A COMPARISON OF DESARDA HERNIA REPAIR WITH LICHTENSTEIN MESH REPAIR IN TREATMENT OF INGUINAL HERNIA Dr. Prasad Bansod* Dr. B. S. Gedam** Dr. V. B. Kale*** Dr. Murtaza Akhtar**** Department of General surgery, NKPSIMS and Lata Mangeshkar Hospital, Nagpur, Maharashtra, INDIA *Resident; **Professor; ***Lecturer; **** Professor & Head

INTRODUCTION Inguinal hernia repair is one of the most frequent operation in general surgery.[1] More than 800,000 surgical repairs for inguinal hernias are performed in the United States.[4] Successful surgical repair of hernia depends on a tension free closure of the hernia defect to attain the lowest possible recurrence rate.[2,3] Modern techniques have improved the recurrence rates by placement of mesh over hernia defect or in the case of laparoscopic repair behind the hernia defect.[2,3]

Tension free closures have shown to cause significantly less pain and discomfort in the short-term postoperative period thus becoming increasingly popular.[1,2,3] Open repair may be particularly beneficial in older, less healthy patients.[5] Laparoscopic repair is usually reserved for recurrent or bilateral hernias. Open and laparoscopic techniques have similar results.[5-6] Both procedures are effective if performed by an experienced surgeon, and have a recurrence rate from 0% to 9.4%.[6]

The common complications of hernia repair are hematomas, including penile or scrotal ecchymosis; seromas; and wound infection.[6] Chronic pain is most common long-term problem after hernia repair, occurring in 5% to 12% of patients, is related to nerve damage, mesh contraction.[6] Complications related to mesh are mesh contraction, mesh migration, mesh infection.

AIMS & OBJECTIVES Comparison of the tissue based Desarda technique with Lichtenstein mesh primarily in terms of postoperative pain and recurrence. To compare the results in respect of complications, returning to normal activity, foreign body sensations, discomfort and stiffness.

MATERIALS AND METHODS Inclusion criteria All patients >18 years of age with inguinal hernia. Uncomplicated reducible or irreducible inguinal hernias; direct and indirect type; unilateral & bilateral.

Exclusion criteria: Patients not willing to participate in the study. Recurrent hernias. All complicated hernias i.e. strangulation, obstruction.

Institutional ethics committee permission. Study design – Hospital based prospective and comparative study. Site – Dept. of General surgery of NKP SIMS and RC, Nagpur. Sample size – 159 patients. Study period – 30 months ( August 2012 to February 2015) [with 12 month follow up]

Desarda’s Repair technique Opened inguinal canal Blunt dissection and identification of sac

Desarda’s Repair technique EOA Strip being created EOA strip sutured down to inguinal canal

EOA of Strip sutured to conjoint tendon Desarda’s Repair technique EOA of Strip sutured to conjoint tendon EOA strip seen sutured

Desarda’s Repair technique A tissue based tension free hernia repair technique. Strip of external oblique aponeurosis used for posterior wall strengthening, by suturing the superior lip with conjoint tendon and inferiorly with inguinal ligament. Physiological repair since no foreign body (Mesh) is used. Lichtenstein mesh repair

Results and outcomes of Desarda’s procedure were compared with Lichtenstein’s procedure. All patients were given analgesics (Tb Diclofenac) till POD 3. Data collected as regards to postoperative pain, returning to basic and work activities, and complications.

Return to normal activity described as the patient’s ability to perform elementary activities. [BASIC] dressing, walking, bathing. [HOME]preparing food, cleaning, household chores. [WORK]returning to all previously performed activities. Patients followed up for one year at interval of one week, 1, 3, 6 and 12 month after discharge to note the complications and recurrence.

RESULTS Overall Age distribution AGE GROUP (YEARS) FREQUENCY N=159 PERCENTAGE 18-30 32 20.12% 31-40 30 18.86% 41-50 21 13.20% 51-60 36 22.64 61-70 31 19.49% 71-80 6 3.77% >80 3 1.88% TOTAL NUMBER 159 100% -MEAN: 47.98 -STANDARD DEVIATION:16.39

Age distribution: Mean age of the patients was 47 Age distribution: Mean age of the patients was 47.98 years, (Standard deviation 16.39) TOTAL SUBJECTS : 159

A total of 159 patients in the study A total of 159 patients in the study. 74 patients in the Desarda (D group) and 85 Patients in the Lichtenstein's (L group,) comprising the two study arms. Mean age of the patients in this study was 47.9 year. The operative time required for both the techniques was almost same. Mean 74.41min for Lichtenstein and 72.50 min for Desarda. Its comparison was found to have no statistical significance. Comparing the postoperative pain, D group had statistically significant outcome in pain relief, compared to L group.

