrent inguinal hernia: A randomized study. BMC Surg. 2012;12:22.
Nyhus LM, Pollak R, Bombeck CT, Donahue PE. The pre peritoneal approach and prosthetic buttress repair for recurrent hernia. The evolution of a technique. Ann Surg.1988;208:733-7.
Hamza Y, Gabr E, Hammadi H, Khalil R. Four arm randomized trial comparing laparoscopic and open hernia repairs. Egyptian J Surg. 2009;28:110-7.
Katri KM. Open pre peritoneal mesh repair of recurrent inguinal hernia. Hernia. 2009;13:585-9.
Karatepe O, Acet E, Altiok M, Adas G, Cakyr A, Karahan S. Pre peritoneal repair (open posterior approach) for recurrent inguinal hernias previously treated with lichtenstein tension-free hernioplasty. Hippokratia. 2010;14:119-21.
Aasvang EK, Gmaehle E, Hansen JB, Gmaehle B, Forman JL, Schwarz J, et al. Predictive risk factors for persistent postherniotomy pain. Anesthesiology.2010;112:957-69.
Massaron S, Bona S, Fumagalli U, Battafarano F, Elmore U, Rosati R. Analysis of post-surgical pain after inguinal hernia repair. A prospective study of 1,440 operations. Hernia. 2007;11:517-25.
Farooq O, Rehman BU. Recurrent inguinal hernia repair by open pre peritoneal approach. J Coll Physicians Surg Pak. 2005;15:261-5.
Farooq O, Batool Z, Din AU, Ullah AA, Butt Q, Kibryia RI. Anterior tension-free repair versus posterior pre peritoneal repair for recurrent hernia. J Coll Physicians Surg Pak. 2007;17:465-8.
Kurzer M, Belsham PA, Kark AE. Prospective study of open pre peritoneal mesh repair for recurrent inguinal hernia. Br J Surg. 2002;89:90-3.
Beg MA, Mehdi SH, Siddiqui SS. Early complications of inguinal hernia repair. Prof Med J. 2007;14:119-22.
Chu L, Averch TD, Jackman SV. Testicular infarction as a sequela of inguinal hernia repair. Can J Urol. 2009;16:4953-4.
Ronka K, Vironen J, Kokki H, Liukkonen T, Paajanen H. Role of orchiectomy in severe testicular pain after inguinal hernia surgery: audit of the Finnish Patient Insurance Centre. Hernia. 2013.
Singh AN, Bansal VK, Misra MC, Kumar S, Rajeshwari S, Kumar A, et al. Testicular functions, chronic groin pain, and quality of life after laparoscopic and open mesh repair of inguinal hernia: A prospective randomized controlled trial. Surg Endosc.2012;26:1304-17.
Lichtenstein IL, Schulman AG. The tension free hernioplasty. Am J Surg. 1989;157:188-9.
Lowham AS, Robert CJ. Mechanism of hernia recurrence after pre peritoneal mesh repair. Annals Surgery. 1997;225(4):422.