Gold standard for inguinal hernia repair: Shouldice or Lichtenstein?

Summary In the knowledge that Lichtenstein inguinal hernia repair is becoming increasingly popular we evaluated this technique in a prospective randomized study. Would the Lichtenstein repair show significant advantages in order to justify it replacing the Shouldice technique, the standard for hernia repair of the last ten years? Between January 1996 and December 1997 the study was undertaken on 385 male patients suffering from 410 primary inguinal hernias. On 164 patients the Shouldice technique (SD) was used and on 221 patients the Lichtenstein repair (LS). 50 % of the operations were performed under local anesthesia, 50 % under spinal anesthesia. The 410 operations were done by 51 different surgeons, most of them in trainee programs. The postoperative local complication rate and duration of hospitalization were similar in both groups. Significant differences were noted concerning operation-time (LS: 80 min, SD: 88 min, p < 0,005) and return to work (LS: 25 days, SD: 41 days, p < 0,00005). The tension-free repair under local anesthesia described by Lichtenstein is an easy operation, with a low complication rate and short recovery period. The Lichtenstein technique is an ideal hernia repair with low costs, high patient comfort and suitability for day-surgery.     

Shouldice repair in inguinal hernia

Among the various types of methods in herniotomy the lowest recurrence rates are reported using the method according to Shouldice. This method is pretty unknown in German literature. The operation technique is shown in principle and in methodic steps. The results in literature and our own experiences are reported.     

Comparison of Shouldice and Lichtenstein repair for treatment of primary inguinal hernia

Purpose: The purpose of this study was to compare the outcome following Lichtenstein open mesh repair or Shouldice repair for the surgical treatment of primary unilateral inguinal hernias.

Patients and methods: Patients with primary unilateral inguinal hernia who underwent a Shouldice repair (n: 120) and a Lichtenstein open mesh techniques (n: 121) between 1994 and 1998 were evaluated retrospectively. Operation time, hospital stay, postoperative analgesic consumption and complications, return to work and recurrence after surgery were assessed and compared.

Results: The two groups were comparable regarding age, types of hernia and the follow-up interval. There were no significant differences in hospital stay and postoperative complications. The number of recurrences differed significantly between the groups with five in the Shouldice group (4.1%) and one in the Lichtenstein group (0.8%) (p < 0.05). The need of analgesic medication after mesh repair was significantly lower than the Shouldice group (3.9 ±1.4 vs. 4.9 ±1.6 gr. p < 0.05). The operation time was 36±14 min. for Lichtenstein repair and 61 ± 12 min. for Shouldice repair (p < 0.05). The time for return to work was shorter in Lichtenstein group (17 ± 4 days) compared to Shouldice group (25 ±5 days) (p< 0.05).

Conclusion: Shorter operation time, faster return to work, less need to analgesia and lower recurrence rate, shows the superiority of Lichtenstein repair against Shouldice repair in the surgical repair of primary unilateral inguinal hernia.     

Endoscopic inguinal hernia repair in comparison with Shouldice and Lichtenstein repair. A systematic review of randomized trials

AIMS: This article provides an overview of randomized studies which compare endoscopic hernia repair techniques (TAPP/TEP) with the Shouldice and Lichtenstein repair. METHODS: Systematic analysis of 33 published studies which meet the criteria of a randomized controlled trial with a high evidence level. RESULTS: The majority of the studies document statistically significant advantages of the endoscopic repair techniques in relation to wound pain (15/22), need for analgesics (16/21), return-to-work time (16/22) and physical activity (18/25), although only one study showed significant advantages of the Lichtenstein method. Six of 28 studies showed a lower morbidity in comparison to open approaches, although 22 of 28 studies documented no significant difference. The first long-term studies with follow-up periods between 5 and 6 years also show advantages of the endoscopic techniques. CONCLUSION: Even with cautious interpretation of the data, it is clear that endoscopic techniques are more comfortable for patients and that morbidity is no higher than for open procedures. Due to the short follow-up periods final evaluation regarding long-term complications and recurrence is not yet possible.     

