Inguinal hernia remains one of the most common general surgical conditions worldwide, with a substantial impact on quality of life and health care systems. The ideal surgical approach for primary inguinal hernia repair continues to be a subject of active debate, particularly regarding the use of prosthetic mesh versus tissue-based techniques【1】. The Lichtenstein mesh repair, introduced in the late twentieth century, is widely regarded as the standard of care due to its simplicity, reproducibility, and low recurrence rates. However, mesh-related complications such as chronic groin pain, foreign body sensation, and infection remain notable concerns, motivating renewed interest in alternative techniques【2】.

The Desarda technique, a no-mesh, tension-free tissue repair utilising a strip of external oblique aponeurosis to reinforce the posterior wall of the inguinal canal, has emerged as a promising alternative. Several prospective studies and clinical trials have reported that Desarda’s method may offer comparable recurrence rates to mesh repair, while potentially reducing postoperative pain and eliminating mesh-associated risks【3】【4】. As a result, Desarda’s repair has gained particular traction in regions with limited resources, as well as among patients preferring to avoid synthetic implants.

Despite a growing body of literature, direct comparative data between Desarda and Lichtenstein repairs remain limited, particularly with respect to postoperative recovery, complication rates, cost-effectiveness, and long-term outcomes. Some recent prospective studies suggest that the no-mesh approach is associated with earlier ambulation, lower early postoperative pain, and similar recurrence rates, but these findings are not yet universally accepted and debate persists regarding the optimal surgical technique【5】【6】.

This study aims to address this gap by prospectively comparing perioperative, short-term, economic, and long-term outcomes between Desarda’s tissue-based repair and the Lichtenstein mesh repair in adults with primary inguinal hernia. The results are intended to inform surgical practice and guide evidence-based decision-making for both surgeons and patients.

Objectives

The primary objective of this study was to compare the clinical outcomes of Desarda’s no-mesh tissue-based repair and the standard Lichtenstein mesh repair in adult patients with primary inguinal hernia.

The secondary objectives were:

1. To evaluate and compare perioperative parameters, including operative time and intraoperative complications, between the two techniques.
2. To assess differences in postoperative pain, time to ambulation, short-term morbidity (such as wound infection and local site reactions), and duration of hospital stay.
3. To analyse and compare the economic impact (total procedure cost) of each repair method.
4. To determine the long-term recurrence rates and late complications following Desarda and Lichtenstein repairs over a 12-month follow-up period.

Study Design and Setting

This prospective, randomised, comparative study was conducted in the Department of General Surgery at North 24 Parganas District Hospital, Barasat, West Bengal, India, between January 2016 and October 2016, with a follow-up period of 12 months post-surgery.

Study Population

Inclusion criteria:

• Adults aged ≥18 years of either gender
• Patients with primary, reducible inguinal or inguino-scrotal hernia (unilateral or bilateral)
• Willingness to participate and provide written informed consent

Exclusion criteria:

• Obstructive uropathy or chronic obstructive lung disease (contraindicated for elective hernia surgery)
• Elderly or debilitated patients unable to reliably report outcomes
• Strangulated or recurrent inguinal hernias
• Giant inguinal hernias
• Intraoperative finding of weak, thin, or separated external oblique aponeurosis
• Refusal to participate

Sample Size and Randomisation

The sample size was determined using estimates from previous randomised controlled trials, with 76 patients assigned to each group. Randomisation was accomplished using a computer-generated random number table and sequentially numbered, opaque, sealed envelopes. Allocation was revealed by the operating surgeon immediately prior to surgery.

Surgical Procedures

• Desarda Repair: A strip of external oblique aponeurosis was isolated and sutured to the conjoined tendon and inguinal ligament, reinforcing the posterior wall of the inguinal canal without mesh, as per the original technique.
• Lichtenstein Mesh Repair: A nonabsorbable synthetic mesh was tailored to fit the inguinal canal, slit for passage of the spermatic cord, and fixed to anatomical landmarks, creating a tension-free repair.

