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Review Article

Comparison of open preperitoneal and Lichtenstein repair


for inguinal hernia repair: a meta-analysis of randomized
controlled trials
Junsheng Li, M.D.*, Zhenling Ji, M.D., Tao Cheng, M.D.
Department of General Surgery, Afliated Zhong-Da Hospital, Southeast University, 210009 Nanjing, Jiangsu, China
Abstract
BACKGROUND: The aim of this article was to compare the outcomes of the open preperitoneal
approaches and the Lichtenstein technique in the repair of inguinal hernias.
METHODS: A systematic literature review was undertaken to identify studies comparing the out-
comes of open preperitoneal and Lichtenstein techniques in the repair of inguinal hernias.
RESULTS: The present meta-analysis pooled the effects of outcomes of a total of 2,860 patients
enrolled into 10 randomized controlled trials and 2 comparative studies. The preperitoneal technique
was associated with a lesser incidence of recurrence (odds ratio .51; 95% condence interval,
.28.92). However, statistically there was no difference in the incidence of chronic pain, hematoma,
wound infection, testicular problem, urinary problem, numbness, inguinal parenthesis, and operative
time.
CONCLUSIONS: The open preperitoneal approach is a feasible alternative for the standard Lichten-
stein procedure with similar complication rates and potentially less postoperative recurrence.
2012 Elsevier Inc. All rights reserved.
KEYWORDS:
Lichtenstein;
Preperitoneal;
Inguinal hernia;
Repair;
Randomized
controlled trials
Inguinal hernia repair is one of the most common surgi-
cal procedures performed, and nearly 80 operative tech-
niques have been described since Bassini reported his
method in 1887. Surgeons continue to search for the ideal
repair method with the best outcome. Because tension-free
inguinal hernia repair has a low recurrence rate, parameters
other than recurrence are becoming increasingly important
to determine the effects of hernia repair (eg, postoperative
inguinal pain and discomfort). Although the laparoscopic
approach was reported to be associated with less pain,
laparoscopic hernia repair is more expensive and has a
longer learning curve and the need for general anesthesia;
hence, most surgeons reserve this approach for specic
indications and in specialized centers.
1
One of the most frequently used open techniques is the
Lichtenstein herniorraphy.
2
Nowadays, chronic pain is
the main problem associated with the Lichtenstein proce-
dure with a reported rate of 15% to 40%.
3,4
The reason of
the postoperative pain was complex, and the position of the
mesh is probably 1 factor. Furthermore, this anterior method
needs extensive dissection of the inguinal wall and the
xation of the mesh.
5
Despite skepticism about the anterior
placement of the mesh, Amid et al
6
supported their claims
that Lichtenstein was a safe, easy, and effective inguinal
hernia method, with a recurrence rate as low as .12% in their
hands.
6
The open preperitoneal approach might benet from put-
ting a mesh in the preferred preperitoneal space free of the
disadvantages of an endoscopic procedure. In the preperi-
* Corresponding author. Tel: 0086-25-13770927641; fax: 0086-25-
83272064
E-mail address: Lijunshenghd@126.com
Manuscript received September 27, 2011; revised manuscript February
5, 2012
0002-9610/$ - see front matter 2012 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjsurg.2012.02.010
The American Journal of Surgery (2012) 204, 769778
toneal approach, the mesh is held in place with intra-ab-
dominal pressure and, thus, needs relatively less or no
xation. The open preperitoneal approach has been in use
for more than 30 years.
7,8
Several different methods have
been designed and proved to be successful, such as the
transinguinal preperitoneal technique (TIPP) with a memory
ring patch
9
and lower abdominal incision with a Kugel
patch.
10
In addition, a currently common used technique,
the Prolene hernia system (PHS; Ethicon, South San Fran-
cisco, CA) with a bilayer mesh, reinforcing both the pre-
peritoneal space and inguinal oor, has the benet of less
xation and less dissection of the inguinal oor and pre-
serves the advantages of open preperitoneal position of the
mesh.
11
To date, there is no meta-analysis specially comparing
the effects of open preperitoneal mesh placement and the
subaponeurotic location. In the present article, we included
several different preperitoneal repair methods based on the
point that, in these methods, the meshes were all placed in
the preperitoneal space, and which is the most important
aspect of these methods, and this is the truly clinical sig-
nicance of the preperitoneal approach.
