European Journal of Cardiovascular Medicine

Inguinal hernia is one of the most common surgical conditions worldwide, accounting for a significant proportion of general surgical procedures. It is defined as the protrusion of abdominal contents through a weakness or defect in the inguinal canal, leading to discomfort, pain, and risk of complications such as incarceration or strangulation. The surgical repair of inguinal hernias remains one of the oldest and most frequently performed operations in surgery, with ongoing debates regarding the optimal surgical technique to reduce recurrence, postoperative pain, and improve overall patient outcomes ^[1].

Historically, non-mesh or tissue-based repairs were the standard surgical approach for inguinal hernias. Techniques such as the Bassini, Shouldice, and McVay repairs involved suturing native tissues to close the hernia defect. These methods, although effective, were associated with relatively higher rates of recurrence, postoperative pain due to tension on tissues, and longer recovery times ^[2]. The introduction of synthetic mesh materials in the 1950s revolutionized hernia surgery by providing a tension-free repair that significantly reduced the recurrence rates. Mesh repair techniques, especially the Lichtenstein tension-free mesh repair, have become the gold standard in many centers globally ^[3].

Despite the widespread acceptance of mesh repair due to its advantages in reducing recurrence, concerns have been raised regarding mesh-related complications. These include chronic postoperative pain, infection, mesh migration, foreign body sensation, and potential allergic reactions. Additionally, the cost of mesh and availability in resource-limited settings remain challenges for its universal adoption ^[4]. Non-mesh techniques, particularly in younger patients or those with small defects, continue to have relevance where mesh-related complications or affordability issues exist.

Several randomized controlled trials and meta-analyses have attempted to compare the outcomes of mesh versus non-mesh repair techniques, focusing on parameters such as recurrence rates, postoperative pain, surgical site infections, hospital stay, and return to daily activities. The evidence largely supports mesh repair in terms of lower recurrence and faster recovery; however, some studies also highlight the importance of surgeon experience, patient selection, and individualizing the surgical approach ^[5].

Aim

To compare the clinical outcomes of mesh versus non-mesh techniques in inguinal hernia repair surgery.

Objectives

1. To evaluate and compare the recurrence rates following mesh and non-mesh inguinal hernia repairs.
2. To assess postoperative pain, complications, and recovery duration in both surgical techniques.
3. To analyze patient satisfaction and quality of life after mesh versus non-mesh hernia repair.

Source of Data

The study data was collected from patients diagnosed with inguinal hernia presenting to the Surgery Department at tertiary care hospital.

Study Design

This was a prospective, observational, comparative study.

Study Location

The study was conducted at the Department of General Surgery.

Study Duration

The study duration was 12 months, from January 2022 to December 2022.

Sample Size

A total of 200 patients diagnosed with inguinal hernia and undergoing elective surgical repair were included. They were divided equally into two groups: 100 patients undergoing mesh repair and 100 undergoing non-mesh repair.

Inclusion Criteria

• Patients aged 18 to 70 years diagnosed with primary unilateral or bilateral inguinal hernia.
• Patients consenting to undergo either mesh or non-mesh surgical repair.
• Patients willing to participate and comply with follow-up visits.

Exclusion Criteria

• Patients with recurrent inguinal hernias.
• Patients with strangulated or incarcerated hernias requiring emergency surgery.
• Patients with coagulopathy or immunocompromised status.
• Patients with previous lower abdominal surgery affecting the inguinal region.
• Patients unwilling or unable to provide informed consent.

Procedure and Methodology

All patients underwent preoperative clinical evaluation and routine investigations including complete blood count, coagulation profile, and relevant imaging as required. Patients were allocated into mesh and non-mesh groups based on surgeon preference and patient suitability after detailed counseling regarding both techniques.

• Mesh Repair Group: Patients underwent tension-free hernioplasty using synthetic polypropylene mesh (Lichtenstein technique). Under appropriate anesthesia, the hernia sac was reduced, and a tailored mesh was placed over the posterior wall of the inguinal canal and fixed with non-absorbable sutures. Care was taken to avoid nerve injury.
• Non-Mesh Repair Group: Patients underwent tissue-based repair techniques, mainly Bassini or Shouldice repair, based on surgeon’s discretion. This involved suturing the conjoint tendon to the inguinal ligament to close the hernia defect under tension without the use of synthetic material.

