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Hernia (2010) 14:357–360
DOI 10.1007/s10029-010-0663-2
ORIGINAL ARTICLE
Lichtenstein or darn procedure in inguinal hernia repair:
a prospective randomized comparative study
H. F. Kucuk · H. E. Sikar · N. Kurt · H. Uzun ·
M. Eser · F. Tutal · Y. Tuncer
Received: 19 August 2009 / Accepted: 9 April 2010 / Published online: 12 May 2010
© Springer-Verlag 2010
Abstract Introduction
Background The aim of this study was to assess the out-
come of patients with inguinal hernia where the Moloney Inguinal hernia repairs can be performed conventionally
darn or Lichtenstein procedure was used as the surgical or laparoscopically by using diVerent methods. The pur-
choice. poses of these methods are obtaining lower recurrent
Method A herniorrhaphy procedure was performed in a rates, better pain-free postoperative periods, and shorter
total of 306 patients at our clinic between January 2003 and convalescence periods [1]. The recurrence rate of tradi-
December 2008. The duration of operations and complica- tional sutured hernia repair techniques is reported to be
tion and recurrent rates were compared between the two between 0.7 and 9.3% [2]. On the other hand, the recur-
groups. Hematoma formation, seroma collection, and rence rate of tension-free mesh repair is less than 1% [3].
wound infection were accepted as early complications, The darn repair, originally described by Moloney [4], is
whereas chronic pain, loss of sensation at the operation site, another tension-free repair method. Mesh repair either
and the rejection of mesh were accepted as late complica- conventionally or laparoscopically is more popular than
tions. the tension-free method, but it is more expensive and can
Results Considering early complications as hematoma cause many complications that cause removal of the
formation, the accumulation of seroma and wound infection mesh as a result [1]. In this study, we compared the
ratios were similar in the two groups. Loss of sensation at results of the Lichtenstein procedure with the darn repair
the operation site and chronic pain, which were classiWed as technique.
late complications, were similar in the groups. However, in
considering rejection, there were three rejections in the
group where mesh was used. Materials and methods
Conclusion The darn repair method is simple, safe, and
has similar recurrence rates when compared to the Lichten- This prospective comparative study was performed at our
stein method in inguinal hernia patients. surgical clinic between January 2003 and December 2008.
The study included 306 patients with inguinal hernia,
Keywords Inguinal hernia · Moloney darn repair · which were divided into two groups. Group I included 176
Lichtenstein repair · Recurrence rate patients and darn repair was performed. Group II included
130 patients and Lichtenstein procedure was performed as
the hernia repair method. The patients had inguinal hernia
as a primary disease and recurrent hernia and incarcerated
H. F. Kucuk (&) · H. E. Sikar · N. Kurt · H. Uzun · hernias were not included. Patients were randomly chosen.
M. Eser · F. Tutal · Y. Tuncer Informed consent from all of the patients was obtained. The
Kartal Research and Education Hospital, operations were performed by four surgeons who were
Petrol-is mh. Sh. Dursun Bakan Sk. Hilal Sit. A Blok D:21, experienced in hernia repair or were performed under the
34862 Kartal, Istanbul, Turkey
e-mail: hasan.kucuk@sbkeah.gov.tr control of these surgeons.
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358 Hernia (2010) 14:357–360
Our darn method was performed by suturing between the wound infection, or suspicion of recurrence during physical
inguinal ligament and fascia of the internal oblique muscle examination.
fascia by using O monoWlament polyprolene suture. The The data were collected postoperatively after the 1st
Wrst suture began at the medial site from the pubic tubercle week, 1st, 3rd, 6th, and 12th month, and 2nd and 3rd year,
and continued to the site of the internal inguinal ring. After or at any time which the patients needed admission due to
placing the Wrst suture, a second suture was done 1 cm for- any of the problems deWned above. The data were assessed
ward and was continued between the inguinal ligament and with SPSS 10.0. The statistical analyses were done using
the internal oblique muscle fascia (Fig. 1). The sensory the unpaired t-test and the Chi-square test.
nerves were preserved in all cases with gentle tissue han-
dling, gentle dissection, meticulous hemostasis, and avoid-
ance of extensive thermal injury. Results
We used a 7.5 £ 15-cm polypropylene mesh in Group
II. The mesh was positioned on the inguinal Xoor between The number of patients in group I was 176 and there were
the inguinal ligament and the internal oblique muscle fas- 130 patients in group II. The mean age, follow-up time,
cia. The meshes were provided by our institution and origi- operation time, sex distribution, side of hernia, and type of
nated from diVerent companies. hernia between groups were similar. The demographic Wnd-
The duration of operations and complication and recur- ings are shown in Table 1. Considering early complications
rent rates were compared between the two groups. Hema- such as hematoma formation, accumulation of seroma, and
toma formation, seroma collection, and wound infection wound infection, the ratios were similar in the two groups.
were accepted as early complications, whereas chronic Loss of sensation at the operation site and chronic pain,
pain, loss of sensation at the operation site, and the rejec- which were classiWed as late complications, were also simi-
tion of mesh and recurrence 6 months after the operation lar in the groups. However, in considering rejection, there
were accepted as late complications. Rejection was were three rejections in the group in which mesh was used.
accepted in the presence of redness of the operative site and The rejection times were 6, 7, and 13 months after the oper-
discharge from the wound and the absence of bacterial ations, respectively. Complications after inguinal hernia
growth in culturing studies. Before obtaining the results of operation are shown in Table 2.
