1. Abstract 1.1. Introduction: The objective of this study is to compare the outcomes of Modified Desarda repair no mesh and Lichtenstein repair for inguinal hernia. 1.2. Methods: This is a prospective randomized controlled trial study of 1342 patients having 1394 hernias operated from January 2008 to December 2020. 690 patients were operated using Lichtenstein repair and 652 using Desarda repair. The demographie data (Age,Sex) , hernia type and location, anesthetic, operative time, postoperative pain and complications were analysed. 1.3. Results: There were no significant differences regarding age, sex, location, type of hernia, and pain in both the groups. The operation time was 52 minutes in Modified Desarda group and 42 minutes in the Lichtenstein group that is significant (p< 0.05). The recurrence was 0.0 % in Modified Desarda group and 0.28 % in Lichtenstein group. But, there were 9 cases of infection to the polypropylene mesh in the Lichtenstein group, 2 of this required re-exploration. The morbidity was also significantly more in Lichtenstein group (7,6 %) as compared to Modified Desarda group (3.8 %). The mean time to return to work in the Modified Desarda group was 8.26 days while a mean of 12.58 days was in the Lichtenstein group. The mean hospital stay was 29 hrs. in Modified Desarda group while it was 49 hours in the Lichtenstein group in those patients who were hospitalized. 1.4. Conclusions: The modified Desarda repair scores significantly on Lichtenstein repair in most of all aspects, including reexplorations and morbidity. Modified Desarda repair is a better option compared to Lichtenstein repair.
Keywords: Desarda Repair; Inguinal Hernia; Lichtenstein Repair; Randomized Trial
2. Introduction In 1890, Eduardo Bassini described suture repair for inguinal hernia. This was a massive leap forward and has been the basis of open repair for over 100 years. The surgeon enters the inguinal canal by opening its anterior wall, the external oblique aponeurosis. The spermatic cord is dissected free and the presence of a lateral or a medial hernia is confirmed. The sac of a lateral hernia is separated from the cord, opened and any contents reduced. The sac is then sutured closed at its neck and excess sac removed. If there is a medial hernia, then it is inverted and the transversalis fascia is suture plicated. Sutures, are now placed between the conjoint tendon above and the inguinal ligament below, extending from the pubic tubercle to the deep inguinal ring. The posterior wall of the inguinal canal is thus strengthened.1Over 150 modifications to the Bassini operation have been described with little or no benefit except for the Should ice modification. In this operation, the transversalis fascia is opened by a central incision from deep inguinal ring to the pubic tubercle and then closed to create a double-thick, two-layered posterior wall (double breasting). The external oblique is closed in similar fashion. Expert centres have reported lifetime failure rates of less than 2 per cent after Should ice repair but it is a technically demanding operation which, in general hands, gives results identical to the Bassini repair. 1.
3. Method This study was designed as a RCT(Randomized Controlled Clinical Trial)among the 1342 patients (652 patients of Modified Desarda’s technique {modification of Desarda’s technique by adding Modified Bassini’s technique [Darn with continuoussuturing with non-absorbable polypropylenesuture]} and 690 patients of Lichtenstein procedure alone) of inguinal herniain Surgery Unit 1 & 2, Enrique Cabrera Hospital, Havana Cuba from a period of January 2008 to December 2020 with a viewto depict the short & intermediate term (05years) outcomes of newly proposed Modified Desarda’s technique in contrast to Lichtenstein procedure. All the patients from both sexes older than 16 years with primary and recurrent inguinal hernias were included. Patients operated on emergency basis were excluded. The diagnosis of inguinal hernia and its type was made by clinical examination. Information was given to the patients as regards the anesthetic procedures. The patient chose type of anaesthesia after discussion with the surgeon. The Randomization was performed using a consecutively numbered, sealed envelope, which was opened, in theatre and all patients having an even number were operated by the Lichtenstein and uneven numbers by the modified Desarda technique. The operating surgeon completed a data sheet. The operating surgeon was at consultant level for all operations. The evaluator was also a surgeon of consultant level. All patients signed a written informed consent. Approval of the local ethical committee was given prior to the onset of the study. Modified Desarda repair was performed according to the surgical technique described by Dr. Desarda and mesh prosthesis repair was undertaken as described in the textbooks. Prophylactic antibiotic was administered in the operating room before surgery (Cefazoline 1g.) in the Lichtenstein group only. All patients were discharged as soon as their post-surgical recovery allowed, and all patients were instructed to do daily, routine, non-strenuous work after discharge. A non-steroidal anti-inflammatory (Diclofanac) analgesic was prescribed for a period of 5 days and continued if required. The consultants followed all the patients at 8 days, 1 month, 6 months and then yearrequired. The consultants followed all the patients at 8 days, 1 month, 6 months and then yearly thereafter. A data sheet was completed by the operating surgeon including type of hernia (Nyhus classification) [4], anaesthesia, technical details and intra-operative complications. At discharge, further data was added including any early post-operative complications. Patients were asked to complete a pain score on the first, third and fifth day after surgery using a linear analogue scale [5,6]. At first follow up, one month after surgery, further data were collected including time to return to normal activities. The Student T test was used to compare the independent measures and the Mann Whitney-U test for non-parametric data. The Chi-squared test and Fisher’s exact test were used to measure the association between quality variables.