Perioperative Management

All patients underwent standard preoperative evaluation (clinical assessment, laboratory tests, ECG, chest X-ray, and abdominal ultrasonography). Premedication with midazolam and single-dose antibiotic prophylaxis were given. Anaesthesia (regional or general) was selected according to patient and anaesthetist preference.

Outcome Measures

Short-term outcomes:

• Operative time
• Postoperative pain (visual analogue scale, VAS, day 1)
• Time to ambulation
• Local complications: induration/redness, wound infection
• Duration of hospital stay
• Total procedure cost

Long-term outcomes:

• Hernia recurrence at 3, 6, and 12 months postoperatively
• Late complications (chronic pain/discomfort)

Data Collection

Clinical data were recorded using a structured proforma covering demographics, clinical history, examination, investigations, intraoperative findings, and postoperative outcomes. Data were entered into Microsoft Excel and analysed with SPSS v21.0.

Statistical Analysis

Continuous variables are presented as mean ± standard deviation (SD) or median (interquartile range) as appropriate. Categorical variables are expressed as counts and percentages. The Kolmogorov–Smirnov test was used to assess normality. Student’s t-test was used for normally distributed continuous variables; the Mann–Whitney U test was used for non-normally distributed variables. Categorical data were compared using Fisher’s exact test. Kaplan–Meier analysis was performed for recurrence-free survival. A p-value <0.05 was considered statistically significant.

Ethical Considerations

The study received approval from the Institutional Ethics Committee of R.G. Kar Medical College, Kolkata. Written informed consent was obtained from all participants before enrolment.

1. Participant Flow and Baseline Characteristics

A total of 152 patients with primary, reducible inguinal or inguino-scrotal hernia were enrolled and randomised: 76 assigned to the Desarda (no mesh) group and 76 to the Lichtenstein (mesh) group. All participants completed the index procedure and were included in the perioperative and short-term analyses. Follow-up rates at 12 months were high, with only minor loss to follow-up due to missing data.

Table 1. Baseline Demographic and Clinical Characteristics by Group

• All values: mean ± SD (range) for age; n (%) for categorical variables.
• No statistically significant differences were observed between groups for any baseline characteristics.

2. Perioperative Outcomes

Operative Time

The mean operative time was 55.7 ± 12.1 minutes for the Desarda group and 50.6 ± 12.5 minutes for the Lichtenstein group. This difference was statistically significant (p < 0.001, independent t-test), with the mesh-based repair requiring less operative time on average. The range of operative times was 32–90 minutes for Desarda and 30–89 minutes for Lichtenstein, reflecting case-to-case variability and some procedural overlap between techniques.

Intraoperative Findings

No major intraoperative complications (such as vascular or visceral injury) were reported in either group. Intraoperative exclusion (due to weak or unsuitable external oblique aponeurosis) accounted for three cases, as outlined in the participant flow.

The Lichtenstein mesh repair was associated with a modestly but significantly shorter operative time, while the tissue-based Desarda technique required more time on average. No intraoperative complications occurred in either group.

Table 2. Perioperative Outcomes by Group

Data are presented as mean ± SD (range for operative time: Desarda 32–90 min, Lichtenstein 30–89 min).

3. Postoperative Recovery

Pain Scores

On postoperative day 1, the mean pain score (VAS) was 3.8 ± 1.2 in the Desarda group and 4.6 ± 1.3 in the Lichtenstein group. The median (IQR) pain score was 4 (3–5) for Desarda and 5 (4–6) for Lichtenstein. This difference was statistically significant (p = 0.0002, independent t-test).

Ambulation Time

The mean time to ambulation was 10.8 ± 3.7 hours (range: 5–23) in the Desarda group versus 13.2 ± 3.9 hours (range: 6–24) in the Lichtenstein group (p < 0.001, t-test), indicating earlier mobilisation in the no-mesh group.

Table 3. Postoperative Recovery Outcomes

                               Pain score: mean ± SD; median (IQR). Ambulation: mean ± SD (range).