Methods
By conducting an intensive search of the literature in the
major databases (ie, PubMed, EMBase, Springer, and Co-
chrane Library), we identied all trials published up to and
including May 2011 that compared the open preperitoneal
and Lichtenstein procedures for the repair of inguinal her-
nias. The term inguinal hernia was used in combination
with the following medical subject headings: preperito-
neal, Lichtenstein, Kugel, PHS, tension-free, and
repair. The reference lists and relevant articles referenced
in these primary studies were downloaded from the data-
bases. The relevance function of the articles in the database
was used to widen the search results. All abstracts, compar-
ative studies, nonrandomized trials, and citations scanned
were searched comprehensively. Ten randomized controlled
trials and 2 well-designed comparisons were identied for
study. The 2 comparative studies had a large number of
cases, long-term follow-up, and comparable baseline char-
acteristics. A total of 2,860 patients were summarized in a
formal meta-analysis. All the nonrelevant articles (eg, arti-
cles that did not compare these 2 procedures, trials that
reported on only 1 technique, and articles that reported pure
surgical experiences) were excluded from this study. A ow
chart of the literature is shown in Figure 1.
To be included, studies had to be published as full-length
articles or letters in peer-reviewed journals. For duplicate
publications, the smaller dataset was excluded. These trials
reported at least 1 of the following outcomes: seroma or
hematoma, infection, numbness, parenthesis, chronic pain,
testicular problems, operating time, urinary problem, or
recurrence (Table 1). Each article was critically reviewed by
Potentially relevant trials identified and
screened for retrival
n=367
Trials retrieved for more detailed
evaluation
n=65
Trials included
n= 14
Potentially appropriate trials to be
included in the meta-analysis
n=18
Trials with usuable information, by
outcome
n=12
Trials withdrawn n=2
Incomplete information n=1
Different outcome n=1
Trials excluded n=4
Femoral hernia trials n=1
Emergency cases studie n=1
Other techniques n=2
Trials excluded n=47
Non-comparative, case report, or review.
n=47
Trials excluded n=302
Trials not relevant n=302
Figure 1 A ow diagram of trial selection.
770 The American Journal of Surgery, Vol 204, No 5, November 2012
2 independent researchers for eligibility in the meta-analy-
sis, and data were extracted separately by the 2 researchers.
Disagreements were resolved by consensus. The following
variables were extracted from each article: author(s), pub-
lication year, journal, country of origin, study design, inter-
vention, and outcome.
Table 1 Basic information of the trials
Study
Type of inguinal
hernia
Sample size
(exp/con)
Experimental
group
Control
group
Outcome (extracted
for meta-analysis) Follow-up
Nienhuijs et al, 2007
14
Primary unilateral 82/84 Kugel Lichtenstein Recurrence
Pain
Numbness
Parenthesia
Testicular problem
Urinary problem
3 mo
Dogru et al, 2006
15
Primary unilateral 69/70 kugel Lichtenstein Recurrence
Wound infection
Hematoma
Testicular problem
Operative time
2 y
Muldoon et al, 2004
16
Primary unilateral 121/126 Read-Rives Lichtenstein Recurrence
Pain
Numbness
Wound infection
Hematoma
Testicular problem
Urinary problem
2 y
Berrevoet et al, 2010
17
Primary unilateral 142/136 TIPP Lichtenstein Recurrence
Pain
Hematoma
Urinary problem
1 y
Koning et al, 2011
18
Primary unilateral 225/271 TIPP Lichtenstein Recurrence
Numbness
Hematoma
3 y
Mayagoitia et al, 2006
19
Primary including
recurrent
36/214 PHS Lichtenstein Recurrence
Pain
Wound infection
Hematoma
Parenthesia
Testicular problem
2 y
Sanjay et al, 2006
20
Primary unilateral 31/33 PHS Lichtenstein Recurrence
Pain
Wound infection
Hematoma
Operative time
4 y
Dalenback et al, 2009
21
Primary 155/158 PHS Lichtenstein Recurrence
Pain
Wound infection
Hematoma
Parenthesia
Testicular problem
Urinary problem
Operative time
3 y
Al Gun et al, 2007
22
Primary unilateral 39/42 Nyhus Lichtenstein Recurrence
Testicular problem
Urinary problem
Operation time
8 y
Vironen et al, 2006
23
Primary and
recurrent
150/149 PHS Lichtenstein Recurrence
Pain
Numbness
Wound infection
Hematoma
Testicular problem
1 y
Nienhuijs et al, 2005
24
Primary unilateral 111/110 PHS Lichtenstein Recurrence
Hematoma
Wound infection
7 mo
Kingsnorth et al, 2002
25
Primary unilateral 103/103 PHS Lichtenstein Recurrence 12 mo
771 J. Li et al. Preperitoneal and Lichtenstein techniques in inguinal hernias
The quality of trials was assessed with the Cochrane
Handbook for Systematic Reviews of Interventions version
5.0.1
12
(Table 2). Each included trial was assessed indepen-
dently to ascertain the following methodologic qualities:
sequence generation, allocation concealment, blinding of
participants, personnel and outcome assessors, incomplete
outcome data, selective outcome reporting, and other
sources of bias. No sponsors were involved in the study
design, data collection, analysis, interpretation, and the writ-
ing and submitting of the report for publication. All authors
had access to the raw data.