4. Results There was no significant difference in relation to sex, age, location and type of inguinal hernia in both the groups. (Table 1). Local anesthesia was used in 294 patients in Lichtenstein group and 399 patients in the Desarda group. All those 707(53.0%) patients were operated on as outpatient basis without hospitalization. In the remainder of 635 patients who were treated as in-patients, the mean hospital stay was 27 hours in Desarda group and 47 hours in the Lichtenstein group (p<0.05) (Table 2).
5. Discussion Mesh repair is now widely used in the developed world and is often referred to as the gold standard despite the relative shortage of clinical trials comparing mesh with suture repair. The cost of surgery [7] and postoperative morbidity that affects the quality of life are important considerations in inguinal hernia surgery. There is no clear scientific evidence to show that prosthetic mesh repair is superior to non-prosthetic repair in this regard [8]. There are advantages and disadvantages associated with all types of open inguinal hernia repairs. The existing non-prosthetic repair (Bassini / Shouldice) is blamed for causing tension in the tissue and the prosthetic mesh repair is attributed to the known complications of a foreign body. Dr. Desarda sutures a strip not separated from the external oblique aponeurosis between the muscular arch and the inguinal ligament to give a strong and physiologically dynamic posterior wall [9]. This results in a tension-free repair without the use of any foreign body. By being simple to perform, it eliminates the disadvantage of the technical difficulty observed with the ice repair should. Different studies have tried to give an answer on which of the existing operations is the best for the repair of inguinal hernia [10,11]. The collaboration of EU Hernia Trialist [12] conducted a systematic review of prospective randomized studies and the analysis of the results of these different studies. He showed that the duration of surgery was shorter in hernioplasty in six studies, longer in three and equal in the remaining six. In our group, there was a significant but slight increase in the operating time with the Desarda operation. Postoperative pain after prosthetic mesh repair may be less than after ice repair in case of reduced tension [12,13]. Our results have shown that there are no significant differences between the two groups for pain from the first to the fifth day after surgery. We found no significant differences in the analgesic requirements between the techniques. The overall morbidity was 5.4%, which is similar to the rates described in other studies (7-12%) [14]. The morbidity rate was higher after Lichtenstein repair (46 cases, 7.1% versus 5.4.0% in the modified Disarda group). There were 8 mesh infections after surgery in the Lichtenstein group. Two cases required partial excision of the mesh and in case, it was associated with recurrence. The modified Desarda technique has a lower morbidity compared to hernioplasty of Discussion We believe that no cases of recurrences observed in the modified Desarda group were due to the adequate lateralization of the cord and the sufficient narrowing of the inner ring as advised by Desarda.
6. Conclusion It was demonstrated that the recently proposed Modified Disarming Technique (combined approach of the Desarda and Modified Bassini technique) is a stronger repair for inguinal hernia in terms of late recurrence and that the use of meshes in the Lichtenstein Technique results in greater morbidity, rejections and reexplorations can be found, which cause discomfort to our patients and their families.
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Pedro Rolando López Rodríguez. Modifield Desarda Repair and Hernioplastia Lichtenstein Repair For Inguinal Hernia. Annals of Clinical and Medical Case Reports 2021.