Patients of D(Desarda) group recovered earlier as compared to L (Lichtenstein) group and the difference was found to be statistically significant. Three patients (1.88%) in the Desarda group had surgical site infection (SSI). 5 patients (3.14%) in Lichtenstein group had groin discomfort. One patient (0.62% each) in Lichtenstein group developed chronic pain. These complications were found to have no statistical difference.

CORRELATIONS Sr. No Factors Frequency N = Mean SD P value 1. Operative time (in minutes) Lichtenstein 85 74.41 14.35 0.41 Desarda 74 72.5 15.06 2 Basic activities (Time taken in days) 4.38 1.60 <0.0001 2.55 0.87 3. Work activities 9.32 2.06 <0.001 7.77 1.68

CORRELATIONS Sr. No PAIN SCORE Frequency N = Mean SD P value 4. Visual analogue scale (POD 1) Lichtenstein 85 5.58 1.06 <0.0001 Desarda 74 4.54 1.40 5. (POD 3) 3.70 1.10 2.71 1.27 6. (POD 7) 2.08 1.02 1.31 1.14

Scheffield’s pain Score CORRELATIONS Sr. No PAIN SCORE Frequency N = Mean SD P value 7. Scheffield’s pain Score (POD 1) Lichtenstein 85 2.68 0.46 0.0002 Desarda 74 2.36 0.60 8. (POD 3) 1.48 0.58 0.042 1.28 0.65 9. (POD 7) 0.38 0.51 0.033 0.22 0.42 Sheffield scale: 0- no pain; 1- no pain at rest but it appears during movement; 2- temporary pain at rest and moderate during movement; 3- constant pain at rest and severe during movements.

Surgical site infection(SSI) CORRELATIONS Sr. No Factors Frequency N = Complication seen P value 10. Groin discomfort Lichtenstein 85 5 0.061* Desarda 74 11. Chronic pain 1 1.000* 12. Surgical site infection(SSI) 0.098* 3 * Calculated by using Fischer exact test

DISCUSSION The Desarda technique is original, new, and different from the historical methods, where a movable aponeurotic strip is considered more ‘physiological’ than the scar tissue produced around a synthetic prosthesis The Lichtenstein technique and its modifications are widely practiced in the world, but the complications of mesh are described. Both the groups are statistically similar with regards to age. The Desarda method of hernia repair seems to be superior to the Lichtenstein method in terms of postoperative pain.

The time taken to ambulate the patient and the time taken for the patient to return to work are all significantly less in the Desarda’s method compared to the Lichtenstein method. The complications observed were not statistically significant.

LIMITATIONS The originally unhealthy tissue is used for the repair may lead to recurrence. Only 1 year follow up. Long term complications were not studied.

CONCLUSION The results of inguinal hernia treatment with the Desarda technique are similar to the results after standard Lichtenstein operations over a 1-year follow up period. Postoperative pain is significantly less in Desarda technique. Patients after Desarda’s operative procedure get ambulatory sooner as compared to the standard Lichtenstein mesh repair. Complications in both the procedures are not statistically significant. Large-scale long term multi-centric trials need to be conducted to evaluate this repair further.

IMPLICATIONS The technique has the potential to enlarge the number of tissue based methods available to treat groin hernias. The most evident indications for use of the Desarda technique include use in -Young patients, -Strangulated inguinal hernias -Financial constraints -A patient disagrees with the use of mesh.

REFERENCES Scott NW, McCormack K, Graham P, Go PM, Ross SJ, Grant AM. - Cochrane Database Syst Rev - ; (4); CD002197 Michael J. Zinner, Stanley W. Ashley. Maginot’s Abdominal operations. 2013,12th edition pp 127 Amid PK, Shulman AG, Lichtenstein IL. The safety of mesh repair for primary inguinal hernias: results of 3019 operations from five diverse surgical sources. Am Surg 1992; 58:pp255-257. U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Digestive diseases statistics for the United States. June 2010. http://digestive.niddk.nih.gov/statistics/Digestive_Disease_Stats_508. pdf. Accessed November 16, 2012 McIntosh A, Hutchinson A, Roberts A, Withers H. Evidence-based management of groin hernia in primary care—a systematic review. Fam Pract. 2000;17(5):442-447. Ruhl CE, Everhart JE. Risk factors for inguinal hernia among adults in the US population. Am J Epidemiol. 2007;165(10):1154-1161.

THANK YOU नकप साल्वे इंस्टिट्यूट ऑफ़ मेडिकल साइंसेस एंड रिसर्च सेंटर NKP Salve Institute of Medical sciences & Research center Nagpur, Maharashtra, INDIA