Pooled estimates of outcomes were calculated using a
xed-effects model, but a randomized-effects model was
used according to heterogeneity. Tests for heterogeneity and
overall effect were provided for each total or subtotal. We
used the chi-square statistic to assess the heterogeneity
between trials and the I
2
statistic to assess the extent of
inconsistency. For dichotomous data, results for each trial
were expressed as odds ratios (ORs) or risk differences
(RDs) with 95% condence intervals (CIs).
12
Forest plots were used for the graphic display of the
results from the meta-analysis. Statistical analysis was per-
formed by Review Manager (RevMan version 5.0), the
Cochrane Collaborations software for preparing and main-
taining Cohrane systematic reviews. Bias was studied using
sensitivity analysis by removing individual studies from the
dataset and analyzing the overall effect size and the
weighted regression test described by Egger et al.
13
Publi-
cation bias was tested using the Egger test.
Results
Figure 1 shows the owchart of studies from the initial
results of publication searches to the nal inclusion or
exclusion. Only randomized controlled trials and well-de-
signed comparative studies that were published in English
were included in the present analysis. The electronic searches
yielded 367 items from PubMed, EMBase, Springer, and the
Cochrane Library. After reviewing these, we identied 12
original studies.
1425
The publication dates ranged from
2004 to 2011. A total of 2,860 patients were enrolled in
these eligible trials.
Recurrence
There was no signicant heterogeneity among the 12
trials
1425
(P .94, I
2
0%); therefore, the xed-effects
model was appropriate. Compared with the Lichtenstein
group, the preperitoneal group showed less postoperative
recurrence (OR .51; 95% CI, .28.92; Fig. 2A). To test
the sensitivity of these results, we excluded 2 trials with
small sample sizes
20,22
and obtained similar results (OR
.48; 95% CI, .25.91; Fig. 2B). We also excluded the trial
with the shortest follow-up time
14
and got the result did not
changed (OR .44; 95% CI, .22.87, Fig. 2C). Further-
more, these results were recalculated with relative risk and
RD, and the same conclusion was obtained. Publication bias
was also tested with the Egger test, and no publication bias
was detected among the present included trials (Fig. 2D).
Pain
Seven
14,16,17,1921,23
of the 12 studies reported chronic
pain (6 months). The random-effects model was used
because of the heterogeneity (P .0001, I
2
80%). The
results showed that there was no signicant difference in
chronic pain between the preperitoneal and Lichtenstein
groups (OR .55; 95% condence interval [CI], .221.39;
Fig. 3).
