Lichtenstein Mesh Research Articles

English

INTRODUCTION: Inguinal hernias are treated by several surgical methods. Our main concern is to find a well-accepted method which is cost effective, with minimal complications, with small learning curve and can be attributed to the masses. OBJECTIVE: To compare the two tension- free methods of hernia repair: trans-abdominal pre-peritoneal laparoscopic mesh repair and the open Lichtenstein mesh technique in terms of operative time, length of hospital stay and chronic post-operative pain and cost effectiveness. MATERIALS AND METHODS: This study was conducted in Department of Surgery Rama Medical College Kanpur during March 2009 to Feb 2013 over a period of 4 years. A total of 264 male patients, aged between 16-60 years, were divided into two groups, A and B. Patients were subjected to Trans-abdominal Pre-Peritoneal (TAPP) laparoscopic and Lichtenstein repairs, respectively. The two groups were compared for operative time, length of hospital stay, chronic groin pain and cost of surgery. Percentages were calculated for categorical data while numerical data were represented as mean ± SD. Chi square test and t test were used to compare categorical and numerical variables, respectively. Probability ≤ 0.05 (P ≤ 0.05) was considered significant. RESULTS: At one month interval, in group A mild, moderate and severe pain was observed in 31 (26.5%), 12(9.09%) and 3 (2.3%) patients compared to 41 (31.6%), 35 (26.5%) and 12 (9.1%) patients, respectively, in group B. Mean operative duration was significantly longer in group A compared to group B (P < 0.001). Mean hospital stay was significantly longer in group B compared to group A (P < 0.001) and mean cost of the procedure was significantly high in group A as compared to group B (P<0.001). CONCLUSION: Trans-abdominal pre-peritoneal laparoscopic inguinal hernia repair is effective in decreasing the incidence of chronic groin pain and post- operative hospital stay in comparison with to tension free mesh hernioplasty. But due to long Surgical learning curve and high cost of surgery TAPP presently can't be attributed for mass scale surgery.

Management of Recurrent Inguinal Hernia at a Tertiary Care Hospital of Southern Sindh, Pakistan

The goal of the present study was to determine the frequency, mode of presentation, and need for reoperation in the treatment of recurrent inguinal hernia at Liaquat University Hospital, Jamshoro, Sindh, Pakistan. This descriptive, cross-sectional study was conducted over a period of four years, from January 2007 through December 2010. A total of 916 patients with inguinal hernia underwent operation in the Department of Surgery at Liaquat University Hospital Jamshoro, Sindh, Pakistan, during the study period. Of them, 62 patients were diagnosed to have recurrent inguinal hernia and were included in the study. Female patients and patients with other types of hernia like femoral, epigastric, and paraumbilical defects were excluded. Among the 62 patients studied, the commonest age group with recurrence was 41-50 years (43.5%). Fifty-one (82.2%) of the patients were ambulatory workers. In 47 cases (75.8%) recurrence was on the right side, and in 15 (24.1%) recurrence was on the left side. First time recurrence was seen in 54 patients (87%) and second time recurrence was seen in 7 patients (11.2 %); third time recurrence was observed in only one patient. All of these patients had an initial open surgery without mesh, except one. Bassini's repair was done as a primary repair in 47 (75.8%) cases. A total of 11 patients (17.7%) had no previous medical records. Darning repair was done in 3 patients (4.8%), and open surgery with mesh was performed in only one patient. The highest recurrence rates were seen in patients whose hernia repairs had been done by postgraduate trainees. That is, 45 of the patients requiring reoperation (72.5%), compared to 11 (17.7%), and 6 (9.6%) operations performed by registrars and consultants, respectively. All patients in our study underwent tension-free Lichtenstein mesh repair. Postoperative complications included retention of urine (40.3%), scrotal hematoma (6.4%), and wound infection (3.2%). Recurrent inguinal hernia is still frequently observed today, and the Lichtenstein tension-free repair has gained great acceptance worldwide and is currently considered the procedure of choice for primary and recurrent inguinal hernias.

Surgical management of inguinal hernias at Bugando Medical Centre in northwestern Tanzania: our experiences in a resource-limited setting.