Randomised trial comparing Lichtenstein vs Trabucco vs Valenti techniques in inguinal hernia repair

Purpose

Following Lichtenstein’s technique, over the last 15 years several variation have been proposed, such as Trabucco’s sutureless technique and the use of two self-regulating prostheses, proposed by Valenti that have given excellent results. The aim of this prospective and randomised study was to determine whether there are differences in the results obtained with these three techniques.

Methods

Of 812 patients submitted to inguinal hernia repair, we selected and randomised 162 patients into three groups of 54 patients each: Lichtenstein (Group L), Trabucco (Group T) and Valenti (Group V). Surgical procedures were performed in all cases by residents in surgery using local anaesthesia. Primary endpoint was intensity of postoperative pain. Median follow-up was 8 years.

Results

The primary analysis of postoperative pain at 48 h did not report any significant difference between the three groups as for secondary analyses except that the Trabucco procedure took less operative time than the Lichtenstein, and the Valenti group was more painful than the Lichtenstein group at the third postoperative day. In our series median operation time was 60 min. Recurrence rate was 1.85 %.

Conclusions

Surgical repair of inguinal hernia according to the Lichtenstein, Trabucco and Valenti techniques is safe and easy to perform regardless of the surgical experience of the operator, with excellent results and no differences due to technique used as regards almost all of the parameters studied.     

Primary inguinal hernia: Shouldice,Lichtenstein, Trabucco. Experience with 1,000 cases

Inguinal hernia repair today offers several techniques, all of which are safe and capable of preventing recurrence. The authors review their experience with 1000 cases treated by the Lichtenstein, Trabucco and Shouldice techniques, analysing the technical features of each and the results achieved after a 2-year follow-up.     

Lichtenstein tension-free repair of inguinal hernia

Recurrences have been a significant problem following hernia repair. The purpose of this study was to present our experience of Lichtenstein tension-free repair of inguinal hernia. In this retrospective study, 223 inguinal hernia repairs were performed between September 2000 and August 2003 in 203 patients, using a polypropylene mesh. The main outcome measure was early and late complications and especially recurrences. There were 189 males (93.1%) and 14 females (6.9%). Inguinal hernia was indirect in 70% of cases (n=156), direct in 25% (n=56), and of the mixed type in 5% (n=11). Bilateral inguinal hernia was found in 20 patients (9.8%). 210 (94.2%) of hernias were de novo, while 13 (5.8%) were recurrences. The mean patients age was 54.3 years (range, 32-71 years). The follow-up was completed in 160 patients (78.8%) by clinical examination. The median follow-up period was 3.0 years (range, 1-5 years). Seroma and postoperative neuralgia were observed in one and 5 patients respectively. There was only one recurrence (0.4%) four years later. Lichtenstein tension-free mesh repair of inguinal hernia is a simple and safe method, with no significant early and late morbidity and achieved a method with no recurrence during the follow-up period.     

UHS与Lichtenstein无张力疝修补术的对比研究

目的比较腹股沟疝应用UHS装置与Lichtenstein修补术式的优缺点。方法回顾性分析2010-12—2012-12间行UHS疝修补114例与Lichtenstein疝修补88例手术时间、术后住院天数、慢性疼痛、并发症等资料。结果 2种术式在住院时间、复发率等方面差异无统计学意义(P>0.05);Lichtenstein修补术手术时间明显短,手术费用低,但术后慢性疼痛评分较高。结论应用UHS装置与Lichtenstein无张力疝修补术均可以用于腹股沟疝修补,各有优缺点。     

Controlled study of cremaster resection in Shouldice repair of primary inguinal hernia