Table 2 Quality assessment of the randomized controlled trials
Study Randomization
Allocation
concealment Blinding
Incomplete
outcome
data
ITT
analysis
Selecting
outcome
reporting
Other
sources
of bias
Nienhuijs et al, 2007
14
Computer
generated
Central allocation Single blind Yes No Unclear Unclear
Dogru et al, 2006
15
Admittance
order
Central allocation Unclear Yes No Unclear Unclear
Muldoon et al 2004
16
Computer
generated
Sealed envelope Unclear Yes No Unclear Unclear
Mayagoitia et al
2006
19
Unclear Unclear Unclear Yes No Unclear Unclear
Sanjay et al 2006
20
Unclear Sealed envelope Unclear Yes No Unclear Unclear
Dalenback et al 2009
21
Unclear Central allocation Single blind Yes No Unclear Unclear
Al Gun et al, 2007
22
Unclear Unclear Unclear Yes No Unclear Unclear
Vironen et al, 2006
23
Unclear Sealed envelope Double blind Yes No Unclear Unclear
Nienhuijs et al, 2005
24
Computer
generated
Sealed envelope Single blind Yes No Unclear Unclear
Kingsnorth et al,
2002
25
Unclear Unclear Double blind Yes No Unclear Unclear
772 The American Journal of Surgery, Vol 204, No 5, November 2012
Study or Subgroup
Berrevoet F 2010
Dalenback J 2009
Dogru O 2006
Gunal O 2007
Kingsnorth 2002
Koning GG 2011
Mayagoitia JC 2006
Muldoon RL 2004
Nienhuijs 2005
Nienhuijs S 2007
Sanjay P 2006
Vironen J 2006
Total (95% CI)
Total events
Heterogeneity: Chi = 4.84, df = 11 (P = 0.94); I = 0%
Test for overall effect: Z = 2.23 (P = 0.03)
Events
4
3
0
1
0
1
0
1
1
2
1
0
14
Total
142
155
69
39
103
225
136
121
111
82
31
150
1364
Events
7
2
1
3
2
3
2
5
3
2
0
1
31
Total
136
158
70
42
103
271
214
126
110
84
33
149
1496
Weight
21.7%
6.1%
4.6%
8.8%
7.8%
8.5%
6.0%
15.2%
9.3%
6.0%
1.4%
4.7%
100.0%
M-H, Fixed, 95% CI
0.53 [0.15, 1.87]
1.54 [0.25, 9.34]
0.33 [0.01, 8.32]
0.34 [0.03, 3.44]
0.20 [0.01, 4.14]
0.40 [0.04, 3.86]
0.31 [0.01, 6.53]
0.20 [0.02, 1.75]
0.32 [0.03, 3.17]
1.02 [0.14, 7.45]
3.30 [0.13, 83.97]
0.33 [0.01, 8.14]
0.51 [0.28, 0.92]
o i t a R s d d O o i t a R s d d O n i e t s n e t h c i L l a e n o t i r e p e r P
M-H, Fixed, 95% CI
0.01 0.1 1 10 100
Favours preperitonal Favours Lichtenstein
Study or Subgroup
Berrevoet F 2010
Dalenback J 2009
Dogru O 2006
Kingsnorth 2002
Koning GG 2011
Mayagoitia JC 2006
Muldoon RL 2004
Nienhuijs 2005
Nienhuijs S 2007
Vironen J 2006
Total (95% CI)
Total events
Heterogeneity: Chi = 3.47, df = 9 (P = 0.94); I = 0%
Test for overall effect: Z = 2.24 (P = 0.02)
Events
4
3
0
0
1
0
1
1
2
0
12
Total
142
155
69
103
225
136
121
111
82
150
1294
Events
7
2
1
2
3
2
5
3
2
1
28
Total
136
158
70
103
271
214
126
110
84
149
1421
Weight
24.1%
6.7%
5.1%
8.6%
9.4%
6.7%
16.9%
10.4%
6.7%
5.2%
100.0%
M-H, Fixed, 95% CI
0.53 [0.15, 1.87]
1.54 [0.25, 9.34]
0.33 [0.01, 8.32]
0.20 [0.01, 4.14]
0.40 [0.04, 3.86]
0.31 [0.01, 6.53]
0.20 [0.02, 1.75]
0.32 [0.03, 3.17]
1.02 [0.14, 7.45]
0.33 [0.01, 8.14]
0.48 [0.25, 0.91]
o i t a R s d d O o i t a R s d d O n i e t s n e t h c i L l a e n o t i r e p e r P
M-H, Fixed, 95% CI
0.01 0.1 1 10 100
Favours preperitoneal Favours Lichtenstein
A
Study or Subgroup
Berrevoet F 2010
Dalenback J 2009
Dogru O 2006
Kingsnorth 2002
Koning GG 2011
Mayagoitia JC 2006
Muldoon RL 2004
Nienhuijs 2005
Vironen J 2006
Total (95% CI)
Total events
Heterogeneity: Chi = 2.90, df = 8 (P = 0.94); I = 0%
Test for overall effect: Z = 2.35 (P = 0.02)
Events
4
3
0
0
1
0
1
1
0
10
Total
142
155
69
103
225
136
121
111
150
1212
Events
7
2
1
2
3
2
5
3
1
26
Total
136
158
70
103
271
214
126
110
149
1337
Weight
25.9%
7.2%
5.5%
9.3%
10.1%
7.2%
18.1%
11.1%
5.6%
100.0%
M-H, Fixed, 95% CI
0.53 [0.15, 1.87]
1.54 [0.25, 9.34]
0.33 [0.01, 8.32]
0.20 [0.01, 4.14]
0.40 [0.04, 3.86]
0.31 [0.01, 6.53]
0.20 [0.02, 1.75]
0.32 [0.03, 3.17]
0.33 [0.01, 8.14]
0.44 [0.22, 0.87]
o i t a R s d d O o i t a R s d d O n i e t s n e t h c i L l a e n o t i r e p e r P
M-H, Fixed, 95% CI
0.01 0.1 1 10 100
Favours preperitoneal Favours Lichtenstein
B
C
Figure 2 (A) Postoperative inguinal hernia recurrence. (B) Postoperative inguinal hernia recurrence; 2 trials with small samples were
excluded from analysis (Sanjay [2006] and Gunal [2007]). (C) Postoperative inguinal hernia recurrence; 1 trial with the shortest follow-up
was excluded from analysis (Nienhuijs [2007] was excluded). (D) The Egger test publication bias plot for postoperative recurrence after the
preperitoneal and Lichtenstein procedures. Using the Egger test, t .06; P .523; and 95% CI, 1.905346 to 1.033382 [includes 0]);
no obvious publication bias was detected.
