Lichtenstein mesh hernioplasty is a tension-free open surgical technique for inguinal hernia repair where a polypropylene mesh is used to support the inguinal muscular layer and repair the defect with fixation of mesh over the hernial defect. The original technique for fixation of mesh in Lichtenstein hernioplasty used non-absorbable sutures placed medially near the pubic periosteum and the upper corner of the mesh, and continuous sutures along the inguinal ligament. [1, 2] Amongst all stated complication after Lichenstein hernioplasty, chronic pain is often noted in 10–30 per cent of patients after the procedures. In post operative period complication noted include pain, foreign body sensation, wound infection and paraesthesia’s. [3-6]

The cause of pain has been contributed to either irritation or damage to the inguinal nerves by sutures or mesh, [7] an inflammatory reaction against the mesh [8] or simply scar tissue [9, 10]. It has been shown that tension-free mesh repair compared with non-mesh inguinal hernia repair causes less chronic pain. [11] .The synthetic mesh is usually secured to the surrounding tissue by non-absorbable or absorbable sutures. The possible influence of different suture materials on chronic groin pain after inguinal hernia repair has not been studied in depth.

This article represents a modification of technique of Lichenstein hernioplasty where mesh fixation is by delayed absorbable suture, polygalactin by using a single air knot over the conjoint tendon to fix the mesh, thereby causing less or no post-operative pain.

This was prospective study conducted at Department of General Surgery, JNU Medical College and Hospital and NIMS Medical College Jaipur Jointly Rajasthan, India during the period of one years. Prior approval of local ethical committee was obtained. Total 200 patients both male and females who underwent Lichtenstein tension free inguinal hernioplasty were included in the study. The patients, who full-filled the following criteria were recruited in the present study.

Inclusion criteria: (i) Unilateral or bilateral hernia; (ii) Elective surgery performed; and (iii) Primary hernia repair

Exclusion criteria: (i) Age < 18 years; (ii) Obstructed/strangulated inguinal hernias; (iii) Emergency repair; and (iv) Recurrent hernia.

All patients were analysed according to age, type, location and site of hernia, post-operative complications, hospital stay, and recurrence rates. Mesh used for surgery was polypropylene and fixation was done using delayed absorbable polyglactin suture fixed by a single air knot over the conjoint tendon. Follow up data was obtained after 1 week, 1 month, 6 months and one year for pain, paraesthesia, seroma, hematoma, infections and recurrences if any

Procedure:

All surgeons were senior consultants with wide experience of open inguinal hernia surgery. Tension-free hernioplasty was done with a 9 × 13-cm trimmed lightweight polypropylene mesh. Indirect hernia sacs were either resected or inverted into the abdomen. Large direct hernias were also inverted into the abdomen with absorbable 2/0 polygalactin sutures with or without repair of the posterior wall by absorbable polygalactin suture. A trimmed mesh was placed between the conjoint tendon, the inguinal ligament, the pubic bone and internal oblique aponeurosis, overlapping the inguinal ligament by about 0•5 cm. In men, the spermatic cord was always passed through a slit in the mesh. [1] Mesh fixation was by absorbable polygalactin 2/0 suture by a single air knot over the conjoint tendon. The exact technique of mesh fixation is shown in Fig. 1 and Fig 2 The ilioinguinal, genitofemoral and iliohypogastric nerves were identified and preserved, as far as possible. Fixation of the mesh with a single air knot prevented any chances of entrapment of nerves within the suture material. The procedures was carried out under spinal anaesthesia.

The operation time started when the surgeon gave the incision and finished after skin closure. The wound was closed by using polygalactin 2/0 subcuticular suture. After surgery the patient was shifted to inpatient ward. No prophylactic antibiotics were used. A single dose of intravenous analgesic was administered post-operatively to all patients and patient was mobilized 12hours after surgery in view of any post spinal headache if occurs. Patient was discharged on post-operative day 1 with no antibiotics and analgesics and was not adviced any bed rest.

Outcomes:

The primary aim of the study was to emphasize on modification of the traditional Lichenstein hernioplasty technique, accepted worldwide, in view of reduced pain post operatively, reduced time for surgery, and no recurrences and no other secondary complications. Preoperative and postoperative pain scores were acquired using a visual analogue scale (VAS; range 0–10) by using Wong Baker faces, and patient choosing the face best depicting the intensity and type of pain. Operative details were recorded, including type and size of the hernia, duration of surgery, nerve injury if identified and bleeding. All postoperative complications were monitored carefully. The patients were followed after 7 days, 30 days, 6 weeks and 1 year after surgery (on telephone); the questions were based on those from the Danish Hernia Database [12] After 1 year, all patients were re-examined clinically, to determine recurrence rates. Chronic pain, paraesthesia, recurrence, reoperations, need for analgesia, sensation of a foreign body and satisfaction were recorded at each time interval. Patients who reported wound haematoma, infection, recurrence or chronic pain were examined clinically by the operating

surgeons. Wound infection was always confirmed using bacterial culture, and the frequency of infections was recorded 1 month after surgery.

Mild pain was defined as occasional pain or discomfort that did not limit daily activity and did not require pain medicine. Moderate pain was defined as pain that interfered with a return to normal everyday activity with rare analgesic requirement. Severe pain was defined as pain that incapacitated the patient, occurred at frequent intervals, or interfered with everyday activities with a frequent need for painkillers. Daily activity included both physical and sport activities, such as walking, lifting a bag, or jogging. Chronic pain was defined as a pain persisting beyond the normal tissue-healing time (assumed to be 3 months) according to the International Association for the Study of Pain. [13] Hernia recurrence was diagnosed by clinical examination and confirmed at reoperation.

