Inguinal hernia repair: a comparison of strengthening the posterior inguinal wall with aponeuroplasty versus the Lichtenstein technique (mesh repair). A randomized controlled trial in a low-resource setting

Background: Inguinal hernia repair is a frequently performed surgical procedure that generally employs prosthetic mesh. However, alternative techniques, notably the reinforcement of the posterior inguinal wall through aponeuroplasty, have not been sufficiently explored, particularly in resource-constrained environments. This study aims to evaluate and compare the efficacy and outcomes of aponeuroplasty against traditional mesh repair in adult patients with inguinal hernias.
Methods: A randomized controlled trial was conducted from April 1, 2019, to May 22, 2024, enrolling 200 adult patients diagnosed with inguinal hernias. Participants were randomized into either Group A (Lichtenstein technique with prosthetic mesh repair, n=96) or Group B (posterior inguinal wall aponeuroplasty, n=104). Patients were monitored for a minimum of two year postoperatively. The aponeuroplasty technique required meticulous dissection of the external oblique and transversus abdominis aponeuroses, ensuring tissue integrity and securing the tissue to the inguinal ligament and muscle arch. Complications, recurrence rates, and other surgical outcomes were systematically analyzed.
Results: Demographic analyses revealed no significant differences between groups. Group B demonstrated significantly shorter operative times (30 ± 9.43 min vs. 38 ± 12.55 min, p=0.004) and lower postoperative pain levels (p=0.031). Over the follow-up period of two years, hydroceles were documented in 9 patients (4.5%), with a notably lower incidence in Group B (1 case, 1.0%) compared to Group A (8 cases, 8.3%, p=0.030). Recurrence rates were similar in both groups (3 in Group A and 2 in Group B, p=0.613).
Conclusions: Strengthening the posterior inguinal wall via aponeuroplasty offers superior outcomes compared to prosthetic mesh repair, particularly regarding postoperative pain and operative time. These findings advocate for the consideration of aponeuroplasty as an effective surgical alternative for inguinal hernia repair in low-resource settings. Future studies are warranted to validate these conclusions across diverse and larger populations.

International guidelines for groin hernia management. Hernia. 2018; 22:1-165. DOI: https://doi.org/10.1007/s10029-017-1668-x

Hammoud M, Gerken J. Inguinal Hernia. StatPearls. Treasure Island (FL) ineligible companies. Disclosure: Jeffrey Gerken declares no relevant financial relationships with ineligible companies. StatPearls Publishing LLC. 2025.

In: Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, editors. Essential Surgery: Disease Control Priorities, Third Edition (Volume 1). Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2015. DOI: https://doi.org/10.1596/978-1-4648-0346-8

Sæter AH, Fonnes S, Li S, et al. Mesh versus non-mesh for emergency groin hernia repair. Cochrane Database Syst Rev. 2023;11:Cd015160. DOI: https://doi.org/10.1002/14651858.CD015160.pub2

Yerxa J, Wang H, Pappas TN. A "New" Nonmesh Technique for Inguinal Hernia Repair: Revisiting E. Wyllys Andrews and His Imbricating Operation. Ann Surg Open. 2023; 4:e310. DOI: https://doi.org/10.1097/AS9.0000000000000310

Desarda MP. Inguinal herniorrhaphy with an undetached strip of external oblique aponeurosis: a new approach used in 400 patients. Eur J Surg. 2001; 167:443-8. DOI: https://doi.org/10.1080/110241501750243798

Emile SH, Elfeki H. Desarda's technique versus Lichtenstein technique for the treatment of primary inguinal hernia: a systematic review and meta-analysis of randomized controlled trials. Hernia. 2018; 22:385-95. DOI: https://doi.org/10.1007/s10029-017-1666-z

Desarda MP. Surgical physiology of inguinal hernia repair--a study of 200 cases. BMC Surg. 2003; 3:2. DOI: https://doi.org/10.1186/1471-2482-3-2

Stabilini C, van Veenendaal N, Aasvang E, et al. Update of the international HerniaSurge guidelines for groin hernia management. BJS Open. 2023; 7:zrad080. DOI: https://doi.org/10.1093/bjsopen/zrad080

Pereira C, Varghese B. Desarda Non-mesh Technique Versus Lichtenstein Technique for the Treatment of Primary Inguinal Hernias: A Systematic Review and Meta-Analysis. Cureus. 2022;14:e31630. DOI: https://doi.org/10.7759/cureus.31630

Youssef T, El-Alfy K, Farid M. Randomized clinical trial of Desarda versus Lichtenstein repair for treatment of primary inguinal hernia. International Journal of Surgery. 2015; 20:28-34.