773 J. Li et al. Preperitoneal and Lichtenstein techniques in inguinal hernias
Hematomas and seromas
Ten studies
1524
reported the incidence of hematomas.
The xed-effects model was used because of the heteroge-
neity (P .24, I
2
22%). The results showed that there
was no signicant difference in the incidence of hematomas
between the preperitoneal and Lichtenstein repair groups
(OR 1.04; 95% CI, .661.64; Fig.4).
Wound infection
Seven studies
15,16,1921,23,24
reported wound infection af-
ter surgery. The main meta-analysis with the xed-effects
model showed no statistically signicant difference between
the 2 groups (RD .01; 95% CI, .00 to .03). The heter-
ogeneity was not signicant (P .27, I
2
21%, Fig. 5).
Testicular problems
Figure 6 shows the testicular problems. Seven studies
were included,
1416,19,2123
and the xed-effects model was
used because of the heterogeneity (P .18, I
2
34%). The
results showed no signicant difference in testicular prob-
lems between the 2 groups (OR .67; 95% CI, .321.42).
Urinary problems
Five studies
14,16,17,21,22
reported urinary problems (ie,
urinary retention/infection). The xed-effects model was
used because of the heterogeneity (P .71, I
2
0%). The
results showed that there was no signicant difference in
urinary problems between the 2 groups (OR .83; 95% CI,
.461.53; Fig. 7).
Numbness
The meta-analysis showed that there was no statistically
signicant difference in postoperative numbness (OR
.50; 95% CI, .181.43). The heterogeneity of the stud-
ies
14,16,18,23
was signicant (P .01, I
2
74%), and the
random-effects model was used.
Inguinal parenthesis
The results of the studies that included information about
inguinal parenthesis
14,19,21
indicated that there was no dif-
ference in the incidence of inguinal parenthesis between the
preperitoneal and Lichtenstein groups (OR .82; 95% CI,
.145.02).
Operative time
The analysis results of the operative time between the pre-
peritoneal and Lichtenstein groups showed that there was no
statistically signicant difference (mean difference
1.94%; 95% CI, 5.41 to 1.53).
Comments
Tension-free hernia repair has reduced the incidence of
recurrence. Although the recurrence rate after tension-free
Egger's publication bias plot
s
t
a
n
d
a
r
d
i
z
e
d

e
f
f
e
c
t
precision
0 .5 1 1.5
-2
-1
0
1
D
Figure 2 Continued
Study or Subgroup
Berrevoet F 2010
Dalenback J 2009
Mayagoitia JC 2006
Muldoon RL 2004
Nienhuijs S 2007
Sanjay P 2006
Vironen J 2006
Total (95% CI)
Total events
Heterogeneity: Tau = 1.17; Chi = 30.77, df = 6 (P < 0.0001); I = 80%
Test for overall effect: Z = 1.26 (P = 0.21)
Events
4
4
1
10
17
4
18
58
Total
142
155
136
121
82
31
150
817
Events
43
4
6
7
34
5
12
111
Total
136
158
214
126
84
33
149
900
Weight
15.1%
13.1%
9.4%
15.5%
17.1%
13.1%
16.7%
100.0%
M-H, Random, 95% CI
0.06 [0.02, 0.18]
1.02 [0.25, 4.15]
0.26 [0.03, 2.16]
1.53 [0.56, 4.16]
0.38 [0.19, 0.77]
0.83 [0.20, 3.42]
1.56 [0.72, 3.36]
0.55 [0.22, 1.39]
o i t a R s d d O o i t a R s d d O n i e t s n e t h c i L l a e n o t i r e p e r P
M-H, Random, 95% CI
0.01 0.1 1 10 100
Favours preperitoneal Favours Lichtenstein
Figure 3 Chronic pain after inguinal hernia repair.
