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Year : 2021  |  Volume : 21  |  Issue : 3  |  Page : 81-86

Efficacy of the tension-free Lichtenstein mesh hernioplasty in the successful management of inguinal hernias in Saudi Arabian athletes

1 King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
2 Department of General Surgery, Al Ansar General Hospital, Medina, Saudi Arabia
3 Department of General Surgery, Al Madinah Al Monawarrah General Hospital, Medina, Saudi Arabia

Date of Submission03-Mar-2021
Date of Acceptance16-Sep-2021
Date of Web Publication13-Dec-2021

Correspondence Address:
Bader Hamza Shirah
King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, P.O. Box: 65362, Jeddah 21556
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjsm.sjsm_7_21

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Background: The tension-free mesh hernioplasty has attained worldwide acceptance because of the superior outcome in decreased rates of recurrence to 1%–2%. The Lichtenstein method of hernioplasty has evolved as the most liked technique to use. In this study, we would like to evaluate the outcome of the Lichtenstein mesh repair of the sport-induced inguinal hernias in Saudi Arabian athletes.
Methods: A prospective cohort study of 274 Saudi Arabian athletes who had the Lichtenstein technique as a method of repair for inguinal hernias from January 2005 to December 2014 was conducted. A polypropylene mesh was used in all patients.
Results: The mean age reported was 23 ± 2.41 years (range 18–33). The mean time to return to full athletic activities was 8 weeks (6–10 weeks). The high effectiveness of the Lichtenstein repair of inguinal hernias in Saudi Arabian athletes was recorded. No recurrence at all has been registered during a 24-month follow-up period. All athlete patients completed 24 months of follow-up.
Conclusions: Lichtenstein tension-free mesh repair was found to possess a high efficacy in the treatment of inguinal hernias in Saudi Arabian athletes promising low morbidity rates and an astonishing recurrence rate of 0%. The remarkable ability of the athletes to reach the same preoperative athletic level in a short period and the high satisfaction rate among the athletes makes the Lichtenstein tension-free mesh repair an efficient approach in managing inguinal hernias in terms of the clinical, athletic, and concurrent socioeconomic outcome.

Keywords: Inguinal hernia, Lichtenstein, mesh repair, recurrence, sports athletes, tension-free

How to cite this article:
Shirah BH, Shirah HA, Zabeery IA, Sogair OA, Alahmari AM. Efficacy of the tension-free Lichtenstein mesh hernioplasty in the successful management of inguinal hernias in Saudi Arabian athletes. Saudi J Sports Med 2021;21:81-6

How to cite this URL:
Shirah BH, Shirah HA, Zabeery IA, Sogair OA, Alahmari AM. Efficacy of the tension-free Lichtenstein mesh hernioplasty in the successful management of inguinal hernias in Saudi Arabian athletes. Saudi J Sports Med [serial online] 2021 [cited 2023 May 31];21:81-6. Available from: https://www.sjosm.org/text.asp?2021/21/3/81/332397

  Introduction Top

Inguinal hernias can result from an increase in the abdominal pressure or groin region which causes the omentum or bowel to bulge through a weak area of the abdominal muscles or inguinal canal in the groin. The worldwide incidence in males is 25% representing a male to female ratio of 20:1 that increases with increasing age. The risk during the lifetime is 27% in males and 3% in females.[1] Among all abdominal wall hernias, they account for 75%. They mainly occur in adults. The indirect type accounts for 65% of the cases and the direct type for 35%. It is bilateral in up to 20% of affected adults.[2]

Athletic pubalgia (sports hernia) is a different entity that presents as groin pain and a dilated superficial ring of the inguinal canal in athletes due to soft tissue injury resulting from sports activities that mandate an abrupt change in direction or hard, twisted movements at high speed. It could develop as an inguinal hernia. The main reported symptoms include pain during sports movements (twisting, stretching, and turning).[3],[4],[5]

The treatment of choice for both types, pure inguinal and sports hernia, is surgery, with a wide variety of open mesh repair, nylon darn, layered Shouldice, tension-free Lichtenstein mesh hernioplasty, and laparoscopic repair.[1],[2],[3],[4],[5] Mesh hernioplasty has attained widespread acceptance, as proved by many clinical reports, because of the outstanding outcome in decreased rates of recurrence to 1%–2%.[6],[7]