Postoperative care was standardized for both groups. Patients were monitored for early complications such as hematoma, seroma, wound infection, and urinary retention. Postoperative pain was assessed using the Visual Analog Scale (VAS) at 24 hours, 48 hours, 7 days, and at subsequent follow-ups.

Patients were followed up at 1 month, 3 months, 6 months, and 1 year to assess recurrence, chronic pain, return to daily activities, and satisfaction.

Sample Processing

Data collected from patient records, operative notes, and follow-up visits were entered into a pre-designed proforma. Pain scores, complication rates, and recurrence data were documented systematically.

Statistical Methods

Data were analyzed using SPSS version 27.0. Continuous variables were expressed as mean ± standard deviation (SD) and compared using Student’s t-test. Categorical variables were expressed as percentages and compared using Chi-square or Fisher’s exact test as applicable. A p-value <0.05 was considered statistically significant.

Data Collection

Data were collected prospectively by the surgical team and research assistants using structured case report forms. Confidentiality was maintained, and data was anonymized before analysis.

Table 1: Baseline Demographic and Clinical Profile of Study Participants (n=200)

Table 1 presents the baseline demographic and clinical characteristics of the 200 study participants divided equally into the mesh and non-mesh groups. The mean age was comparable between the mesh group (46.8 ± 12.9 years) and the non-mesh group (45.3 ± 13.4 years), with no statistically significant difference (t = 0.79, p = 0.43). Male predominance was observed in both groups, comprising 87.0% and 90.0% of participants in the mesh and non-mesh groups, respectively, with no significant gender distribution difference (χ² = 0.43, p = 0.51). The right-sided hernia was present in 62.0% of the mesh group and 66.0% of the non-mesh group, showing no significant difference (χ² = 0.32, p = 0.57). Duration of hernia prior to surgery was similar, averaging 23.4 ± 10.7 months in the mesh group and 21.9 ± 11.1 months in the non-mesh group (t = 1.01, p = 0.31). Comorbid conditions were reported in 28.0% of mesh patients and 33.0% of non-mesh patients, with no significant difference (χ² = 0.67, p = 0.41). Overall, the groups were well matched at baseline.

Table 2: Recurrence Rates Following Mesh and Non-Mesh Inguinal Hernia Repairs (n=200)

*Statistically significant at p < 0.05

Table 2 compares the recurrence rates after inguinal hernia repair between the two groups. The mesh group showed a significantly lower recurrence rate of 3.0% compared to 12.0% in the non-mesh group (χ² = 6.23, p = 0.013), with a 95% confidence interval for difference ranging from 2.9% to 15.1%. Time to recurrence, although longer in the mesh group (9.6 ± 2.4 months) versus the non-mesh group (7.8 ± 3.1 months), did not differ significantly (t = 1.89, p = 0.061). This indicates a clear advantage of mesh repair in reducing hernia recurrence.

Table 3: Postoperative Pain, Complications, and Recovery Duration (n=200)

*Statistically significant at p < 0.05

Table 3 details postoperative pain, complications, and recovery times. The mesh group experienced significantly lower pain scores at 24 hours post-surgery (mean VAS 3.8 ± 1.2) compared to the non-mesh group (4.5 ± 1.4) (t = -3.73, p = 0.0003). Early postoperative complications occurred in 15.0% of the mesh group and 21.0% of the non-mesh group, but this difference was not statistically significant (χ² = 1.35, p = 0.24). Specific complications such as wound infections (5.0% vs. 8.0%, p = 0.35) and hematoma/seroma formation (6.0% vs. 9.0%, p = 0.34) were also comparable between groups. Importantly, patients undergoing mesh repair returned to routine work significantly earlier (12.7 ± 3.8 days) than those with non-mesh repair (15.1 ± 4.3 days) (t = -4.36, p < 0.0001).