BackgroundInguinal hernia repair remains the commonest operation performed by general surgeons all over the world. There is paucity of published data on surgical management of inguinal hernias in our environment. This study is intended to describe our own experiences in the surgical management of inguinal hernias and compare our results with that reported in literature.MethodsA descriptive prospective study was conducted at Bugando Medical Centre in northwestern Tanzania. Ethical approval to conduct the study was obtained from relevant authorities before the commencement of the study. Statistical data analysis was done using SPSS software version 17.0.ResultsA total of 452 patients with inguinal hernias were enrolled in the study. The median age of patients was 36 years (range 3 months to 78 years). Males outnumbered females by a ratio of 36.7:1. This gender deference was statistically significant (P = 0.003). Most patients (44.7%) presented late (more than five years of onset of hernia). Inguinoscrotal hernia (66.8%) was the commonest presentation. At presentation, 208 (46.0%) patients had reducible hernia, 110 (24.3%) had irreducible hernia, 84 (18.6%) and 50(11.1%) patients had obstructed and strangulated hernias respectively. The majority of patients (53.1%) had right sided inguinal hernia with a right-to-left ratio of 2.1: 1. Ninety-two (20.4%) patients had bilateral inguinal hernias. 296 (65.5%) patients had indirect hernia, 102 (22.6%) had direct hernia and 54 (11.9%) had both indirect and direct types (pantaloon hernia). All patients in this study underwent open herniorrhaphy. The majority of patients (61.5%) underwent elective herniorrhaphy under spinal anaesthesia (69.2%). Local anaesthesia was used in only 1.1% of cases. Bowel resection was required in 15.9% of patients. Modified Bassini’s repair (79.9%) was the most common technique of posterior wall repair of the inguinal canal. Lichtenstein mesh repair was used in only one (0.2%) patient. Complication rate was 12.4% and it was significantly higher in emergency herniorrhaphy than in elective herniorrhaphy (P = 0.002). The median length of hospital stay was 8 days and it was significantly longer in patients with advanced age, delayed admission, concomitant medical illness, high ASA class, the need for bowel resection and in those with surgical repair performed under general anesthesia (P < 0.001). Mortality rate was 9.7%. Longer duration of symptoms, late hospitalization, coexisting disease, high ASA class, delayed operation, the need for bowel resection and presence of complications were found to be predictors of mortality (P < 0.001).ConclusionInguinal hernias continue to be a source of morbidity and mortality in our centre. Early presentation and elective repair of inguinal hernias is pivotal in order to eliminate the morbidity and mortality associated with this very common problem.

Open Preperitoneal Techniques versus Lichtenstein Repair for elective Inguinal Hernias

Current techniques for inguinal hernia repair show similar recurrence rates. Therefore, recurrence is no longer the main issue discussed when considering improving the current standards for groin hernia repair. Post surgical chronic pain represents a major, largely unrecognised clinical problem. Consequently, there is a need to not only decrease an extensive dissection in the inguinal canal with less manipulation of the inguinal nerves, but also to minimize the interaction between the mesh and major surrounding structures. As a result, placing the mesh in the preperitoneal space is a valuable option. To compare elective open preperitoneal mesh techniques with Lichtenstein mesh repair in terms of pain. We searched The Cochrane Central Register of Controlled Trials (The Cochrane library 2011, Issue 4), MEDLINE (January 1966 to April 2011), EMBASE (1947 to October 2009), and ISI WEB OF KNOWLEDGE (1900 to April 2011) for randomized controlled trials. The reference list of identified trials, the World Journal of Hernia and Abdominal Wall Surgery, and relevant book chapters were handsearched for useful trials. If we found relevant ongoing trials using national and international trials registers, we contacted the main investigators for further information. The language of the trials was not an exclusion criterion. Randomized controlled studies comparing elective open preperitoneal mesh techniques with Lichtenstein mesh repair. Three authors independently extracted the pre-specified data and assessed the methodological quality using domain-based evaluation. Missing information was obtained by contacting the original investigators using open-ended questions. Three eligible trials involving 569 patients were identified. Due to methodological limitations in the included studies, there was considerable variation in the results of acute (risk range 38.67% to 96.51%) and chronic pain (risk range 7.83% to 40.47%) across the control groups. Therefore, meta-analysis was not performed but the results of the outcomes in the individual trials were compared. Two trials involving 322 patients reported less chronic pain after preperitoneal repair (relative risk (RR) 0.18, number needed to treat (NNT) 8; RR 0.51, NNT 5), whereas one trial, including 247 patients, described more chronic pain after this repair (RR 1.17, NNT 77). The same trials favoured the preperitoneal technique concerning acute pain (RR 0.17, NNT 3; RR 0.78, NNT 7), whereas in the third trial it was almost omnipresent and thus comparable in both intervention arms (RR 0.997, NNT 333). Early and late hernia recurrence rates were similar across the studies, whereas contrasting results were reported for other early outcomes as infection and hematoma. No late mesh infection occurred in the included trials. Both techniques are valid as they result in similar low recurrence rates. Evaluation of pain results in the individual trials shows some evidence that preperitoneal repair causes less or comparable acute and chronic pain compared to the Lichtenstein procedure. We emphasize the need for homogeneous high quality randomized trials comparing elective preperitoneal inguinal hernia techniques and Lichtenstein repair in terms of chronic pain.