Elsebae MM, Nasr M, Said M. Tension-free repair versus Bassini technique for strangulated inguinal hernia: A controlled randomized study. Int J Surg. 2008; 6:302-5. DOI: https://doi.org/10.1016/j.ijsu.2008.04.006

Messias BA, Nicastro RG, Mocchetti ER, et al. Lichtenstein technique for inguinal hernia repair: ten recommendations to optimize surgical outcomes. Hernia. 2024; 28:1467-76. DOI: https://doi.org/10.1007/s10029-024-03094-w

Youssef T, El-Alfy K, Farid M. Randomized clinical trial of Desarda versus Lichtenstein repair for treatment of primary inguinal hernia. Int J Surg. 2015; 20:28-34. DOI: https://doi.org/10.1016/j.ijsu.2015.05.055

Kugel RD. Minimally invasive, nonlaparoscopic, preperitoneal, and sutureless, inguinal herniorrhaphy. Am J Surg. 1999; 178:298-302. DOI: https://doi.org/10.1016/S0002-9610(99)00181-6

Arregui ME, Young SB. Groin hernia repair by laparoscopic techniques: current status and controversies. World J Surg. 2005;29:1052-7. DOI: https://doi.org/10.1007/s00268-005-7968-9

Supsamutchai C, Wattanapreechanon P, Saengsri S, et al. Sexual dysfunction between laparoscopic and open inguinal hernia repair: a systematic review and meta-analysis. Langenbecks Arch Surg. 2023;408:277. DOI: https://doi.org/10.1007/s00423-023-03006-z

Hay JM, Boudet MJ, Fingerhut A, et al. Shouldice inguinal hernia repair in the male adult: the gold standard? A multicenter controlled trial in 1578 patients. Ann Surg. 1995; 222:719-27. DOI: https://doi.org/10.1097/00000658-199512000-00005

Sapiyeva ST, Abatov NT, Aliyakparov MT, et al. Non-mesh inguinal hernia repair: Review. Asian J Surg. 2024;47:4669-73. DOI: https://doi.org/10.1016/j.asjsur.2024.06.055

Philipp M, Leuchter M, Lorenz R, et al. Quality of Life after Desarda Technique for Inguinal Hernia Repair—A Comparative Retrospective Multicenter Study of 120 Patients. 2023;12:1001. DOI: https://doi.org/10.3390/jcm12031001

Birindelli A, Sartelli M, Di Saverio S, et al. 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias. World J Emerg Surg. 2017;12:37. DOI: https://doi.org/10.1186/s13017-017-0149-y

Miserez M, Peeters E, Aufenacker T, et al. Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2014; 18:151-63. DOI: https://doi.org/10.1007/s10029-014-1236-6

Ndong A, Tendeng JN, Diallo AC, et al. Is Desarda technique suitable to emergency inguinal hernia surgery? A systematic review and meta-analysis. Annals of Medicine and Surgery. 2020; 60:664-8. DOI: https://doi.org/10.1016/j.amsu.2020.11.086

Papaziogas B, Lazaridis C, Makris J, et al. Tension-free repair versus modified Bassini technique (Andrews technique) for strangulated

inguinal hernia: A comparative study. Hernia : the journal of hernias and abdominal wall surgery. 2005; 9:156-9.

Mabula JB, Chalya PL. Surgical management of inguinal hernias at Bugando Medical Centre in northwestern Tanzania: our experiences in a resource-limited setting. BMC Research Notes. 2012; 5:585. DOI: https://doi.org/10.1186/1756-0500-5-585

Turaga KK, Garg N, Coeling M, et al. Inguinal hernia repair in a developing country. Hernia. 2006; 10:294-8. DOI: https://doi.org/10.1007/s10029-006-0111-5

Manyilirah W, Kijjambu S, Upoki A, Kiryabwire J. Comparison of non-mesh (Desarda) and mesh (Lichtenstein) methods for inguinal hernia repair among black African patients: a short-term doubleblind RCT. Hernia. 2012; 16:133-44. DOI: https://doi.org/10.1007/s10029-011-0883-0

Jain SK, Bhatia S, Hameed T, et al. A randomised controlled trial of Lichtenstein repair with Desarda repair in the management of inguinal hernias. Ann Med Surg (Lond). 2021; 67:102486. DOI: https://doi.org/10.1016/j.amsu.2021.102486

18th Annual Hernia Repair. Hernia. 2017; 21:1-137. DOI: https://doi.org/10.1007/s10029-017-1571-5

Szopinski J, Dabrowiecki S, Pierscinski S, et al. Desarda Versus Lichtenstein Technique for Primary Inguinal Hernia Treatment: 3-Year Results of a Randomized Clinical Trial. World J Surg. 2012;36:984-92. DOI: https://doi.org/10.1007/s00268-012-1508-1

Panos RG, Beck DE, Maresh JE, Harford FJ. Preliminary results of a prospective randomized study of Cooper's ligament versus Shouldice herniorrhaphy technique. Surg Gynecol Obstet. 1992;175:315-9.