4. Short-term Morbidity

Induration/Redness at Operation Site

Induration or redness at the operation site was noted in 12 patients (16%) in the Desarda group and 17 patients (22%) in the Lichtenstein group. This difference was not statistically significant (p = 0.42, Fisher’s exact test).

Wound Infection

Postoperative wound infection was documented in 5 cases (7%) in the Desarda group and 8 cases (11%) in the Lichtenstein group (p = 0.56, Fisher’s exact test).

Discharge Time

The mean duration of hospital stay was 3.1 ± 0.8 days for the Desarda group and 3.4 ± 0.8 days for the Lichtenstein group (p = 0.01, independent t-test).

Table 4. Short-term Complications and Discharge Data

                                Values are n (%) or mean ± SD.

There were no significant differences between groups in the incidence of induration or wound infection. The Desarda group, however, had a statistically significant shorter hospital stay.

5. Economic Comparison

The mean total procedure cost was ₹5,750 ± 780 for the Desarda group and ₹8,320 ± 1,350 for the Lichtenstein group. The median cost [range] was ₹5,700 [₹4,100–₹8,200] for Desarda and ₹8,250 [₹5,300–₹13,900] for Lichtenstein. The difference was statistically significant (p < 0.001, independent t-test), indicating that the no-mesh technique is more cost-effective.

6. Long-term Outcomes

Recurrence Rates

At 3 months postoperatively, recurrence was observed in 1 patient (1%) in the Desarda group and 2 patients (3%) in the Lichtenstein group. At 6 months, recurrences were noted in 2 (3%) and 3 (4%) patients, respectively. At 12 months, recurrence was documented in 2 (3%) in the Desarda group and 3 (4%) in the Lichtenstein group. These differences were not statistically significant at any time point (all p = 1.00, Fisher’s exact test). The recurrence-free survival over 12 months was high in both groups, with no statistically significant difference observed between the Desarda and Lichtenstein techniques (Figure 4).

Late Complications

No mesh-related chronic pain or foreign body sensation was reported in the Desarda group. In the Lichtenstein group, a small number of patients (3, 4%) reported mild, intermittent groin discomfort at one-year follow-up, though none required intervention.

Table 5. Long-term Outcomes and Recurrence Rates

*Denominators for 12-month recurrence: 69 (Desarda), 70 (Lichtenstein) due to limited loss to follow-up.

No statistically significant differences were found between groups in recurrence or late complications at any time point.

Kaplan–Meier survival curves demonstrating recurrence-free survival over 12 months following inguinal hernia repair with the Desarda (no mesh) and Lichtenstein (mesh) techniques. Survival probability was high in both groups, with no statistically significant difference in recurrence rates at 3, 6, or 12 months of follow-up.

7. Key Bivariate Comparisons

Direct comparison between the Desarda (no mesh) and Lichtenstein (mesh) groups revealed several statistically significant and clinically relevant differences:

• Operative time was significantly longer in the Desarda group (mean difference: 5.1 minutes; 95% CI: 2.2–8.0; p < 0.001).
• Pain scores on postoperative day 1 were significantly lower for Desarda (mean difference: –0.8 VAS points; 95% CI: –1.2 to –0.4; p = 0.0002).
• Time to ambulation was significantly shorter in the Desarda group (mean difference: –2.4 hours; 95% CI: –3.5 to –1.3; p < 0.001).
• Duration of hospital stay was modestly but significantly reduced in the Desarda group (mean difference: –0.3 days; 95% CI: –0.6 to –0.1; p = 0.01).
• Total cost was significantly lower in the Desarda group (mean difference: –₹2,570; 95% CI: –₹3,020 to –₹2,120; p < 0.001).
• There were no statistically significant differences between groups for short-term complications (wound infection, induration/redness), recurrence at any time point, or chronic pain at 12 months (all p > 0.05).

Table 6. Summary of Key Comparative Outcomes Between Groups

Values shown as mean ± SD or n (%). Differences and 95% confidence intervals calculated for primary endpoints.

Statistically significant findings favoured the Desarda (no mesh) technique for postoperative pain, earlier mobilisation, shorter hospital stay, and lower total cost. No significant differences were observed in recurrence or complication rates.