Local Versus Spinal Anesthesia in Lichtenstein Mesh Technique for Inguinal Hernia Repair in Ambulatory Patients: A Randomized Controlled Trial

Objective: This study aimed to determine whether Lichtenstein mesh Technique under local anesthesia results in better patient outcomes when compared with repair under spinal anesthesia. Methods: Patients &gt; 18 years old, with primary, unilateral inguinal hernia handled between January 2008 to July 2010, and who fulfilled the specific inclusion criteria were enrolled. They were randomly assigned to either local anesthesia (LA), or, the spinal anesthesia (SA) groups. Outcome variables monitored included: total operative time, postoperative pain from days 1-7, complications, number of analgesic doses, and, time interval from surgery to resumption of routine occupational and sexual activities. Results: There were 101 patients (98 males and 3 female) LA group included 54 patients (52.5%) while the SA group, 48 patients (47.5%). Patients in LA group are younger in age but this is of no statistical significance (P=0.07). Significant differences between the two groups included: presence of urinary retention and more postoperative analgesia required within the first 24 hours among SA patients. Overall, LA group had less postoperative pain, fewer complications, and faster recovery with early resumption of occupational and sexual activities. Conclusion: This study offers significant evidence to prove that local anesthesia is a safe, cost-effective and practical alternative to spinal anesthesia for fast-track ambulatory inguinal hernia repair. Key words: inguinal hernia, lichtenstein mesh repair, local anesthesia, spinal anesthesia

Current trends in the diagnosis and management of post-herniorraphy chronic groin pain.

Inguinodynia (chronic groin pain) is one of the recognised complications of the commonly performed Lichtenstein mesh inguinal hernia repair. This has major impact on quality of life in a significant proportion of patients. The pain is classified as neuropathic and non-neuropathic related to nerve damage and to the mesh, respectively. Correct diagnosis of this problem is relatively difficult. A thorough history and clinical examination are essential, as is a good knowledge of the groin nerve distribution. In spite of the common nature of the problem, the literature evidence is limited. In this paper we discuss the diagnostic tools and treatment options, both non-surgical and surgical. In addition, we discuss the criteria for surgical intervention and its optimal timing.

Chronic Groin Pain Following Lichtenstein Mesh Hernioplasty for Inguinal Hernia. Is It a Myth, How True is It?

Going through the article titled “chronic groin pain following Lichtenstein mesh hernioplasty for inguinal hernia. Is it a myth?”, was a treat to read that such an important aspect of a routine surgery has been addressed to, which usually is forgotten in this very common surgical procedure. It is good to see such an astonishing amount of cases being performed i.e. 470 cases which almost reaches to two cases per day considering only <300 working days a year in Indian scenario which is land of festivals. We wanted to clarify that in the material and methods it has been mentioned that patients were followed up at 3 months, 6 month, 1 year and 2 year after surgery. Since the study period was from 01 Feb. 2006 to 29 Feb. 2008 which constitutes only two years, then how is it possible that many patients reached the end point described in material and method. Even if we consider the date of paper submission as last date of study i.e. November 2008 only those cases which were operated before November 2006 would have been followed up for 2 years postoperatively , which would amount to almost one third of the total patients only. Why we are stressing on this is that the frequency of chronic groin pain reported by the author of 0.78% is extremely low compared to range of 0% to 37% of patients undergoing conventional hernia repair [1]. Johann Cunningham et al noted 12% incidence of moderate or severe pain one year after open hernia surgery [2]. Having said that, there are also series which have reported very low rates as well. Sergio Alfieri et al observed chronic severe pain in only 0.5% of patients at 1-year follow-up [3]. This is paramount in saying that if there is such a low incidence of chronic groin pain with polypropylene mesh than where is the need for all the light weight meshes which are being propagated. This low rate reported is tremendous in that we should recommend the technique of surgery which has been used by the author and should standardize the procedure Electronic supplementary material The online version of this article (doi:10.1007/s12262-010-0147-8) contains supplementary material, which is available to authorized users.