In 1986, Lichtenstein introduced the technique of open mesh repair for inguinal hernias. It has become the most frequent technique used due to its simplicity in providing a tension-free repair, its good reported long-term results, its less postoperative pain association, quick recovery postoperatively, the normal activity early return, and a very low recurrence rate. Tension-free mesh repair was not found to be affiliated with side effects such as pain, foreign-body reaction, mesh migration, shrinkage, wound infection, fistula formation, and recurrence. The reported complications of the Lichtenstein repair included skin bruising and hematoma formation, seroma formation, anesthesia, orchitis, and testicular atrophy.[8],[9],[10] Several materials of mesh have been tested, the most commonly used include Polyester Mesh (Dacron, Mersilene), Polypropylene (Marlex, Prolene), and expanded polytetrafluoroethylene.[11],[12],[13],[14]

In the past 30 years, inguinal hernias were the second most common surgical condition encountered in Al Ansar Hospital with an average of 300 cases per year for different patients categories in which nylon darn was the most common method used. The Lichtenstein mesh repair was adopted in 2001 as our standard open method. Consequently, we observed some differences in the outcome of reparing inguinal hernias in athletes and nonathletes. Therefore, in this study, we would like to evaluate the outcome of the Lichtenstein mesh repair of the sport-induced inguinal hernias in Saudi Arabian athletes and to outline the effectiveness and safety of repairing inguinal hernias by a mesh in the Saudi Arabian athletic community.

  Methods Top

A prospective cohort study of the outcome of surgically treated inguinal hernias in Saudi Arabian athletes during the period between January 2005 and December 2014 at Al Ansar General Public Health Hospital in Medina, Saudi Arabia, was done.

Ethical approval was obtained from the medical ethics committee and the management guidelines and clinical pathway subcommittee of the quality care program at Al Ansar Hospital.

The inclusion criteria included male adult athletes aged 18 years and older (according to the Saudi Olympic Federation Age Classification) who were diagnosed at or referred to the outpatient clinics and operated electively for inguinal hernia. Furthermore, patients presenting to the emergency with incarcerated or strangulated inguinal hernias and recurrent hernias were included. Exclusion criteria included patients who were proven by a thorough diagnostic workup to have athletic pubalgia. They were referred to specialized sports medical centers.

All patients were diagnosed clinically and by ultrasound (the presence of abdominal wall defect and hernial sac contents). Standardized diagnostic investigations were done on all the patients (complete blood count, blood chemistry, chest X-ray, ultrasound abdomen, and electrocardiogram). The surgical procedures were done by the same team of surgeons according to a standard operative protocol. Prophylactic antibiotics were given routinely 1 h before surgery (1 g cefazolin and 500 mg metronidazole intravenously). General anesthesia was done on all the patients. All patients' hernias were repaired according to the Lichtenstein technique. A polypropylene mesh was used in all patients. No drains were used.

The operative procedure was carried out as follows: in a supine position, the groin area is cleaned with iodine and alcohol and properly draped. Skin incision, dissection of the subcutaneous tissue and external oblique aponeurosis, and spermatic cord elevation away from the posterior wall of the inguinal canal were carried out.

In indirect hernias cases, hernial sac identification is carried out, followed by dissection up to the internal ring where it was opened to allow for the inspection of its contents.Ligation of the sac and excision of the distal portion were done.

In cases of indirect inguinal hernias that the sac descended to the scrotum, the sac's distal portion is left open to prevent future formation of a hydrocele and to allow for spontaneous obliteration.

A polypropylene mesh (3 × 5 inches) is fashioned to adequately fit the anatomical shape of the floor of the inguinal canal. Using a 2-0 Prolene suture, the apex is sutured to the pubic tubercle, and the lower border of the mesh to the free edge of the inguinal ligament after making a wide enough opening into the lower edge to accommodate the spermatic cord. The continuous suture is extended up medial to the anterior superior iliac spine to fix the mesh, then the two cut edges of the mesh are sutured together around the spermatic cord by interrupted Prolene sutures.