774 The American Journal of Surgery, Vol 204, No 5, November 2012
repair was as low as 2% to 5% recently,
26
other variables
such as postoperative pain and discomfort gained more
attention considering the patients quality of life after sur-
gery. There is still an ongoing debate on what the preferred
technique is in the treatment of inguinal hernia. Commonly
used tension-free repair techniques include the Stoppa pro-
cedure, the Kugel technique, the PHS procedure, Gilbert
procedure, mesh plug repairs, and laparoscopic hernia re-
pairs.
14,19,20
Among these inguinal hernia repair techniques,
the meshes were placed in 2 different positions: either the
anterior or posterior (preperitoneal space) layer.
Some surgeons prefer the anterior subaponeurotic tech-
nique because it is technically easier and, when performed
correctly, is associated with very low recurrence rates,
6,27
whereas others state that all the anterior approaches involve
an extensive dissection (especially in the Lichtenstein po-
cedure) of the inguinal canal; however, an open preperito-
neal dissection approach might have the benet of a mesh in
the preferred preperitoneal space, with limited inguinal ca-
nal dissection, but without the disadvantages of an endo-
scopic procedure.
Until now, no consensus has been reached regarding
the best surgical approach to inguinal hernia repair,
28,29
and there has been no meta-analysis comparing these 2
techniques published in the English literature. In the
present study, we combined several preperitoneal tech-
niques in 1 group including the Kugel, Read-Rives, Ny-
hus, and Tipp procedures and PHS because all these
techniques involve the preperitoneal placement of the
mesh and have the same clinical signicance. In PHS
repair, the upper part of the mesh is placed in the inguinal
canal; however, the anterior inguinal canal dissection is
limited. Furthermore, the large and lower important part
is placed in the preperitoneal place, with the main aim of
preventing any form of hernia recurrence through the
myopectineal orice.
17,20
Therefore, there are no clini-
cally relevant differences in these preperitoneal proce-
dures. Further subgroup analysis would only hinder the
statistical evaluation. The Lichtenstein operation is the
most widely accepted anterior tension-free approach, so
we used the Lichtenstein procedure as the control group
in the present meta-analysis.
In this meta-analysis, more recurrence was found in the
Lichtenstein group compared with the preperitoneal group.
The recurrence after inguinal hernia repair may be situated
near the pubic tubercle, through the internal ring, or lateral
Study or Subgroup
Berrevoet F 2010
Dalenback J 2009
Dogru O 2006
Gunal O 2007
Koning GG 2011
Mayagoitia JC 2006
Muldoon RL 2004
Nienhuijs 2005
Sanjay P 2006
Vironen J 2006
Total (95% CI)
Total events
Heterogeneity: Chi = 11.61, df = 9 (P = 0.24); I = 22%
Test for overall effect: Z = 0.19 (P = 0.85)
Events
2
15
2
1
4
1
9
1
1
2
38
Total
142
155
69
39
225
136
121
111
31
150
1179
Events
4
8
0
1
3
1
7
3
0
11
38
Total
136
158
70
42
271
214
126
110
33
149
1309
Weight
11.0%
19.5%
1.3%
2.6%
7.3%
2.1%
17.3%
8.1%
1.3%
29.6%
100.0%
M-H, Fixed, 95% CI
0.47 [0.08, 2.62]
2.01 [0.83, 4.88]
5.22 [0.25, 110.78]
1.08 [0.07, 17.86]
1.62 [0.36, 7.30]
1.58 [0.10, 25.44]
1.37 [0.49, 3.79]
0.32 [0.03, 3.17]
3.30 [0.13, 83.97]
0.17 [0.04, 0.78]
1.04 [0.66, 1.64]
o i t a R s d d O o i t a R s d d O n i e t s n e t h c i L l a e n o t i r e p e r P
M-H, Fixed, 95% CI
0.01 0.1 1 10 100
Favours preperitoneal Favours Lichtenstein
Figure 4 Hematoma after hernia repair.