Out of 200 patients, 196 were male and 4 were females. Average age ranged from 25 years to 85 years. All patients were operated under spinal anaesthesia, intravenous analgesic was given as a single dose after surgery.

 All the patients were discharged on day 1 of surgery and asked for regular follow up.

4 out of 200 (2%) patient complained of moderate pain, ranging from 3-5 as per VAS score depicted by Wong Baker faces, (Fig) these patients were given tablet diclofenac 50mg twice a day for 3 days and pain was relieved thereafter. None of the patients were given antibiotics.  We lost follow up after 1 week of 2 patient, until then none of the patients complained of pain. Out of 198 patients, none of the patients reported with any other significant complaints. Follow up after 1 year of surgery, was on telephone; the questions were based on those from the Danish Hernia Database and none of the patients complained of pain or recurrence. 4 out of 200 (2%) patients developed wound infection on day 7 of surgery, the infection was in the superficial plane and not below the aponeurosis sheath, was not mesh related. Pus culture and sensitivity was sent and antibiotic started accordingly. 4 out of 198 (2.02%) patients complaint of foreign body sensation. 2 out of 198 (1.01%) patients had parasthesias on the inguinal region and the medial part of thigh.

The average duration of surgery was around 35mins+/-5mins.

The present study was conducted to evaluate the intensity of post-operative pain in open inguinal hernia repair by a modification in technique of Lichenstein hernioplasty. It also evaluates the secondary complications like wound infection, foreign body sensation and paraesthesia if complained by patients.  As per study by Freidman et al incidence of chronic pain after classical tension free Lichenstein inguinal hernia repair ranged from 0% to more than 30%. [14] The results of our study showed that pain was found only in 2%, the pain was moderate in intensity and relieved on mediciation. According to Callesen T et al 19 per cent patients reported some degree of pain, and 25 (6 per cent) had moderate or severe pain. Pain restricted daily function in 6 per cent of the patients. The incidence of moderate or severe pain was higher after repair of recurrent than primary hernias. In the present study only 2% of the pateints had pain, 1 week after surgery and of moderate intensity. Recurrent hernia were excluded from the study and all primary uncomplicated inguinal hernia were taken as cases and study was conducted. The study showed a clear reduction in incidence of pain in patients operated with the modified inguinal hernia repair technique with mesh fixation by delayed absorbable suture and air knot fixation method. [3]

As per Heise et al pain is attributed to nerve entrapment in suture or during mesh fixation. In our technique we modified the surgical technique and did not take a continuous running over the inguinal ligament as per classical Lichenstein technique, leading to less chances of nerve entrapment or nerve injury and hence can be a cause of less pain after surgery, only 2%. [7] Chronic pain and wound complications were accounted for more than two thirds of all the reported side effects of surgery in the study by Paajanen et al.[15] The study also states that inguinal hernioplasty appears to be safe in general, but chronic inguinal pain and deep infections are associated with severe patient discomfort and financial compensation. Minor complications, such as wound hematoma or swelling accounts for 1%–7% of the total patients, superficial infection was found in 1%–2%of the total cases, and scrotal swelling and numbness (1%–9%), were reported in various case controlled studies.[16,17]. The present study also states a rate of infection to be 2% which is in correlation with the previous literature

O’dwyer et al did a review to examine the cause of acute and chronic in patients undergoing groin hernia repair and to evaluate the outcome of those who suffer long-term pain. They could not comment whether mesh or non-mesh leads to less post-operative pain and whether nerve preservation or nerve excision can lead to less pain after surgery, our study also comments that delayed absorbable suture with single air knot can lead to less post-operative pain and reduce less post-operative complication. [11]

According to study by Ashish Kharadi & Viral Shah the development of post-operative paraesthesia, was less when mesh was fixed with non-absorbable suture material. The important reason behind the development of paraesthesia is attributed to entrapment of a nerve by suture or mesh. There is low rate of post-operative groin pain, and groin discomfort in delayed absorbable suture material using air knot technique. The study also states that in Lichtenstein tension free open inguinal hernioplasty mesh fixation with delayed absorbable suture material is simple safe and effective alternative. With compared to traditional method of fixation with non-absorbable suture fixation with air knot there is less chances of chronic groin pain and paraesthesia due to less nerve compression. There is no statistical difference in recurrence rates in both techniques. Therefore, delayed absorbable material can be a good alternative for mesh fixation. [18] The present study also is in conjunction with the study and clearly states that mesh fixation with delayed absorbable suture material is a safe and alternative method of inguinal hernia repair by tension free Lichenstein mesh hernioplasty.

As per population based registry study by Novik B et al, all 82015 Lichtenstein inguinal hernioplasties were considered and mesh fixation was done by using short term absorbable, long term absorbable and non-absorbable suture material for mesh fixation. Recurrence was increased 3 times with short term absorbable and no change in the relative risk was observed in long term absorbable suture and non-absorbable suture material. Pain was found to be less in patients in whom mesh was fixed with absorbable suture material. [19] Our study also shows no rate of early recurrence as observed 1 year after surgery. Pain was observed only in 2%of the patients.  Due to less complication and less pain on post-operative day, patient was sent back home early and early return to work was observed.

As per the recent scenario the result and prognosis of inguinal hernia repair is analysed by quality of life rather than recurrence which became low after mesh hernioplasty was invented. Quality of life is assessed by chronic groin pain after surgery which is significantly low in our modified technique. Hence with reasonable confidence it can be stated that the modification of Lichenstein mesh hernioplasty with a single air knot over the conjoint tendon with a delayed absorbable suture material is an effective alternative or new modified technique for open inguinal hernia repair leading to  less or no chronic pain after inguinal hernia surgery.  The above mentioned modification of technique is being performed routinely in our centre in all patient being operated for uncomplicated inguinal hernia with excellent outcomes

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