culturing studies, a sultamicillin 750 mg tablet twice a day
was prescribed for 10 days. The patients were observed for
about 2 months. In the secondary operation, the mesh was Discussion
not attached to surrounding tissue, as it was excluded from
the body and was removed. Wound infection was deWned Many types of operative management have been described
purulent discharge or the presence of microorganisms in the repair of inguinal hernias and much clinical investi-
which were present in culture studies in any discharge. gation has been performed. The anterior approach, poster-
Chronic pain was deWned as the continuation of pain after ior approach, laparoscopic, and open operations have been
2months which required painkillers. The ultrasonographic research. Anterior repair methods are the most common and
examination was performed in the presence of complica- tension-free repairs are now standard procedures. The aims
tions such as hematoma formation, seroma collection, of all these types of operations are to obtain lower recur-
rence rates, lower complication rates, earlier return to daily
activities, and cost-eVectiveness [1].
Tension in a repair method is the principal cause of
recurrence [5]. Using mesh as a prosthetic material has
been described by Lichtenstein in the repair of inguinal her-
nia and is a tension-free method and has become very popu-
lar [6]. The darn method using nylon suture described by
Moloney is also a tension-free method. We compared the
complication and the recurrence rates of both repair proce-
dures in this study. There was no diVerence between the
two groups considering early complications such as hema-
toma formation, seroma formation, and wound infection.
Also, there was no diVerence when considering late compli-
cations such as sensory loss at the operation site and
Fig. 1 Picture of darn method between the inguinal ligament and the chronic pain. Rejection was detected in three of our patients
internal oblique muscle fascia where the Lichtenstein method was used. The Wndings in
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Hernia (2010) 14:357–360 359
Table 1 Demographic data of the patients
n = 306 Group I (n = 176) Group II (n =130) P-value
Mean age (years) § SD 53.82 § 17.37 51.96 § 16.17 NS (0.339)a
Mean follow-up time (months) § SD 24.63 § 13.65 23.23 § 12.65 NS (0.359)b
Mean operation time (min) § SD* 44.83 § 4.49 44.80 § 4.69 NS (0.947)c
Sex (male/female) 146/30 (83%/17%) 102/28 (78.5%/21.5%) NS (0.322)
Side of hernia (right/left/bilateral) 73/82/21 53/55/22 NSd
Type of hernia (indirect/direct/pantaloon) 101/58/17 73/45/12 NSe
NS not signiWcant; Group I: darn repair; Group II: Lichtenstein repair
*Two surgeons performed bilateral hernia repair at the same time
a t =0.957
b t = 0.918
c t =0.066
d P = 0.901/0.456/0.214
e P = 0.830/0.761/0.899
Table 2 Early and late postoperative complications after inguinal her- the side-loop to prevent the rupture of Wbrils. They claim
nia repair that this method is superior to the original darn method.
n = 306 Group I Group II P-value There was no recurrence in their modiWed darn method and
(n =176) (n = 130) a complication rate of only 1.9%. The duration of opera-
Early tions were also similar between the groups in our study, as
in the studies of Zeybek et al. and Kaynak et al. [6, 10].
Hematoma 2 (1.1%) 0 (0%) NS (0.223) Recurrence seen 6 months after the surgery was evalu-
Seroma 3 (1.7%) 3 (2.3%) NS (0.707) ated as late recurrence in our study. Although there is no
Wound infection 9 (5.1%) 7 (5.4%) NS (0.916) consensus on this issue, we believe that recurrence within
Late 6months after the operation may be due to technical insuY-
Sensory loss 1 (0.6%) 1 (0.8%) NS (0.829) ciency. There were no recurrences in our patients, as all of
Chronic pain 1 (0.6%) 0 (0%) NS (0.389) the patients had inguinal hernia as a primary disease and
Rejection 0 (0%) 3 (2.3%) 0.043 recurrent hernia and incarcerated hernias were not included.
NS not signiWcant; Group I: darn repair; Group II: Lichtenstein repair Both methods were also tension-free. Gentle and meticulous
surgery is another reason for decreased recurrence. On the
these patients were similar to the Wndings in the study of other hand, our mean follow-up time was around 24 months.
Hofbauer et al. [7]. The rejection can be due to chronic for- Bisgaard et al. [11] followed primary Lichtenstein mesh and
eign body reactions of the prosthesis used in the surgery. sutured inguinal repair patients for 8 years and observed that
Wang et al. [8] suggested that host versus mesh reaction is cumulative recurrence was increasing in the mesh group
the cause of rejection. Koukourou et al. [9] compared poly- until 5 years postoperatively. In conclusion, the Moloney
prolene mesh with the nylon darn hernia repair method and darn repair method is simple, safe, and has similar recur-
they observed an early complication rate of 28% in the rence rates when compared to the Lichtenstein method in
mesh group versus 33% in the darn group and, also, the late inguinal hernia patients. On the other hand, in the Lichten-
complication rates were 15 and 20% in mesh and darn stein method, there is risk of rejection of the mesh which
groups, respectively; there was no statistically signiWcant requires its removal as result. Although there are a limited
diVerence between the groups. The recurrence rates were number of similar studies comparing the above-mentioned
similar after 1 year, being 4%. The mean follow-up times methods, the Moloney darn repair method can be used in the
were 24.63 § 13.65 and 23.23 § 12.65 months in the darn treatment of primary inguinal hernia.
group and Lichtenstein group, respectively, in our study
and there was no recurrence in the groups. Kaynak et al.
[10] compared the Lichtenstein hernioplasty and Moloney References
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