Study or Subgroup
Dalenback J 2009
Dogru O 2006
Mayagoitia JC 2006
Muldoon RL 2004
Nienhuijs 2005
Sanjay P 2006
Vironen J 2006
Total (95% CI)
Total events
Heterogeneity: Chi = 7.64, df = 6 (P = 0.27); I = 21%
Test for overall effect: Z = 1.35 (P = 0.18)
Events
6
1
0
0
12
2
3
24
Total
155
69
136
121
111
31
150
773
Events
3
0
2
0
8
1
2
16
Total
158
70
214
126
110
33
149
860
Weight
19.4%
8.6%
20.6%
15.3%
13.7%
4.0%
18.5%
100.0%
M-H, Fixed, 95% CI
0.02 [-0.02, 0.06]
0.01 [-0.02, 0.05]
-0.01 [-0.03, 0.01]
0.00 [-0.02, 0.02]
0.04 [-0.04, 0.11]
0.03 [-0.07, 0.14]
0.01 [-0.02, 0.04]
0.01 [-0.00, 0.03]
Preperitoneal Lichtenstein Risk Difference Risk Difference
M-H, Fixed, 95% CI
-0.1 -0.05 0 0.05 0.1
Favours preperitoneal Favours Lichtenstein
Figure 5 Wound infection.
775 J. Li et al. Preperitoneal and Lichtenstein techniques in inguinal hernias
to the mesh. Recently, evidence was published suggesting
that recurrent femoral hernias are 15 times more frequent
than primary femoral hernias,
30
and these recurrences occur
earlier than inguinal recurrences, suggesting the femoral
hernia is overlooked at the primary operation. Furthermore,
it has been reported that the incidence of femoral hernias
after preperitoneal repair is half that observed after Lich-
tenstein repair, which also proves the advantage of the
preperitoneal approach in this situation.
30
The myopetineal
orice is a large potential area of weakness in the lower
abdominal wall that is closed by the fascia transversalis with
the inguinal above and femoral canal below and transversed
by the inguinal ligament and permits inguinal and femoral
hernias. All the listed preperitoneal repair approaches in this
meta-analysis (eg, Kugel, Tipp, PHS, and so on), close
weakness at the myopectineal orice completely rather than
partly in its anterior inguinal portion (as in the Lichtenstein
approach). In the present meta-analysis, femoral hernia re-
currence was clearly identied in only 1 trial.
21
Most of the
recurrences in the Lichtenstein group were inguinal hernias
rather than additional femoral hernias. This result is consis-
tent with the observation of Muldoon et al,
16
who pointed
out that the early failure in the Lichtenstein series was
presumed to be secondary to surgical error. Shulman et al,
27
from the Lichtenstein Clinic states that it is not an onlay
but an inlay technique because the prosthesis lies beneath
the external oblique aponeurosis, and Kux
31
also believes
this is the right layer for the patch.
Although postoperative recurrence was a failure of in-
guinal hernia repair, some authors regarded chronic pain as
a more severe complication than recurrence because of its
incapacitating character.
14
Chronic pain has signicant ef-
fects on all daily activities, including walking, working,
sleep, mood, relationships with other people, and the gen-
eral enjoyment of life.
32
The exact incidence of chronic pain
is unknown. Well-conducted, large, and unselected epide-
miologic studies suggest that about 20% of patients after
inguinal hernia repair are affected with chronic pain.
30,3234
Five issues have been addressed to minimize the postoper-
ative pain including using a small incision, minimal dissec-
tion around the inguinal nerves, a better location of the mesh
in the preperitoneal space, minimal xation of the mesh, and
a lesser amount of material to prevent severe local inam-
mation and brosis around the nerves and the cord struc-
tures during tissue ingrowth.
17
Researchers also imply that
early postoperative pain intensity can reliably predict the
likelihood of postoperative chronic pain, and the pain scores
during the rst 14 days correlated well with the pain scores
at the long-term follow-up.
