A Comparative Study Between Desarda's Technique and Lichtenstein Mesh Repair in Treatment of Inguinal Hernia: A Prospective Randomized Comparative Parallel Study

Inguinal hernia is defined as an abnormal protrusion of abdominal contents through a weakened area in the abdominal wall, specifically in the inguinal region [1]. It represents one of the most common surgical conditions worldwide, with a lifetime risk of 27% in men and 3% in women [2]. The surgical management of inguinal hernia has evolved significantly over the centuries, from simple tissue approximation techniques to sophisticated mesh-based repairs [3].

The history of inguinal hernia repair dates back to ancient times, with documented evidence from Mesopotamian and Egyptian cultures around 1550 BC [4]. The modern era of hernia surgery began in the 19th century with Eduardo Bassini's revolutionary technique in 1884, which involved a layered suture repair of the posterior inguinal wall [5]. This was followed by various modifications, including the Shouldice repair in the 1940s, which utilized a multilayered continuous suture technique under local anesthesia [6].

The introduction of prosthetic materials marked a significant milestone in hernia surgery. Irving Lichtenstein's tension-free mesh repair, described in 1986, revolutionized the field by using polypropylene mesh to reinforce the weakened abdominal wall without creating tension [7]. This technique rapidly gained popularity due to its simplicity, reproducibility, and low recurrence rates, eventually becoming the gold standard for inguinal hernia repair [8]. The European Hernia Society guidelines in 2009 recommended mesh-based techniques, particularly the Lichtenstein repair, as the treatment of choice for primary inguinal hernia in adult men (strength of recommendation 1A) [9].

Despite its widespread acceptance, Lichtenstein mesh repair is not without limitations. The implantation of synthetic mesh can lead to complications such as foreign body sensation, chronic groin pain, abdominal wall stiffness, and surgical site infections [10]. Chronic groin pain following mesh repair has been reported in up to 19% of patients, significantly affecting quality of life [11]. Additionally, mesh-related complications including migration, erosion into adjacent structures, and inflammatory reactions have been documented [12]. These concerns have renewed interest in tissue-based repair techniques that avoid synthetic materials.

Desarda's technique, introduced in 2001, represents a tissue-based approach to inguinal hernia repair [13]. This method utilizes a strip of the external oblique aponeurosis to reinforce the posterior wall of the inguinal canal, creating a dynamic, physiologically functional repair without the use of synthetic mesh [14]. The technique is based on the principle that the external oblique aponeurosis provides adequate strength for repair when properly mobilized and sutured [15]. Preliminary studies have shown promising results with Desarda's technique, including low recurrence rates and reduced incidence of chronic pain compared to mesh repairs [16].

The International Guidelines for Groin Hernia Management (2018) noted that while Desarda's technique has shown promising results in non-randomized studies, the level of evidence remains moderate, and no specific recommendations could be formulated [17]. This highlights the need for well-designed randomized controlled trials to evaluate the efficacy of Desarda's technique compared to the established Lichtenstein repair.

Several studies have compared these two techniques with varying results. Youssef et al. reported no significant differences in recurrence rates between Desarda and Lichtenstein repairs in a 2-year follow-up study [18]. Szopinski et al. found similar outcomes in terms of chronic pain and recurrence at 3 years [19]. However, most of these studies had relatively small sample sizes and limited follow-up periods, leaving questions about the long-term efficacy of Desarda's technique.

The primary research gap lies in the lack of high-quality evidence comparing these two techniques in diverse populations, particularly in resource-limited settings where mesh procurement may be challenging. Additionally, there is a need to evaluate the cost-effectiveness and patient-reported outcomes following these procedures.

This study aimed to compare the efficacy of Desarda's technique and Lichtenstein mesh repair in the treatment of inguinal hernia, with a focus on post-operative pain, complications, and long-term outcomes. The primary objective was to assess and compare post-operative pain between the two techniques, while secondary objectives included comparing operating time, complications, length of hospital stay, chronic groin pain, and recurrence rates..

This prospective randomized comparative parallel study was conducted at the Department of General Surgery, Deen Dayal Upadhyay Hospital, New Delhi, between May 2022 and May 2024.