Lichtenstein's Operation, Mesh Plug, or Prolene Hernia System Repair for Groin Hernia: Which is Better?

Lichtenstein's Operation, Mesh Plug, or Prolene Hernia System Repair for Groin Hernia: Which is Better?

Prophylactic antibiotic usage in patients undergoing inguinal mesh hernioplasty — A clinical study

There is ambiguity about the use of antibiotic prophylaxis in inguinal mesh hernioplasty. We have tried to assess the efficacy of antibiotic prophylaxis in this procedure. A randomized double blind placebo controlled study was conducted which included 55 patients who underwent an inguinal mesh hernioplasty over a 2 year period. The patients were evaluated for the status of the suture line as well as the presence of wound infection. Out of 55 patients 29 were randomized to the antibiotic arm and 26 to the placebo group. The groups were well matched for all variables studied excluding wound infections, which occurred at a rate of 10.34% (n = 3) in the antibiotic group and 15.38% (n = 4) in the placebo arm, (p > 0.01). This study did not document any statistically significant difference observed between those who received antibiotics and those receiving placebo in terms of any of the prognostic end points evaluated for Lichtenstein mesh hernioplasty.

Groin hernia repair in young males: mesh or sutured repair?

Large-scale data for the optimal inguinal hernia repair in younger men with an indirect hernia is not available. We analysed nationwide data for risk of reoperation in younger men after a primary repair using a Lichtenstein operation or a conventional non-mesh hernia repair. Prospective recording of all inguinal hernia repairs from 1 January 1998 to 31 December 2005 in the national Danish Hernia Database, using reoperation rate as a proxy for recurrence. We included only men between the age of 18 and 30 years with a primary repair of a primary indirect inguinal hernia. A primary sutured repair was performed in 1,120 men (median age 23 years, range 18-30) and a Lichtenstein mesh repair in 2,061 young men (24 years, range 18-30) (total 3,181 patients). The observation time after conventional hernia repair was median 62 months (range 0-96) and 41 months (range 0-96) after a Lichtenstein repair. The cumulative incidence of reoperation at 5 years was 1.6% (Lichtenstein) versus 3.9% (sutured repair), while overall reoperation rates were almost three-fold as high after a sutured repair (39 reoperations, overall reoperation rate = 3.5%) compared to a Lichtenstein repair (24 reoperations, overall reoperation rate = 1.2%; P = 0.0003). Lichtenstein repair for an indirect inguinal hernia reduces the risk of recurrence in young men between the age of 18 and 30 years compared with a sutured repair. The use of a Lichtenstein mesh repair in young males must be balanced against the risk of chronic pain.

Over a thousand ambulatory hernia repairs in a primary care setting

This paper outlines the development and feasibility of a dedicated ambulatory primary care hernia service and examines the outcomes achieved during the period 1 March 2005 to 31 December 2008. A prospective analysis of 1164 patients who underwent abdominal wall hernia repair at Probus Surgical Centre during the study period. The operations were carried out by two GPs with a special interest (GPwSI) and one retired surgeon. The techniques used were a Lichtenstein mesh repair or modified Shouldice repair for inguinal hernias and a primary sutured repair for ventral hernias. All procedures were performed as day-cases under local anaesthesia without sedation. All patients were reviewed routinely at 6 weeks. The primary outcomes of the study were recurrence and patient satisfaction levels, and complications such as infection, haematoma and chronic pain. No patient required conversion to general anaesthesia. There were three (0.3%) recurrences. Complication rates were low and similar to those obtained in other specialist hernia units. More than 90% of patients were satisfied with the service and would recommend it to a friend. Routine elective abdominal wall hernia repairs can be performed in a primary care setting, safely and with excellent outcomes.

Chronic groin pain following lichtenstein mesh hernioplasty for inguinal hernia. Is it a myth?

