Study design
Retrospective comparative study that included patients undergoing open inguinal hernia correction with mesh, using Lichtenstein-type open hernioplasty versus Nyhus-type preperitoneal hernioplasty, in two centers in Bogota, Colombia, during a period of two years (2018-2020). The study has been reported in line with the STROCSS criteria [8].
Inclusion and exclusion criteria
We included patients over 18 years of age who were taken for primary inguinal hernia correction on an outpatient basis with open mesh technique, who underwent pre-habilitation prior to surgery. Patients under 18 years of age, hernia recurrence, previous alteration of the preperitoneal space (prostatectomy, cystectomy), untreated symptomatic benign prostatic hyperplasia, collagen diseases, incarcerated or strangulated inguinal hernias and presence of inguinal, abdominal or systemic active soft tissue infection were excluded.
Data collected
The following clinical variables were evaluated: age, sex, type of hernia according to the European hernia society classification, type of open surgery performed, surgical time, bleeding, postoperative pain, hernia recurrence, surgical site infection, need for reoperation, work incapacity, complications and mortality. A clinical follow-up was performed by outpatient clinic for a minimum of one year postoperatively, evaluating the variables previously described in patients who presented hernia recurrence, chronic pain or complications secondary to the procedure.
Pre-surgical habilitation
For the pre-surgical habilitation, the following considerations were taken into account:
1. Patients who reported that they were smokers were only taken to surgery if they had stopped smoking for at least three months beforehand.
2. Patients were only taken to surgery if their body mass index was equal to or less than 28.
3. If the patients were diabetic, they were taken to surgery if the patients had glycosylated hemoglobin less than and equal to 7 mg/dl.
The procedures were performed depending on the surgeon's choice, based on his or her surgical experience with each of the two techniques. Each surgeon had at the time of the study three years of experience in performing these procedures.
Description of Lichtenstein-type open hernioplasty technique
An anterior approach to the inguinal region was performed, opening the aponeurosis of the greater oblique or roof of the inguinal canal. The inguinal ileal nerve was identified and preserved, the hernia sac was identified and the hernial content was reduced, the elements of the spermatic cord or round ligament of the hernial sac were dissected. Subsequently, high ligation of the hernial sac was performed at the level of the epigastric vessels. The low density macroporous polypropylene mesh was placed and fixed to the joint tendon and the inguinal ligament with three 1-0 polypropylene stitches. The neo-ring was created through the mesh for the spermatic cord elements in male cases and for the round ligament in female cases, then closure by planes with absorbable suture and skin with polypropylene.
Description of the Nyhus-type open preperitoneal hernioplasty technique
A posterior approach to the inguinal region was performed, entering the preperitoneal space. The medial component is reduced to the epigastric vessels identifying Cooper's ligament. The lateral component is reduced to the epigastric vessels, identifying and preserving them. In case of bleeding, the vessels were ligated with non-absorbable suture. The hernial contents are reduced and the elements of the spermatic cord are separated from the hernial sac in male patients or the round ligament in female patients. Subsequently, high ligation of the hernial sac was performed at the level of the epigastric vessels. The low density macroporous polypropylene mesh was placed and fixed to Cooper's ligament with three 1-0 polypropylene stitches. The neo-ring was created through the mesh for the spermatic cord elements in male cases or the round ligament in female cases and extended throughout the preperitoneal space reinforcing Fruchaud's hemi-quadrilateral. The abdominal wall is closed in planes with absorbable suture and the skin with polypropylene.
Postoperative follow-up
1. All patients were discharged 3 hours postoperatively once they had recovered from the regional anesthesia to which all patients were subjected.
2. All patients had a follow-up appointment after 8 days for stitch removal and postoperative check-up.
3. All patients were monitored at 6 months and 1 year.
4. Due to the health affiliation system of these patients, if they presented chronic groin pain or any late complication associated with the procedure, they were referred as a priority to the treating surgeon, which ensured strict follow-up of postoperative outcomes and prevented patients from being lost and managed by other surgeons and in other institutions.
Statistical analysis
For statistical analyses, IBM SPSS® V26 was used. Frequencies and percentages were calculated. Continuous data are presented as mean and standard deviation (SD). Discrete data are presented as median and range (IQR). A bivariate analysis was performed to compare groups, according to the complications presented between the two techniques, according to normality for dichotomous variables using Fisher's test. Statistical significance was determined with a p <0.05.
Ethical Statements
This study was conducted using an appropriate consent process and ethics process. All protocols were approved by the Hospital Cardiovascular del Niño de Cundinamarca Ethics Committee, and in accordance with the Helsinki Declaration (1983). All study methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all study participants and/or their legal guardians prior to participation in this study.