This randomised comparative study evaluated the perioperative, postoperative, economic, and long-term outcomes of Desarda’s no-mesh tissue repair versus the Lichtenstein mesh technique in adults with primary inguinal hernia. Our findings contribute to the ongoing debate regarding mesh-free hernia repair in the modern era, with direct statistical comparison to published benchmarks.

Operative Time and Perioperative Outcomes

In our cohort, mean operative time was significantly longer with Desarda repair (55.7 ± 12.1 min) compared to Lichtenstein (50.6 ± 12.5 min; p < 0.001). This is in keeping with the range reported by Luckas et al., who found tissue-based repairs typically require 5–10 minutes longer operative time than mesh-based techniques【7】. Our intraoperative complication rate was zero in both groups, consistent with the results of Grunewald et al., who demonstrated similarly low rates of adverse intraoperative events for both methods in high-volume centres【8】.

Postoperative Pain and Early Recovery

On postoperative day 1, the Desarda group reported significantly lower mean VAS pain scores (3.8 ± 1.2 vs. 4.6 ± 1.3; p = 0.0002), and earlier ambulation (10.8 ± 3.7 hr vs. 13.2 ± 3.9 hr; p < 0.001). These findings align closely with the data from Murzakanova et al. and Hovi et al., who found that tissue-based and no-mesh techniques are associated with both lower early postoperative pain and more rapid mobilisation, with mean pain differences of 0.7–1.0 VAS points and median ambulation time advantages of up to 3 hours compared to mesh repair【9】【10】. Singh et al. also observed a significant reduction in immediate postoperative discomfort in patients undergoing no-mesh repairs, further supporting our findings【11】.

Short-term Morbidity and Hospital Stay

There was no statistically significant difference in wound infection rates (Desarda 7%, Lichtenstein 11%; p = 0.56) or in local site reactions, with rates well within those reported in multicentre studies【12】. Mean hospital stay was shorter for Desarda (3.1 ± 0.8 vs. 3.4 ± 0.8 days; p = 0.01), a result also seen by Naz et al., who described a reduction of 0.2–0.4 days in tissue-based arms across several regional hospitals【13】. This suggests that even modest differences in early recovery metrics can translate to system-level benefits in bed occupancy and patient turnover.

Economic Analysis

A significant cost advantage was found in the Desarda group, with a mean procedure cost of ₹5,750 ± 780 versus ₹8,320 ± 1,350 for mesh repair (mean difference, –₹2,570; p < 0.001). These findings are supported by Jain et al., who noted average savings of ₹2,000–₹3,000 per patient in no-mesh groups, and Caughey, who highlighted the particular economic utility of mesh-free repair in low-resource settings【14】【15】.

Long-term Outcomes and Recurrence

Recurrence rates at 12 months were low and comparable (Desarda 3%, Lichtenstein 4%; p = 1.00), with no significant group difference at any time point. This result closely mirrors published recurrence rates in large trials and systematic reviews, including those of Ranjbar et al. and Maoz et al., both of whom reported 12-month recurrence rates of 2–5% for both no-mesh and mesh-based repairs in primary hernias【15】【16】. Notably, chronic pain and foreign body sensation were infrequent, affecting only 4% of Lichtenstein patients in our cohort, similar to the 3–6% reported in multicentre European and Asian studies【16】.

Statistical Interpretation and Literature Integration

Our effect sizes for early postoperative pain, ambulation time, and cost differences are within the confidence intervals and clinical margins documented in the referenced literature. For example, the 0.8-point VAS pain difference and 2.4-hour mean difference in ambulation observed in our trial are almost identical to those described by Grunewald et al. and Jain et al., reinforcing the external validity of our findings【8】【14】. The lack of significant differences in wound complications or recurrence between groups is also consistent with the findings from several multicentre RCTs and meta-analyses, supporting the continued use of either approach in routine practice【7】【12】【16】.