Sample Size Calculation

The sample size was calculated based on a previous study by Prakash et al. (2018), which reported the proportion of patients with pain up to 7 days as 23.3% in the Desarda group and 46.7% in the Lichtenstein group. Using the formula for comparing two proportions with 95% power and 95% confidence interval, the required sample size was calculated as 39 patients per arm. Considering potential loss to follow-up, a total of 100 patients were randomized (50 in each group).

Selection of Patients

Inclusion Criteria

1.       Age more than 20 years

2.       Uncomplicated inguinal hernia

3.       Strong external oblique aponeurosis (assessed clinically based on compactness of fibers, absence of splaying, and lack of flabbiness)

Exclusion Criteria

1.       Femoral or obturator hernia

2.       Recurrent hernia

3.       Inadequate external oblique aponeurosis for Desarda repair

Randomization

Block randomization with sealed envelope system was employed. Ten randomly generated treatment allocations were prepared within sealed opaque envelopes, assigning five patients to each group (A: Desarda technique, B: Lichtenstein technique). Patients were randomized in blocks of ten, ensuring equal distribution between groups.

Surgical Techniques

Both procedures were performed under spinal anesthesia by experienced surgeons.

Desarda Technique

The external oblique aponeurosis was assessed for adequacy in repairing the posterior wall of the inguinal canal. Through a standard oblique inguinal incision, the external oblique was incised in line with the upper crus of the superficial ring. The hernia sac was excised in all cases except direct hernias, where it was inverted. The medial leaf of the external oblique aponeurosis was sutured to the inguinal ligament from the pubic tubercle to the abdominal ring using continuous polypropylene No. 1 sutures. A splitting incision was made in the sutured medial leaf, creating a 1-2 cm wide strip while maintaining its medial insertion and lateral continuation. The upper free border of this strip was sutured to the internal oblique or conjoined muscle using continuous polypropylene No. 1 sutures, positioning the strip behind the cord to form a new posterior wall. The spermatic cord was then placed in the inguinal canal, and the lateral leaf of the external oblique was sutured to the newly formed medial leaf.

Lichtenstein Technique

An oblique incision was made from the internal to the external ring. After opening the abdominal wall layers, the spermatic cord was dissected, and the hernia sac was managed according to its type (inverted for direct hernias, ligated and excised for indirect hernias). A 7.5×15 cm piece of polypropylene mesh was placed over the posterior wall, behind the spermatic cord at the deep inguinal ring. The mesh was secured to the inguinal ligament and conjoint tendon using polypropylene No. 1 sutures. The external oblique was closed with 2-0 polyglactin, followed by closure of the subcutaneous tissue and skin.

Follow-up Protocol

1.       Patients were followed up for a minimum period of 18 months. Clinical assessments were performed on post-operative day 1, day 7, day 14, at 1 month, and then at 3-month intervals. The following outcomes were evaluated:

2.       Operating time: Calculated from skin incision to completion of skin suturing.

3.       Post-operative pain: Assessed using the Visual Analogue Scale (VAS) ranging from 0 (no pain) to 10 (worst possible pain). Patients were instructed to take analgesics when VAS score was ≥3.

4.       Complications: Presence of seroma, hematoma, and surgical site infection was recorded.

5.       Length of hospital stay: Calculated from the day of operation to discharge.

6.       Chronic groin pain: Defined as persistent pain in the groin after 3 months of surgery, assessed using VAS.

7.       Recurrence: Clinically assessed during follow-up visits.

Statistical Analysis

Data were analyzed using appropriate statistical methods. Continuous variables were presented as mean ± standard deviation (SD) and compared using Student's t-test for normally distributed data or Mann-Whitney U test for non-normally distributed data. Categorical variables were presented as frequencies and percentages and compared using chi-square test or Fisher's exact test as appropriate. A p-value <0.05 was considered statistically significant. Statistical analysis was performed using SPSS version 25.0 (IBM Corp., Armonk, NY, USA).

A total of 104 patients were assessed for eligibility, of which 100 were randomized to either Desarda's technique (n=50) or Lichtenstein mesh repair (n=50). Three patients in the Desarda group did not receive the allocated intervention due to inadequate external oblique aponeurosis. Five patients were lost to follow-up (2 in the Desarda group and 3 in the Lichtenstein group). Thus, 45 patients in each group completed the study and were included in the final analysis.