Finally, the inferomedial corner of the mesh is attached to overlap the pubic tubercle. A plug with loosely sutured mesh was used to repair the deep ring and posterior wall in 134 (48.9%) patients when the deep ring was more than 2 cm with a weak posterior wall. Loose sutured mesh only was used to repair the posterior wall in 140 (51.1%) patients, either with a direct hernia and intact deep ring or an indirect hernia with the deep ring <2 cm in size.

The external oblique aponeurosis is then closed using absorbable sutures (Vicryl 2-0). The skin was closed with 3-0 Vicryl subcuticular sutures (cosmetic wound repair).

Postoperatively, all the patients had the same care protocol that included three doses of the same antibiotics as preoperatively, and intramuscular and oral analgesia (meperidine and acetaminophen.

The patients were discharged home on the 1st postoperative day. Follow-up at the outpatient clinic was scheduled as a visit every week for the 1st month, then a visit every 2 weeks for the following 2 months, then a visit every month for the following 9 months, and finally, a visit every 3 months for the following 12 months (total of 24 months).

The patients were recommended to refrain from riding activities (bikes, motorcycles, camels, horses, etc.,) and lifting heavy objects >10 kg for 2 weeks. The gradual return to sports activity practice was planned as follows: light physical training (without forceful straining) after 4 weeks, then moderate physical training after 6 weeks, then heavy physical training after 8 weeks, and then, team practice (full activity) after 10 weeks.

A database study protocol file was initiated for each patient. Data recorded included age, sex, predisposing factors, symptoms, duration of the symptoms, exact site of the hernia, whether uni- or bilateral hernia, all postoperative occurrences and complications, signs and time of recurrence, return to the preoperative level of sports activity, and athlete satisfaction.

For data analysis, IBM Statistical Package for the Social Sciences (SPSS) version 22 (IBM SPSS Statistics, IBM Corporation, Armonk, NY, USA). was used. All results were represented by percentages and mean.

  Results Top

Two hundred and seventy-four Saudi Arabian adult male athletes with uncomplicated inguinal hernias were reviewed. The mean age was 23 ± 2.41 years (range 18–33 years). The type of athletic sport practiced was as follows: football (soccer) 119 (43.4%) athletes, basketball 42 (15.3%) athletes, handball 27 (9.9%) athletes, heavy weight lifting 26 (9.5%) athletes, boxing 19 (6.9%) athletes, martial arts 16 (5.8%) athletes, equestrian 13 (4.7%) athletes, and long and high jumping 12 (4.4%) athletes.

Inguinal swelling alone was the dominant symptom followed by inguinoscrotal swelling, limitation of physical activity, and inguinal pain. Physical trauma was the dominant predisposing factor followed by heavy physical straining, heavy weight lifting, chronic constipation, and chronic cough. The mean duration of symptoms was 5.5 weeks (range 3–8 weeks) [Figure 1].
Figure 1: The presenting symptoms and predisposing factors of inguinal hernia in Saudi Arabian athletes

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One hundred and fourteen (41.6%) patients had an inguinal hernia on the right side, 109 (39.8%) patients had a hernia on the left side, and 51 (18.6%) patients presented with a bilateral hernia. One hundred and seventy-two (62.8%) patients had an indirect hernia, and 102 (37.2%) patients had a direct hernia. One hundred and eighty-six (67.9%) patients presented with pure inguinal hernia, while 88 (32.1%) patients presented with an inguinoscrotal hernia. Two hundred and thirty-seven (86.5%) presented with uncomplicated inguinal hernia, while 37 (13.5%) presented with incarcerated inguinal hernia [Table 1].
Table 1: Types of inguinal hernia in Saudi Arabian athletes and the related morbidity of the Lichtenstein mesh repair

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One hundred and ninety-seven (71.9%) were operated on by a consultant surgeon and 77 (21.9%) by a specialist surgeon. Duration of surgery was <1 h in 189 (69%) patients, and more than 1 h in 85 (31%). The mean operative time was 64.14 ± 2.8 min (55–75 min).