237 Shouldice operations with resection of the cremaster muscle from the Department of Surgery of the RWT University of Aachen were compared with 153 Shouldice repairs without resection of the cremaster muscle from the Department of Surgery of the Elizabeth Hospital in Essen. The aim of this prospective controlled trial was to determine the value of the resection of the cremaster muscle in Shouldice's hernia repair. A comparable follow-up of 12 to 26 months in both groups revealed no significant differences in early-postoperative complications. In the group without resection of the cremaster muscle the incidence of chronic inguinal pain was reduced. However, avoidance of the cremaster resection is not advisable because it leads to atypical indirect recurrences and totally higher recurrence rate (2.6%), so four indirect recurrent hernias were diagnosed. In the group with resection of the cremaster muscle no indirect recurrent hernia was detected, only one direct recurrent hernia was documentated. The significantly elevated rate of recurrent hernias (p less than 0.05) and the occurrence of atypical indirect recurrent hernias in the group without resection of the cremaster muscle demonstrates the important influence on the technique of repair. Based on our results the resection of the cremaster muscle is an essential part of Shouldice's hernia repair.     

The place of Shouldice operation in inguinal hernia repair

The Shouldice operation has been increasingly applied in our department since 1996. Between 1998-2000 its proportion has achieved 58% (Lichtenstein: 30%, laparoscopy: 2%, TEPP: 3%, other: 7%). A total of 343 patients have been operated on according to Shouldice. These patients were followed for 3-5 years in the mean. So far we observed 3 recurrences corresponding to a recurrence rate of 0.9%. The recurrence rate decreased compared to a historical control group from 10 to 0.9% using the Shouldice technique instead of Bassini. We conclude from this study that the surgeon must know several surgical techniques and choose the most applicable one during operation. The overwhelming majority of cases can be resolved by the Shouldice operation. For elderly patients, the Lichtenstein operation is an appropriate alternative. For cases with large defects of the posterior wall we can choose between Lichtenstein operation, the laparoscopic procedures and transinguinal preperitoneal mesh plasty.     

腹腔镜全腹膜外疝修补术与Lichtenstein修补术的对比研究

目的:对比腹腔镜全腹膜外网片修补术与Lichtenstein修补术的临床疗效.方法:选择2008年3月至2009年12月86例腹股沟疝患者,随机分为两组,观察组行腹腔镜全腹膜外网片疝修补术,对照组行Lichtenstein无张力疝修补术.对比两组患者术后并发症、住院时间、下床时间等,术后随访7～27个月,对比两组的复发...     

Lichtenstein repair of inguinal hernia with Surgisis inguinal hernia matrix soft-tissue graft in immunodepressed patients

While polypropylene mesh remains the preferred prosthesis material for hernioplasties, there are some problems with infections, intestinal obstruction and fistulization, and migration particularly in immunodepressed patients. A new degradable and reabsorbable material, the porcine small intestinal submucosa (Surgisis) has been developed for hernia repairs in humans. This prospective study evaluated the safety and efficacy of Lichtenstein hernioplasty using the Surgisis inguinal hernia matrix soft-tissue graft as a mesh in ten immunodepressed subjects. Six subjects were HIV-positive in the immunodepressive phase, and the other four had undergone transplantation (three kidney, one liver). There were no intraoperative or postoperative complications, recurrences, or wound infections. Thus Lichtensteins hernioplasty using the Surgisis inguinal hernia matrix soft-tissue graft in immunodepressed patients promises safety and efficacy.     

Randomized trial of Lichtenstein versus Shouldice hernia repair in general surgical practice