Demographic and Clinical Characteristics

The demographic and clinical characteristics of the study participants are presented in Table 1. The mean age was 44.67±10.70 years in the Lichtenstein group and 45.64±11.83 years in the Desarda group, with no statistically significant difference (p=0.682). All participants were male. The hernia was right-sided in 57.8% of patients in the Lichtenstein group and 53.3% in the Desarda group, with no significant difference between groups (p=0.671).

Primary Outcome: Post-operative Pain

Post-operative pain assessed using VAS showed no statistically significant differences between the two groups at any time point (Table 2). On post-operative day 0, the mean VAS score was 4.49±0.73 in the Lichtenstein group and 4.31±0.85 in the Desarda group (p=0.185). By post-operative day 7, the mean VAS scores had decreased to 0.07±0.45 in the Lichtenstein group and 0.11±0.53 in the Desarda group (p=0.577). At 1 month, the mean VAS score was 0.00±0.00 in the Lichtenstein group and 0.07±0.45 in the Desarda group (p=0.328).

Secondary Outcomes

Operating Time

The mean operating time was 43.40±4.18 minutes in the Lichtenstein group and 43.47±4.74 minutes in the Desarda group, with no statistically significant difference (p=0.868) (Table 2).

Complications

No cases of seroma, hematoma, or surgical site infection were observed in either group during the study period (Table 3).

Length of Hospital Stay

All patients in both groups were discharged after 24 hours as per hospital protocol, with no differences in length of hospital stay between groups.

Chronic Groin Pain

At 3 months, no patients in either group reported chronic groin pain. At 6 months, chronic groin pain was reported by 1 patient (2.2%) in the Lichtenstein group and 2 patients (4.4%) in the Desarda group (p=1.000). At 12 months, 1 patient (2.2%) in the Lichtenstein group reported chronic groin pain, while no patients in the Desarda group reported pain (p=1.000) (Table 3).

Recurrence

No recurrences were observed in either group during the 18-month follow-up period.

Table 1: Demographic and Clinical Characteristics of Study Participants

SD: Standard deviation

Table 2: Comparison of Operating Time and Post-operative Pain Between Groups

VAS: Visual Analogue Scale; POD: Post-operative day; SD: Standard deviation

Table 3: Comparison of Complications, Chronic Groin Pain, and Recurrence Between Groups

This prospective randomized comparative study evaluated the efficacy of Desarda's tissue-based technique versus Lichtenstein mesh repair for inguinal hernia treatment. The findings demonstrate that both techniques have comparable outcomes in terms of post-operative pain, operating time, complications, hospital stay, chronic groin pain, and recurrence rates during an 18-month follow-up period.

The primary outcome of post-operative pain showed no significant differences between the two groups at any time point. This finding is consistent with several previous studies. Youssef et al. reported no significant differences in mean postoperative VAS scores for pain between Desarda and Lichtenstein repairs in their study of 168 patients [18]. Similarly, Szopinski et al. found no significant differences in post-operative pain between the two techniques in their 3-year follow-up study of 208 patients [19]. These results suggest that Desarda's technique, despite being a tissue-based repair, provides similar pain control to the established mesh-based Lichtenstein repair.

The mean operating time was comparable between the two groups in our study (43.40±4.18 minutes for Lichtenstein vs. 43.47±4.74 minutes for Desarda). This contrasts with some previous studies that reported shorter operating times for Desarda's technique. For instance, Youssef et al. found a significantly shorter operating time for Desarda repair (59.4±6.3 minutes) compared to Lichtenstein repair (72.3±12.2 minutes, p<0.001) [18]. Similarly, Ahmed et al. reported shorter operating times for Desarda repair (29 minutes) compared to Lichtenstein repair (40 minutes) [20]. The discrepancy between our findings and these studies may be attributed to differences in surgical expertise, institutional protocols, or patient characteristics.

No complications such as seroma, hematoma, or surgical site infection were observed in either group in our study. This is in contrast to some previous studies that reported higher complication rates with Lichtenstein repair. Szopinski et al. found significantly higher rates of seroma and surgical site infection in the Lichtenstein group compared to the Desarda group (5.8% vs. 3.8% for seroma and 1.9% vs. 0.9% for SSI, respectively) [19]. Prakash et al. reported no complications in the Desarda group but observed surgical site infections in 10% of patients in the Lichtenstein group [21]. The absence of complications in our study may be attributed to meticulous surgical technique, proper patient selection, and adherence to aseptic protocols.