Three (1.1%) patients developed wound hematoma, 5 (1.8%) felt numbness at the operation's site, 7 (2.6%) reported a sensation of a foreign body at the groin area, 2 (0.7%) had a documented wound infection, 1 (0.4%) developed scrotal swelling, 2 (0.7%) developed seroma, and 3 (1.1%) reported chronic groin pain at the site of the operation. The overall morbidity rate was 7.3% [Figure 2].
Figure 2: The morbidity of Lichtenstein mesh repair for inguinal hernia in Saudi Arabian athletes

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The mean time of full return to athletic activities was 8 weeks (6–10 weeks). Two hundred and sixty-eight (97.8%) athletes reported a full return to the preoperative level of sports activity, while 6 (2.2%) reported minimal limitations. Two hundred and sixty-three (96%) athletes reported a high satisfaction result of the overall outcome of the treatment, while 11 (4%) reported moderate satisfaction. No recurrence was documented after a 24-month follow-up period, and all athlete patients completed 24-month follow-up.

  Discussion Top

The management of inguinal hernias of a sports athlete is different from nonathletes. Most sports activities are physically demanding and exert a different amount of stress on certain body parts. Consequently, the postoperative care is different in the sports group of patients, mainly regarding the time to return to full activity and the degree of physical efforts allowed, though the surgical method of repair is the same for both groups. On the other hand, it is difficult to design a study to compare the two (e.g. comparing between a soccer player and a regular desk employee).

All the athlete patients in our study were allowed to return to full sports and physical activities according to a planned program. The mean time to return to the full athletic activities was 8 weeks (6–10 weeks). Comparing this result with the results of our published paper about Lichtenstein repair of inguinal hernias in nonathletes regular patients,[2] who had no special program, which showed an overall median time to return to work and normal daily activities of 10 days (7–14 days), clearly demonstrates the difference between inguinal hernia repair in common people and sport athletes who require a special rehabilitation program to return to work.

In a prospective randomized clinical study of more than 1000 inguinal hernia patients repaired with mesh hernioplasty, the median time to return to normal activities or work was 7 days, while the manual worker took a longer time (12 days) than did the desk employees.[15] Conversely, a study in 1999[16] showed that National Hockey League players who had abdominal wall injuries needed an average of 6–8 weeks to be able to return to full activity. A study in 2006[17] found that the first phase of convalescence took about 6 weeks for the tensile strength provided by tissue ingrowth into the mesh to reach nearly 80%. We found that the postoperative rehabilitation of the sports athletes is the only difference in the Lichtenstein repair of inguinal hernias between sports athletes and regular nonathlete patients.

All the patients in our study complained of mild pain postoperatively which was assessed by the patient's request for analgesic drugs. All the patients needed no more than three injections of meperidine (75 mg) intramuscularly. Only seven patients required oral analgesia for more than 4 weeks. Postoperative pain can adversely affect the time to return to regular activity after hernia repair. Köninger et al.[18] investigated postoperative pain as a cause of functional limitation and concluded that (Shouldice method)-open suture-and (Lichtenstein method)-open mesh-inguinal hernia repairs were associated with a higher level of pain and postoperative limitation of normal activity as compared to laparoscopic techniques (13%–15% vs. 2.4%).

In our series, all patients were instructed to walk out of bed 4 h postoperatively. Reviewing the recorded data showed that only 1 (0.4%) patient developed scrotal edema which disappeared within 3–7 days, while 2 (0.7%) patients had wound seroma which only needed aspiration by syringe with complete resolution. Clinical reports suggested that patients who had an open repair of an inguinal hernia could walk freely 4 h postoperatively with little discomfort and that it would help in reducing certain complications such as seroma accumulation.[19]

In our series, 2 (0.7%) patients developed superficial wound infections which only needed frequent dressing and short antibiotics course. Clinically proven, the management of wound infection in which there is a synthetic prosthesis is not different from that of an infected wound. The theoretical objection to using a mesh, like foreign-body rejection or untreatable infection that requires mesh removal, was not sufficient, and many clinical trials proved that the utilization of the mesh did not substantially increase the incidence of wound infection or manipulate the superficial wound infection incidence.[19],[20]