BACKGROUND: The aim of the present randomized trial was to compare the Shouldice procedure and the Lichtenstein hernia repair with respect to recurrence rate, technical difficulty, convalescence and chronic pain. A further aim was to determine to what extent general surgeons in routine surgical practice were able to reproduce the excellent results reported from specialist hernia centres. METHODS: Three hundred patients with primary inguinal hernia were randomized to either a Shouldice repair or to a tension-free Lichtenstein repair. In a pretrial training programme the five participating general surgeons were taught to perform the two techniques in a standard manner. Follow-up was performed after 8 weeks, 1 year and 3 years. The last examination was performed by an independent blinded assessor. RESULTS: There was a significant difference in operating time in favour of the Lichtenstein technique. After a follow-up of 36-77 months seven recurrences were found in the Shouldice group (95 per cent confidence interval (c.i.) 1.3 to 8.1) and one in the mesh group (95 per cent c.i. 0.0 to 2.0). Chronic groin pain was reported by 4.2 and 5.6 per cent in the Shouldice and Lichtenstein groups respectively. It was characterized as mild or moderate in all except two patients who had the Shouldice operation. CONCLUSION: Lichtenstein hernia repair was easier to learn, took less time and resulted in fewer recurrences. It was possible to achieve excellent results with this technique in a general surgical unit.     

Lichtenstein术治疗腹股沟疝的疗效分析

目的探讨Lichtenstein术治疗腹股沟疝的疗效。 方法回顾性分析2010年1月至2015年12月,南安市医院722例行Lichtenstein手术的腹股沟疝患者资料,对其手术记录、术后疝复发、慢性疼痛、阴囊血肿或血清肿、术区感染等并发症进行查看、记录、总结分析。 结果722例患者中双侧腹股沟疝44例,共行Lichtenstein手术766例,术后疝复发15例、慢性疼痛2例、阴囊血肿或血清肿19例、术区感染3例;其中疝复发以内环大和腹横筋膜不完整为主,占13例。 结论Lichtenstein术治疗腹股沟疝手术风险小,术后整体并发症少,但对内环大和腹横筋膜不完整的腹股沟疝患者术后存在较高的复发率,临床上可根据术前的判断或术中具体的情况,如疝环大小和腹横筋膜完整性的情况来进一步确定修补方式,采取个体化治疗方案,以减少术后复发的风险。     

腹腔镜腹膜前与Lichtenstein腹股沟疝无张力修补术的对比研究

目的：研究3D补片在腹腔镜经腹腹膜前疝修补术（transabdominal preperitoneal,TAPP）中的疗效。方法：回顾分析2012年2月至2013年4月收治的100例腹股沟疝患者的临床资料,50例患者应用3D补片行腹腔镜TAPP（观察组）,50例应用聚丙烯平片行腹股沟疝无张力修补术（Lichtenstein,对照组）。对比两组术中、术后情况及住院总费用。结果：观察组术后疼痛指数较小,术后疼痛持续时间较短,术后可较早地下床活动,术后并发症发生率较低,两组相比差异均有统计学意义（P〈0.05）;但观察组住院总费用较高,差异有统计学意义（P〈0.05）;观察组手术时间相对较长,但差异无统计学意义（P〉0.05）。术后随访8个月,观察组与对照组复发率分别为2%与4%,两组复发率相比差异无统计学意义（P〉0.05）。结论：腹腔镜TAPP体现了微创理念,术后不良反应较少,对腹股沟疝修补的治疗效果值得肯定。3D补片与TAPP术式配合应用可达到更好的效果。     

完全腹膜外疝修补术与李金斯坦修补术治疗成人腹股沟疝的对比研究

目的比较完全腹膜外疝修补术（TEP）与李金斯坦修补术（Lichtenstein）治疗成人腹股沟疝的临床效果。方法回顾性分析2012年1月至2013年10月,华润武钢总医院收治成人腹股沟疝220例手术治疗的临床资料,其中102例行TEP（观察组）,118例行开放式Lichtenstein修补术（对照组）,对比二组手术时间,术后住院时间,并发症发生率,术后疼痛评分,住院费用及复发情况。结果观察组较对照组住院时间明显缩短（t=7．622,P=0．005）,术后疼痛症状极轻,但住院费用相对较高,二组术后并发症无统计学差异（x^2=1．529,P=0．144）;术后随访6—18个月,对照组未出现复发,观察组复发1例。结论TEP修补术治疗腹股沟疝具有手术时间短、住院时间短,且安全性高,复发率低,值得临床推广。