Chronic groin pain is a significant concern following inguinal hernia repair, with reported rates ranging from 0% to 37% [22]. In our study, at 12 months, only one patient (2.2%) in the Lichtenstein group reported chronic groin pain, while no patients in the Desarda group reported pain. Although this difference was not statistically significant, it aligns with the theoretical advantage of Desarda's technique in reducing chronic pain by avoiding mesh-related nerve entrapment and inflammatory reactions. Desarda proposed that mesh may cause extensive fibrosis, leading to nerve entrapment and chronic groin pain [23]. Several studies have reported lower rates of chronic pain with Desarda's technique compared to mesh repairs [24,25]. However, the presence of chronic pain in some patients following Desarda's repair in our study suggests that factors other than mesh, such as nerve injury during dissection or fibrosis from tissue mobilization, may also contribute to this complication.

No recurrences were observed in either group during the 18-month follow-up period in our study. This finding is consistent with several previous studies that reported low recurrence rates with both techniques. Youssef et al. reported no recurrences in either group after two years of follow-up [18]. Similarly, Prakash et al. observed no recurrences in either group during a 6-month follow-up period [21]. However, longer follow-up periods may be necessary to adequately assess recurrence rates, as some studies have reported recurrences occurring beyond 18 months [26,27].

The comparable outcomes between Desarda's technique and Lichtenstein repair observed in our study have important clinical implications, particularly in resource-limited settings. Desarda's technique eliminates the need for synthetic mesh, reducing the cost of surgery and avoiding mesh-related complications. This makes it an attractive option in settings where mesh procurement is challenging or cost-prohibitive. Additionally, the tissue-based nature of Desarda's technique may be preferable in cases where mesh implantation is contraindicated, such as in patients with contaminated fields or history of mesh-related complications.

Our study has several limitations. First, it was conducted at a single institution, which may limit the generalizability of the findings. Second, the sample size, although calculated based on previous studies, may be insufficient to detect small differences in outcomes, particularly for rare events such as recurrences. Third, the follow-up period of 18 months may be inadequate to assess long-term outcomes, especially recurrence rates, which may occur beyond this timeframe. Fourth, the study included only male patients, limiting the applicability of the findings to female patients with inguinal hernia. Finally, the assessment of external oblique aponeurosis strength was subjective and based on clinical evaluation, which may introduce bias in patient selection for Desarda's technique.

Future research should address these limitations through multicenter studies with larger sample sizes, longer follow-up periods, inclusion of female patients, and objective assessment of tissue adequacy for Desarda's repair. Additionally, cost-effectiveness analyses and patient-reported outcome measures should be incorporated to provide a more comprehensive evaluation of these techniques.

This prospective randomized comparative study demonstrates that Desarda's tissue-based technique is comparable to Lichtenstein mesh repair in the treatment of inguinal hernia. Both techniques showed similar outcomes in terms of post-operative pain, operating time, complications, length of hospital stay, chronic groin pain, and recurrence rates during the 18-month follow-up period. The absence of recurrences in either group highlights the efficacy of both techniques in preventing hernia recurrence. The comparable outcomes between these two approaches suggest that Desarda's technique may serve as a viable alternative to Lichtenstein repair, particularly in resource-limited settings where mesh procurement is challenging. The tissue-based nature of Desarda's technique eliminates mesh-related complications and reduces the cost of surgery, making it an attractive option for healthcare systems with limited resources. These findings contribute to the growing body of evidence supporting tissue-based repairs for inguinal hernia and provide surgeons with an effective alternative to mesh-based repairs.

1.       Kingsnorth A, LeBlanc K. Hernias: inguinal and incisional. Lancet. 2003;362(9395):1561-1571.

2.       Burcharth J, Pedersen M, Bisgaard T, Pedersen C, Rosenberg J. Prevalence of groin hernia repair in risk of inguinal hernia incidence in men. Br J Surg. 2017;104(8):1068-1074.

3.       Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009;13(4):343-403.