Despite a relatively short follow-up period (24 months), no single recurrence was reported in our series. The incidence of hernia recurrence following the primary repair was reported to vary between 1% in specialized clinical centers and 30% in the general survey. Most of the recurrent cases appear within 2–3 years after primary repair.[21] Patients with a multi-recurrent hernia are a troublesome problem to the surgeon, but the use of the alternative approach to the classical methods should be considered for repair including the utilization of prosthetic mesh in the posterior preperitoneal approach, a giant prosthetic reinforcement through an anterior preperitoneal approach, or posterior preperitoneal laparoscopic repair.[22]

We utilized a polypropylene mesh in the Lichtenstein repair of inguinal hernias of our athletes. The most important advantage to using a mesh patch with or without a plug is that it is technically easier to work than the classical methods and much simpler to secure to the surrounding tissues. When the mesh interstices become thoroughly infiltrated with fibroblast, it remains permanently strong.[23]

In our practice, we used a monofilament nonabsorbable suture (polypropylene) with nonabsorbable mesh. This is because the process of groin hernia repair healing will approximately take 1 year, and at the end of 6 months, the wound is estimated to have had gained almost 80% of its final strength. Hence, the wound should be at least supported for this time by using monofilament nonabsorbable suture.[24]

Our technique in the suturing method of fixation of the mesh was a loose continuous suturing. Several clinical reports showed that the technique of continuous suturing has a greater bursting pressure of the wound than the methods of simple interrupted. This is because it is actually perceived to be spiral and giving a much better distribution of tension forces along the entire length of the approximated tissue. While in the interrupted technique, the tension is directed at every individual stitch. For that, dehiscence will begin at the stitch where the tension had exceeded the suturing holding capacity.[25],[26]

In our protocol, no drains were used at all in any patient due to the meticulous dissection and careful approach that minimized bleeding and tissue injury. Clinical studies showed that drainage postoperatively should not be routinely utilized in a standard, noncomplicated hernia repair. On the other hand, postoperative suction drainage can significantly decrease the incidence of wound seroma, hematoma, and infection when repairing large hernias, difficult hernias that require much dissection, recurrent hernia, and other forms of complicated hernias. If it is a must, the drain should be used selectively according to the difficulty encountered. It should be brought out through a separate abdominal wall stab incision and discarded as soon as possible to avoid developing a retrograde infection.[2],[10],[11],[13]

In our series, the mean duration of symptoms was 5.5 weeks (range 3–8 weeks) which indicates a late presentation pattern, but it did not affect the outcome of the Lichtenstein mesh repair despite that 37 (13.5%) athletes presented with incarcerated inguinal hernia. However, it raised many queries about the reason behind such late presentation in sport athletes. A thorough search of the literature did not yield papers or articles specifically addressing that issue either locally or internationally.

Given our results and the quite good number of pure inguinal hernias in sports athletes (not athletic pubalgia), we raised the question in our clinical practice of the reason behind developing such a condition in the Saudi Arabian athletes. Could it be due to the inadequate training programs of the athletes? or because of the inappropriate implementation of the safety protocol in our sports practice? Such inquiries need to be addressed seriously. Therefore, we recommend conducting scientific studies to investigate that issue.

  Conclusions Top

Lichtenstein tension-free mesh repair was found to possess a high efficacy in the treatment of inguinal hernias in Saudi Arabian sports athletes promising low early and late morbidity rates, and an astonishing recurrence rate of 0%. The remarkable ability of the athletes to reach the same preoperative athletic level in a short period and the high satisfaction rate among the athletes makes the Lichtenstein tension-free mesh repair an efficient approach in managing inguinal hernias in terms of the clinical, athletic, and concurrent socioeconomic outcome.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Shirah BH, Shirah HA. Lichtenstein mesh hernioplasty for inguinal hernias: Simplicity is the ultimate sophistication. Int Surg J 2016;3:230-6.  Back to cited text no. 2
Meyers WC, Yoo E, Devon ON, Jain N, Horner M, Lauencin C, et al. Understanding “sports hernia” (athletic pubalgia): The anatomic and pathophysiologic basis for abdominal and groin pain in athletes. Oper Tech Sports Med 2007;15:165-77.  Back to cited text no. 3
Farber AJ, Wilckens JH. Sports hernia: Diagnosis and therapeutic approach. J Am Acad Orthop Surg 2007;15:507-14.  Back to cited text no. 4
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  [Figure 1], [Figure 2]

  [Table 1]


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