The Lichtenstein mesh hernioplasty is currently the most popular operative technique for open repair of inguinal hernia. The incidence of chronic groin pain (CGP) following this procedure is reported to be high. However, since our experience did not support this observation, this study was undertaken at our centre, to assess the incidence of CGP following Lichtenstein mesh hernioplasty. A prospective study was conducted on all patients undergoing elective hernia repair at a tertiary care teaching hospital. The patients underwent Lichtenstein mesh hernioplasty and were followed up for the primary outcome measures of development of recurrence and Chronic Groin Pain. A total of 470 patients were enrolled for the study. Out of these 16 patients never reported for follow up after discharge from hospital. The remaining 454 patients with 510 primary inguinal hernias were included in the study. Of these 449 patients were male and 5 were female. The mean follow-up period was 14 months (range - six months to twenty four months). One patient had recurrence of hernia and CGP was reported in four patients. In all four patients CGP was mild and was well controlled with oral NSAIDS used on SOS basis. The incidence of CGP in our study is 0.78% for the number of operated hernias. This is not only considerably less than what is generally reported but is also less disabling.

Prolene Hernia System, Lichtenstein mesh and plug-and-patch for primary inguinal hernia repair: 3-year outcome of a prospective randomised controlled trial

Dissection requirements differ between various methods for inguinal hernia repair, which may affect operation times, pain response and possibly recovery time. The objectives of this study were to establish if any differences concerning these aspects could be detected following three principally different techniques for primary inguinal hernia repair. A total of 472 men between 30 and 75 years of age with primary inguinal hernias were included in a prospective controlled study and randomised to Lichtenstein mesh (L), PerFix Plug (P) or the Prolene Hernia System (PHS) procedure. All patients were seen and data were collected after 2 weeks, 3 months, 1 year and 3 years. The follow-up rates were 100, 99.8, 98.7 and 95.3%, respectively. The mean operation time was shorter for P (35.5 min, P < 0.001) and PHS (37.4 min, P < 0.02) versus L (40.4 min). More than 85% of the procedures were performed under local anaesthesia. There were no statistically significant differences between the groups concerning early or late complications, return to full functional ability, early pain response, analgesic consumption or the studied late-outcome parameters after 3 years of observation. Seven (1.5%) evenly distributed recurrences were registered. All of the techniques are suitable for operation under local anaesthesia. The PHS and P techniques can be performed with shorter operation times than the L method. Early and late outcomes are, however, comparable, with no significant differences concerning complication rates, return to full functional status and/or pain response.

Local anaesthesia as a risk factor for recurrence after groin hernia repair

The literature is inconclusive regarding the effect of local infiltration anaesthesia on the risk of recurrence after groin hernia repair. Based upon the Danish Hernia Database, reoperations after a primary Lichtenstein mesh repair were assessed in 43,123 patients between 1998 and 2005. Data were analysed in relation to type of inguinal hernia and whether repaired in public hospitals or by private hernia surgeons. The nationwide data showed no overall difference in reoperation rate (about 3.5% after five years), whether performed in local or general/regional anaesthesia. Reoperation rates were about 50% higher when performed for a direct hernia than for an indirect hernia. The use of local anaesthesia was followed by higher reoperation rates compared with general or regional anaesthesia after repair of a direct but not an indirect hernia in hospitals. However, reoperation rates after both direct and indirect hernia repairs were lower among private hernia surgeons, with uniform use of local anaesthesia compared with reoperations following primary surgery in hospitals. These extensive nationwide data suggest that surgical experience and hernia type may be important factors for reoperation, and that it is independent of the type of anaesthesia. When performed in general hospitals, local anaesthesia may be a risk factor for recurrence after primary repair of a direct hernia.

The comparison of preperitoneal and Lichtenstein repair for incarcerated groin hernias: A randomised controlled trial