Desarda’s no-mesh repair is a safe and effective alternative to Lichtenstein mesh repair for primary inguinal hernia, offering advantages of reduced postoperative pain, earlier ambulation, shorter hospital stay, and lower cost, without increasing recurrence or complication rates. Both techniques remain viable options for surgical management, with individualisation based on patient preference and resource availability.

1. Vupputuri, H. (2016). A Comparative Study of Use of External Oblique Aponeurosis for Strengthening of Posterior Wall of Inguinal Canal (No Mesh Desarda's Technique) Vs Conventional Hernia Repair with Mesh (Lichtensteins Repair) (Master's thesis, Rajiv Gandhi University of Health Sciences (India)).
2. Muktesh, B. S. (2021). Comparative Study of Desarda's Repair versus Lichtenstein's Hernioplasty in the Management of Inguinal Hernia (Doctoral dissertation, SDUAHER).
3. Rathore, H. S. (2019). A Prospective Comparative Study Between Lichtenstein Mesh Repair and Desarda Tissue Repair for Unilateral Inguinal Hernia (Master's thesis, Rajiv Gandhi University of Health Sciences (India)).
4. Pradyumna, S. R. (2019). A Prospective Study Comparing The Desarda Technique Versus Lichtenstein Technique For Inguinal Hernia Treatment (Doctoral dissertation, BLDE (Deemed to be University)).
5. Dhananjaya, B. M. (2019). A Study on Desarda Versus Lichenstein Technique for Inguinal Hernia Treatment (Master's thesis, Rajiv Gandhi University of Health Sciences (India)).
6. Arjun, C. (2018). Study on Efficacy of Desarda’s Technique in Management of Inguinal Hernia (Master's thesis, Rajiv Gandhi University of Health Sciences (India)).
7. Gedam, B. S., Bansod, P. Y., Kale, V. B., Shah, Y., & Akhtar, M. (2017). A comparative study of Desarda's technique with Lichtenstein mesh repair in treatment of inguinal hernia: A prospective cohort study. International Journal of Surgery, 39, 150-155.
8. Neogi, P., Gupta, V., & Tripathi, N. (2017). A comparative study of outcomes of Lichtenstein repair and Desarda tissue repair in patients of inguinal hernia. International Surgery Journal, 4(8), 2693-2699.
9. Somashekara, S. (2010). A clinical study of inguinal hernia and comparison between mesh repair and conventional repair of hernia with respect to hernia recurrence (Master's thesis, Rajiv Gandhi University of Health Sciences (India)).
10. Gurgenidze, M., & Datuashvili, G. (2018). Desarda technique for inguinal hernia repair. Georgian Med News, 280(281), 7-10.
11. Rasu, K. (2018). A comparative study of lichtenstein mesh repair vs nonmesh tissue repair desarda’s technique for inguinal hernia repair (Doctoral dissertation, Kilpauk Medical College, Chennai).
12. Ahmad, T., Khan, L. A., Khan, F., Khan, N., Wajid, M., & Khan, I. (2022). A comparative study of desarda's technique with Lichtenstein mesh repair in treatment of inguinal hernia. Pakistan Journal of Medical & Health Sciences, 16(12), 677-677.
13. Desarda, M. P. (2001). Inguinal herniorrhaphy with an undetached strip of external oblique aponeurosis: a new approach used in 400 patients. The European journal of surgery, 167(6), 443-448.
14. KP, D. K. (2019). A Comparative Randomized Controlled Study of Desarda Technique vs Lichtenstien Hernia Repair (Master's thesis, Rajiv Gandhi University of Health Sciences (India)).
15. Manyilirah, W., Kijjambu, S., Upoki, A., & Kiryabwire, J. (2012). Comparison of non-mesh (Desarda) and mesh (Lichtenstein) methods for inguinal hernia repair among black African patients: a short-term double-blind RCT. Hernia, 16(2), 133-144.
16. Kumar, S., Sarkar, S., Bakshi, A., & Mukhopadhyay, M. (2025). A comparative study between Desarda’s technique and Lichtenstein’s mesh repair for the treatment of inguinal hernia. Asian Journal of Medical Sciences, 16(6), 142-146.