A modified technique of lichtenstein repair using fibro-cremasteric sheath to cover the mesh versus traditional Lichtenstein hernioplasty
Authors: Ibrahim Ayman H 
Published: October 2019

Introduction
The Lichtenstein hernioplasty is the most widely used repair for inguinal hernia, with recurrence rate of 1–2%. Incidence of chronic postsurgery pain ranges from 10 to 50%. Pain may be due to peripheral neuropathy in the ilioinguinal and iliohypogastric nerves, which are entrapped in inguinal canal in contact with mesh, which produces a massive fibrotic reaction. In this study, a modification in Lichtenstein repair was suggested, in which the mesh was covered by a layer derived from cremasteric sheath of the cord to avoid contact of the cord and nerves of the canal with the mesh thus reducing their affection by massive fibrotic reaction. A comparative study between this modified technique and traditional Lichtenstein repair was done.

Aim
To evaluate the results of the modified technique versus traditional method of Lichtenstein repair especially on postoperative pain and other postoperative complications.

Patients and methods
A total of 90 patients are classified into two groups: group A (45 patients) was operated by modified technique and group B (45 patients) was operated by traditional technique. Operative time, hospital stay, return to normal activities, and early and late complications, particularly pain, were assessed, and data were collected for statistical analysis in a follow-up period of 18 months.

Results
No intraoperative complications or recurrences were reported in both groups. The operative time in the new technique was 58.4±9.2 min compared with 51.3±10.6 min in the traditional method, which is significantly shorter. The mean hospital stay was 1±0.4 days in the modified technique group and 1.2±0.6 in the traditional group. Hospital stay and complications other than postoperative pain were similar in both groups and had no significance. Early postoperative pain showed minimal nonsignificant difference as mean visual analogue scale was slightly lower in patients of the modified method (3.9) than in the traditional group (4.1). A total of 17 (37.7%) patients in group A and 15 (33.3%) patients in group B required no medication, whereas others were administered nonsteroidal analgesics. Patients who needed analgesics in the first week postoperatively were 10 (22%) in group A and 12 (26.6%) in group B. In the second and third weeks, none of patients in group A and three (6.5%) patients in group B needed pain medication. At 6-month follow-up, it was reported that the rate of pain-related impairment of function was 11% (five cases) after modified method and 17.7% (eight cases) after Lichtenstein repair. Pain-related impairment of function at 1-year follow-up occurred in three (6.5%) patients of group A and six (13.3%) patients in group B. At 18 months, two (4.4%) patients in group A and five (11%) patients in group B had pain and discomfort at the inguinal region. There were statistically significant differences in chronic pain between both groups at 6, 12, and 18 months.

Conclusion
The results showed that suggested modification may be better or at least comparable to traditional Lichtenstein procedure in reduction of chronic postoperative pain with no increase in complication rates. However, larger studies with long-term follow-up are needed to assess this technique.