Background Lichtenstein hernioplasty can be performed successfully as an emergency operation for incarcerated inguinal hernia. The aim of the study was to compare the short-term and long-term outcomes of the preperitoneal mesh with the Lichtenstein mesh technique in strangula groin hernia. Methods Forty consecutive patients with strangulated inguinal hernia were randomized (according to a random table) to undergo either a preperitoneal or a Lichtenstein repair under general anesthesia. Early outcome measures were age, gender, duration of surgery, operating time (min), side of hernia, other pathology, contents of hernia sac, the ratio of the bowel resection, required laparatomy, complete release of the intestinal loop and postoperative complications, time to return to work, driving and full activity. Long-term outcome measures were recurrence. A Student's t-test and Chi-square analysis were used for statistical analysis. Results They were randomly allocated to undergo either a preperitoneal mesh repair ( n = 19) or a tension-free mesh repair Lichtenstein ( n = 21). There were no persistent complications. Mean duration of surgery in the preperitoneal group was 54 min (SD – 11) versus 50 min in the Lichtenstein group (SD – 8). There was no significant difference with regards to age, race, gender, or comorbidities between the 2 groups. Four of the 21 patients (10.5%) who required an additional incision developed some type of complication. This circumstance was found to have significant influence on morbidity ( P = 0.003) but not on mortality. The median follow-up for the study was 24 months. Patients were seen 1 to 2 weeks after surgery. Conclusions In conclusion we recommend preperitoneal repair in strangulated hernia instead of Lichtenstein repair. The use of preperitoneal hernia repair for strangulated inguinal hernia is safe, and any need for laparatomy if bowel resection is necessary.

Moloney Darn Repair Versus Lichtenstein Mesh Hernioplasty for Open Inguinal Hernia Repair

To compare two tension-free techniques of inguinal hernia repair: the Moloney darn repair (MDR) and Lichtenstein mesh hernioplasty (LMH). The subjects of this study were 651 patients from a total 732 who underwent open inguinal herniorrhaphy at our clinic between January 2000 and January 2006. We evaluated and compared analgesic requirement in the first 24 h, operative time, hospital stay, early postoperative complications, time until return to work, and recurrence, between patients who underwent MDR (group A) and patients who underwent LMH (group B). Group B patients required less analgesia in the first 24 h than group A patients. Conversely, the mean operative time and postoperative hospital stay were shorter in group A. Early postoperative complication rates and the time until return to work did not differ significantly between the two groups. During follow-up, recurrences developed in three patients from group A and four from group B. The cost of MDR was significantly less than that of LMH. Both MDR and LMH resulted in rapid recovery and low recurrence rates; however, the advantage of the MDR lies in the fact that it does not require mesh, so it is much less expensive.

Authors' reply: Risk of recurrence 5 years or more after primary Lichtenstein mesh and sutured inguinal hernia repair (Br J Surg 2007; 94: 1038–1040)

Authors' reply: Risk of recurrence 5 years or more after primary Lichtenstein mesh and sutured inguinal hernia repair (<i>Br J Surg</i> 2007; 94: 1038–1040)

Risk of recurrence 5 years or more after primary Lichtenstein mesh and sutured inguinal hernia repair (Br J Surg 2007; 94: 1038–1040)

Risk of recurrence 5 years or more after primary Lichtenstein mesh and sutured inguinal hernia repair (<i>Br J Surg</i> 2007; 94: 1038–1040)

Risk of recurrence 5 years or more after primary Lichtenstein mesh and sutured inguinal hernia repair

The risk of recurrence of inguinal hernia within 5 years of repair is lower after mesh than sutured repair in men, but no large-scale studies have compared the risk of recurrence beyond 5 years. The Danish Hernia Database prospectively collects data on almost all primary inguinal hernia repairs in men (older than 18 years). This study used data recorded over 8 years, analysing reoperations for recurrent hernia in the intervals 0-30 months, 30-60 months and 60-96 months after operation. The reoperation rate was significantly lower after Lichtenstein open mesh repairs than open sutured repairs (Cox hazard ratio (HR) 0.45 (95 per cent confidence interval (c.i.) 0.39 to 0.51) for 0-30 months after surgery; HR 0.38 (95 per cent c.i. 0.29 to 0.49) for 30-60 months). In 13 674 primary inguinal hernia repairs with an observation interval of 5 years or more, the risk of reoperation after Lichtenstein repair was a quarter of that after sutured repair (HR 0.25 (95 per cent c.i. 0.16 to 0.40) for 60-96 months after surgery). After 5 years, the reoperation rate increased continuously after sutured repair but not after mesh repair. Lichtenstein mesh repair for inguinal hernia prevented recurrence beyond 5 years after the primary operation, but sutured repair did not.

Randomized clinical trial of Lichtenstein's operation versus mesh plug for inguinal hernia repair (Br J Surg 2007; 94: 36–41)

Randomized clinical trial of Lichtenstein's operation <i>versus</i> mesh plug for inguinal hernia repair (<i>Br J Surg</i> 2007; 94: 36–41)