24
The Lichtenstein procedure was reported with an inci-
dence of chronic pain more than 15%,
32
and in this meta-
analysis no difference in chronic pain was detected between
Study or Subgroup
Dalenback J 2009
Dogru O 2006
Gunal O 2007
Mayagoitia JC 2006
Muldoon RL 2004
Nienhuijs S 2007
Vironen J 2006
Total (95% CI)
Total events
Heterogeneity: Chi = 7.54, df = 5 (P = 0.18); I = 34%
Test for overall effect: Z = 1.04 (P = 0.30)
Events
0
1
0
0
2
1
6
10
Total
155
69
39
136
121
82
150
752
Events
1
1
7
0
5
0
2
16
Total
158
70
42
214
126
84
149
843
Weight
8.8%
5.8%
42.4%
28.6%
2.9%
11.4%
100.0%
M-H, Fixed, 95% CI
0.34 [0.01, 8.35]
1.01 [0.06, 16.55]
0.06 [0.00, 1.09]
Not estimable
0.41 [0.08, 2.14]
3.11 [0.12, 77.46]
3.06 [0.61, 15.42]
0.67 [0.32, 1.42]
o i t a R s d d O o i t a R s d d O n i e t s n e t h c i L l a e n o t i r e p e r P
M-H, Fixed, 95% CI
0.005 0.1 1 10 200
Favours preperitoneal Favours Lichtenstein
Figure 6 Testicular problems after inguinal hernia repair.
Study or Subgroup
Berrevoet F 2010
Dalenback J 2009
Gunal O 2007
Muldoon RL 2004
Nienhuijs S 2007
Total (95% CI)
Total events
Heterogeneity: Chi = 2.16, df = 4 (P = 0.71); I = 0%
Test for overall effect: Z = 0.59 (P = 0.56)
Events
9
1
1
8
1
20
Total
142
155
39
121
82
539
Events
8
4
1
11
0
24
Total
136
158
42
126
84
546
Weight
33.2%
17.1%
4.1%
43.6%
2.1%
100.0%
M-H, Fixed, 95% CI
1.08 [0.41, 2.89]
0.25 [0.03, 2.26]
1.08 [0.07, 17.86]
0.74 [0.29, 1.91]
3.11 [0.12, 77.46]
0.83 [0.46, 1.53]
o i t a R s d d O o i t a R s d d O n i e t s n e t h c i L l a e n o t i r e p e r P
M-H, Fixed, 95% CI
0.01 0.1 1 10 100
Favours preperitoneal Favours Lichtenstein
Figure 7 Urinary retention/infection after inguinal hernia repair.
776 The American Journal of Surgery, Vol 204, No 5, November 2012
the Lichtenstein and preperitoneal approaches. As Berre-
voet et al suggested,
7
chronic pain was affected not only by
the position of the mesh but also by the length of the
incision, the extent of the dissection, and the need for mesh
xation.
Hematomas and seromas are potential complications of
placing the mesh in the preperitoneal layer, which were
addressed by laparoscopic repair. However, in our meta-
analysis, the incidence of hematomas and seromas when
using the preperitoneal approach was not signicantly dif-
ferent from that when using the Lichtenstein repair. Simi-
larly, in this meta-analysis, no differences in urinary prob-
lems (ie, urinary retention), numbness, wound infection,
testicular problems, or parenthesis were found between the
preperitoneal and Lichtenstein groups.
The evaluation of long-term complications in the meta-
analysis of randomized controlled trials is still difcult
although the overall follow-up rates were indeed high,
reaching above 95% in this meta-analysis. However, most
of the follow-up periods were of a short duration (Table 1).
Moreover, the mode of examination (eg, questionnaire, tele-
phone interview, clinical examination, or ultrasound or sur-
gical exploration) and the blinding status of the investiga-
tors tend to be unclear. These problems might affect the
recurrence rate after hernia repair.
This study also had other limitations including the fact
that there was heterogeneity among the trials in this meta-
analysis (Table 1). The rst possible cause of heterogeneity
in the included trials would be the different repair method in
the preperitoneal group. The second possible cause of het-
erogeneity would be the different anesthesia type because
local epidural anesthesia and general anesthesia were all
used in these trials. Third, all these trials were performed by
different surgeons. Also, the follow-up time of several out-
comes in these trials was not consistent, which could lead to
high performance bias and measuring bias.
Based on the present meta-analysis, we concluded that
for surgeons who prefer an open procedure, the preperito-
neal approach is a feasible alternative for the standard Lich-
tenstein procedure, with similar postoperative complication
rates and potentially less postoperative recurrence. How-
ever, more trials with longer follow-up evaluations are re-
quired to strengthen this evidence.
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778 The American Journal of Surgery, Vol 204, No 5, November 2012
2012 Elsevier

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