4.       Skandalakis JE, Colborn GL, Skandalakis LJ, et al. Groin hernia: anatomical and surgical history. Arch Surg. 2006;141(10):1035-1042.

5.       Read RC. The centenary of Bassini's contribution to inguinal herniorrhaphy. Am J Surg. 1987;153(3):324-326.

6.       Rutkow IM, Robbins AW. Demographic, classificatory, and socioeconomic aspects of hernia repair in the United States. Surg Clin North Am. 1993;73(3):413-426.

7.       Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. The tension-free hernioplasty. Am J Surg. 1989;157(2):188-193.

8.       Amid PK. Lichtenstein tension-free hernioplasty: its inception, evolution, and principles. Hernia. 2004;8(1):1-16.

9.       Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009;13(4):343-403.

10.    Amato G, Romano G, Agrusa A, et al. Long-term follow-up of laparoscopic inguinal hernia repair in pregnant women. Surg Endosc. 2017;31(4):1816-1820.

11.    Bay-Nielsen M, Perkins FM, Kehlet H. Pain and functional impairment 1 year after inguinal herniorrhaphy: a nationwide questionnaire study. Ann Surg. 2001;233(1):1-7.

12.    Brown CN, Finch JG. Which mesh for hernia repair? Ann R Coll Surg Engl. 2010;92(4):272-278.

13.    Desarda MP. New method of inguinal hernia repair: a new solution. ANZ J Surg. 2001;71(4):241-244.

14.    Desarda MP. Physiological repair of inguinal hernia: a new technique (study of 860 patients). Hernia. 2006;10(2):143-146.

15.    Desarda MP. Surgical physiology of inguinal hernia repair: a study of 200 cases. BMC Surg. 2003;3:5.

16.    Desarda MP. Desarda's repair for inguinal hernia. Indian J Surg. 2016;78(4):298-302.

17.    Hynes DM, Stroupe KT, Luo P, et al. Cost-effectiveness of laparoscopic versus open mesh repair for elective inguinal hernia repair. J Am Coll Surg. 2006;203(4):497-507.

18.    Youssef T, El-Alfy K, Farid M. Randomized clinical trial of Desarda versus Lichtenstein repair for treatment of primary inguinal hernia. Int J Surg. 2015;20:28-34.

19.    Szopinski J, Dabrowiecki S, Pierscinski S, Jackowski M, Jaworski W, Szczepanik AM. Desarda versus Lichtenstein technique for primary inguinal hernia treatment: 3-year results of a randomized clinical trial. World J Surg. 2012;36(5):984-992.

20.    Ahmed R, Khan FA, Khan AA, et al. Desarda versus Lichtenstein repair for inguinal hernia: a randomized, multi-center controlled trial with promising results. Int Surg J. 2018;5(8):2723-2726.

21.    Prakash PB. Comparative study of open mesh repair and Desarda's no mesh repair for inguinal hernia, in GMKMCH, Salem, India. Int J Surg. 2018;5(9):3139-3145.

22.    Aasvang EK, Mohl B, Bay-Nielsen M, Kehlet H. Pain related sexual dysfunction after inguinal herniorrhaphy. Pain. 2006;122(3):258-266.

23.    Desarda MP. Desarda's repair for inguinal hernia. Indian J Surg. 2016;78(4):298-302.

24.    Abbas Z, Bhat SK, Koul M, Bhat R. Desarda's no mesh repair versus Lichtenstein's open mesh repair of inguinal hernia: a comparative study. J Evol Med Dent Sci. 2015;4(77):13279-13286.

25.    Manyilirah W, Kijjambu S, Mpairwe H, et al. Comparison of non-mesh (Desarda) and mesh (Lichtenstein) methods for inguinal hernia repair among black African patients: a short-term double-blind RCT. Hernia. 2012;16(2):133-144.

26.    Rodriguez PR, Gonzàlez OC, et al. A randomized trial comparing Desarda repair no mesh and Lichtenstein repair for inguinal hernia (A study of 2225 patients). Biomed J Sci Tech Res. 2018;6(4):5445-5449.

27.    Mitura K, Romańczuk M. Comparison between two methods of inguinal hernia surgery--Lichtenstein and Desarda. Pol Merkur Lekarski. 2008;24(143):392-395.