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A comparison of hernia sac ligation versus invagination in Lichtenstein tension-free mesh hernioplasty: does the type of hernia play a role in outcomes?

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Abstract

Background

Management of the indirect hernial sac in inguinal hernia repairs has long been a subject of debate among general surgeons. Although hernial sac high ligation (HL) is a time-honored concept in groin hernia surgery, non-ligation/invagination is gaining popularity. This study was intended to compare the effects of hernia sac ligation and invagination in patients undergoing Lichtenstein mesh hernioplasty (LMH). Another aim was to investigate the possible association between the hernial defect size and postoperative early pain in both groups.

Methods

Patients with indirect inguinal hernia undergoing elective LMH under spinal anesthesia were included in this prospective randomized study. Patients were classified according to European Hernia Society (EHS) criteria and were randomized into two groups, HL and non-HL/invagination. Postoperative pain levels at 6, 12, and 24 h, 7 days, and 1 year were compared using a ten-point visual analog scale (VAS). In addition, recurrence was examined in the postoperative first year. Postoperative complications, length of hospital stay, drain use, and surgery times were evaluated as secondary outcomes. This study was registered at www.clinicaltrials.gov. (The clinicaltrials.gov ID number is: NCT05308251).

Results

Ninety-three out of a total of 108 patients were included in the study between January 2020 and January 2021 (HL group n = 44, non-HL group n = 49). Demographic characteristics were comparable between the groups. Mean VAS scores were significantly higher in the HL group at 6 and 12 h postoperatively (p < 0.05 and p = 0.036 respectively). While there was no difference in pain levels between the groups in EHS 1 and EHS 2 hernias (p > 0.05 for all), VAS scores were significantly higher in the ligation group in EHS 3 hernias (p < 0.05 for all). Recurrence and complication rates were unaffected with non-ligation at a median 18 months follow-up.

Conclusion

Hernia sac invagination was superior to ligation in patients who underwent LMH, as it reduced early postoperative pain levels without disturbing repair integrity. We therefore recommend that ligating the hernial sac be avoided, especially in EHS 3 patients who undergo LMH.

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Data availability

The datasets generated during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

The authors are indebted to Mustafa Safa Uyanık, who was blinded to the randomization, for his help with collecting the postoperative patient data.

Funding

This research received no external funding.

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Authors and Affiliations

  1. Department of General Surgery, Samsun University, Samsun Training and Research Hospital, Barış Bulvarı, Kadıköy Mahallesi, No:199 PK:55090, İlkadım, Samsun, Turkey

    A. Burak Ciftci & S. Ocak

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  1. A. Burak Ciftci
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  2. S. Ocak
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Contributions

Conceptualization, A.B.C.; data collection, A.B.C., S.O.; formal analysis, A.B.C., S.O.; writing—original draft preparation, A.B.C.; writing—review and editing A.B.C., S.O. All authors have read and agreed to the published version of the manuscript.

Corresponding author

Correspondence to A. Burak Ciftci.

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Conflict of interest

Ahmet Burak Çiftci and Sönmez Ocak declare that they have no conflict of interest.

Ethics approval

This prospective study was approved by the Institutional Review Board of Samsun Education and Research Hospital. (Approval No. GOKA/2020/4/10). The study was also registered as NCT05308251 at ClinicalTrials.gov.

Human and animal rights

This study including human subjects has been performed in accordance with the ethical standards of the Declaration of Helsinki and its later amendments.

Institutional review board statement

The study was conducted in accordance with the Declaration of Helsinki and was approved by the Samsun Education and Research Hospital ethical committee (approval No. GOKA/2020/4/10).

Informed consent statement

Informed consent was obtained from all subjects involved in the study. Written informed consent was obtained from the patients for the publication of this paper.

Informed consent

Written informed consent was obtained from all patients before surgery.

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Ciftci, A.B., Ocak, S. A comparison of hernia sac ligation versus invagination in Lichtenstein tension-free mesh hernioplasty: does the type of hernia play a role in outcomes?. Hernia 26, 1153–1159 (2022). https://doi.org/10.1007/s10029-022-02637-3

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