Table 4: Patient Satisfaction and Quality of Life Post Hernia Repair (n=200)

*Statistically significant at p < 0.05

Table 4 addresses patient satisfaction and quality of life after surgery. The mesh group reported a significantly higher mean satisfaction score (8.7 ± 1.3) compared to the non-mesh group (7.9 ± 1.6) (t = 3.87, p = 0.0002). The incidence of chronic pain was significantly lower in the mesh group (9.0%) than in the non-mesh group (19.0%) (χ² = 4.56, p = 0.033). Although a higher percentage of patients in the mesh group (82.0%) reported improvement in quality of life compared to the non-mesh group (73.0%), this difference did not reach statistical significance (χ² = 2.29, p = 0.13). These findings suggest better overall patient satisfaction and less chronic pain with mesh repair.

Baseline Demographic and Clinical Profile (Table 1) The baseline characteristics of the study groups showed no statistically significant differences in age, gender distribution, hernia laterality, duration of hernia, or presence of comorbidities. This comparability is essential to ensure unbiased outcome assessment between mesh and non-mesh groups. Similar demographic patterns were reported by Kouhia S et al. (2015)^[6], who observed male predominance and mean age in the mid-40s in inguinal hernia repair patients. The distribution of comorbid conditions was also consistent with findings by Bracale U et al. (2019)^[7], indicating that patient profiles across repair techniques are generally similar, supporting the validity of direct comparison.

Recurrence Rates (Table 2) A significantly lower recurrence rate was observed in the mesh group (3.0%) compared to the non-mesh group (12.0%) (p = 0.013). This finding corroborates extensive literature demonstrating the superiority of mesh repair in reducing hernia recurrence. The landmark Lichtenstein trial and subsequent meta-analyses have consistently shown recurrence rates around 1-4% with mesh repairs versus 8-15% with tissue-based repairs Finch DA et al. (2019)^[8]. The non-significant difference in time to recurrence suggests that recurrences in the mesh group tend to occur slightly later but are overall less frequent. This aligns with the review by Manyilirah W et al. (2012)^[9], which emphasized tension-free mesh repair’s durability.

Postoperative Pain, Complications, and Recovery (Table 3) The mesh group experienced significantly less postoperative pain at 24 hours and a faster return to routine activities than the non-mesh group (p < 0.001). These results are consistent with findings by Alabi A et al. (2022)^[10], where patients undergoing mesh repair reported lower pain scores and quicker functional recovery. Although rates of early complications such as infection and hematoma were lower in the mesh group, the differences were not statistically significant, mirroring observations by Bracale U et al. (2019)^[7] indicating comparable safety profiles between techniques when performed by experienced surgeons.

Patient Satisfaction and Quality of Life (Table 4) Patients in the mesh group reported higher satisfaction scores and significantly lower chronic pain incidence compared to the non-mesh group (p = 0.0002 and p = 0.033 respectively). These outcomes reflect mesh repair’s benefits in improving long-term patient quality of life, as reported by Tripoloni DE et al. (2011)_[11] who found mesh repair associated with less chronic groin pain and better satisfaction. Although quality of life improvement was numerically higher in the mesh group, it did not reach statistical significance, possibly due to sample size or subjective variability. Overall, the data support mesh repair as the preferred technique for optimized patient-centered outcomes.

This study demonstrates that mesh repair for inguinal hernia is superior to non-mesh techniques in significantly reducing hernia recurrence rates. Patients undergoing mesh repair experienced less postoperative pain, faster recovery, and higher satisfaction scores compared to those receiving non-mesh tissue repair. While early postoperative complications were comparable between groups, the mesh technique showed clear advantages in long-term outcomes, including lower chronic pain incidence and improved quality of life. Therefore, mesh repair should be considered the preferred surgical approach for inguinal hernia repair in suitable patients, balancing clinical efficacy and patient-centered benefits.

LIMITATIONS OF THE STUDY

1. The study was conducted at a single tertiary care center, limiting generalizability to other settings or populations.
2. Follow-up duration of one year may not capture very late recurrences or long-term complications comprehensively.
3. The allocation of patients to mesh or non-mesh repair was based on surgeon preference rather than randomization, introducing potential selection bias.
4. Subjective measures such as pain and satisfaction scores could be influenced by patient perception and reporting bias.
5. The sample size, although adequate for primary outcomes, may limit the power to detect differences in less frequent complications.

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