Hernia (2010) 14:357360
DOI 10.1007/s10029-010-0663-2
O R I G I N A L A R T I CL E
Lichtenstein or darn procedure in inguinal hernia repair:
a prospective randomized comparative study
H. F. Kucuk H. E. Sikar N. Kurt H. Uzun
M. Eser F. Tutal Y. Tuncer
Received: 19 August 2009 / Accepted: 9 April 2010 / Published online: 12 May 2010
Springer-Verlag 2010
Abstract
Background The aim of this study was to assess the out-
come of patients with inguinal hernia where the Moloney
darn or Lichtenstein procedure was used as the surgical
choice.
Method A herniorrhaphy procedure was performed in a
total of 306 patients at our clinic between January 2003 and
December 2008. The duration of operations and complica-
tion and recurrent rates were compared between the two
groups. Hematoma formation, seroma collection, and
wound infection were accepted as early complications,
whereas chronic pain, loss of sensation at the operation site,
and the rejection of mesh were accepted as late complica-
tions.
Results Considering early complications as hematoma
formation, the accumulation of seroma and wound infection
ratios were similar in the two groups. Loss of sensation at
the operation site and chronic pain, which were classiWed as
late complications, were similar in the groups. However, in
considering rejection, there were three rejections in the
group where mesh was used.
Conclusion The darn repair method is simple, safe, and
has similar recurrence rates when compared to the Lichten-
stein method in inguinal hernia patients.
Keywords Inguinal hernia Moloney darn repair
Lichtenstein repair Recurrence rate
H. F. Kucuk (&) H. E. Sikar N. Kurt H. Uzun
M. Eser F. Tutal Y. Tuncer
Kartal Research and Education Hospital,
Petrol-is mh. Sh. Dursun Bakan Sk. Hilal Sit. A Blok D:21,
34862 Kartal, Istanbul, Turkey
e-mail: hasan.kucuk@sbkeah.gov.tr
Introduction
Inguinal hernia repairs can be performed conventionally
or laparoscopically by using diVerent methods. The pur-
poses of these methods are obtaining lower recurrent
rates, better pain-free postoperative periods, and shorter
convalescence periods [1]. The recurrence rate of tradi-
tional sutured hernia repair techniques is reported to be
between 0.7 and 9.3% [2]. On the other hand, the recur-
rence rate of tension-free mesh repair is less than 1% [3].
The darn repair, originally described by Moloney [4], is
another tension-free repair method. Mesh repair either
conventionally or laparoscopically is more popular than
the tension-free method, but it is more expensive and can
cause many complications that cause removal of the
mesh as a result [1]. In this study, we compared the
results of the Lichtenstein procedure with the darn repair
technique.
Materials and methods
This prospective comparative study was performed at our
surgical clinic between January 2003 and December 2008.
The study included 306 patients with inguinal hernia,
which were divided into two groups. Group I included 176
patients and darn repair was performed. Group II included
130 patients and Lichtenstein procedure was performed as
the hernia repair method. The patients had inguinal hernia
as a primary disease and recurrent hernia and incarcerated
hernias were not included. Patients were randomly chosen.
Informed consent from all of the patients was obtained. The
operations were performed by four surgeons who were
experienced in hernia repair or were performed under the
control of these surgeons.
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358
Our darn method was performed by suturing between the
inguinal ligament and fascia of the internal oblique muscle
fascia by using O monoWlament polyprolene suture. The
Wrst suture began at the medial site from the pubic tubercle
and continued to the site of the internal inguinal ring. After
placing the Wrst suture, a second suture was done 1 cm for-
ward and was continued between the inguinal ligament and
the internal oblique muscle fascia (Fig. 1). The sensory
nerves were preserved in all cases with gentle tissue han-
dling, gentle dissection, meticulous hemostasis, and avoid-
ance of extensive thermal injury.
We used a 7.5 15-cm polypropylene mesh in Group
II. The mesh was positioned on the inguinal Xoor between
the inguinal ligament and the internal oblique muscle fas-
cia. The meshes were provided by our institution and origi-
nated from diVerent companies.
The duration of operations and complication and recur-
rent rates were compared between the two groups. Hema-
toma formation, seroma collection, and wound infection
were accepted as early complications, whereas chronic
pain, loss of sensation at the operation site, and the rejec-
tion of mesh and recurrence 6 months after the operation
were accepted as late complications. Rejection was
accepted in the presence of redness of the operative site and
discharge from the wound and the absence of bacterial
growth in culturing studies. Before obtaining the results of
culturing studies, a sultamicillin 750 mg tablet twice a day
was prescribed for 10 days. The patients were observed for
about 2 months. In the secondary operation, the mesh was
not attached to surrounding tissue, as it was excluded from
the body and was removed. Wound infection was deWned
purulent discharge or the presence of microorganisms
which were present in culture studies in any discharge.
Chronic pain was deWned as the continuation of pain after
2 months which required painkillers. The ultrasonographic
examination was performed in the presence of complica-
tions such as hematoma formation, seroma collection,
Fig. 1 Picture of darn method between the inguinal ligament and the
internal oblique muscle fascia
123
Hernia (2010) 14:357360
wound infection, or suspicion of recurrence during physical
examination.
The data were collected postoperatively after the 1st
week, 1st, 3rd, 6th, and 12th month, and 2nd and 3rd year,
or at any time which the patients needed admission due to
any of the problems deWned above. The data were assessed
with SPSS 10.0. The statistical analyses were done using
the unpaired t-test and the Chi-square test.
Results
The number of patients in group I was 176 and there were
130 patients in group II. The mean age, follow-up time,
operation time, sex distribution, side of hernia, and type of
hernia between groups were similar. The demographic Wnd-
ings are shown in Table 1. Considering early complications
such as hematoma formation, accumulation of seroma, and
wound infection, the ratios were similar in the two groups.
Loss of sensation at the operation site and chronic pain,
which were classiWed as late complications, were also simi-
lar in the groups. However, in considering rejection, there
were three rejections in the group in which mesh was used.
The rejection times were 6, 7, and 13 months after the oper-
ations, respectively. Complications after inguinal hernia
operation are shown in Table 2.
Discussion
Many types of operative management have been described
in the repair of inguinal hernias and much clinical investi-
gation has been performed. The anterior approach, poster-
ior approach, laparoscopic, and open operations have been
research. Anterior repair methods are the most common and
tension-free repairs are now standard procedures. The aims
of all these types of operations are to obtain lower recur-
rence rates, lower complication rates, earlier return to daily
activities, and cost-eVectiveness [1].
Tension in a repair method is the principal cause of
recurrence [5]. Using mesh as a prosthetic material has
been described by Lichtenstein in the repair of inguinal her-
nia and is a tension-free method and has become very popu-
lar [6]. The darn method using nylon suture described by
Moloney is also a tension-free method. We compared the
complication and the recurrence rates of both repair proce-
dures in this study. There was no diVerence between the
two groups considering early complications such as hema-
toma formation, seroma formation, and wound infection.
Also, there was no diVerence when considering late compli-
cations such as sensory loss at the operation site and
chronic pain. Rejection was detected in three of our patients
where the Lichtenstein method was used. The Wndings in
Hernia (2010) 14:357360 359

Table 1 Demographic data of the patients

n = 306 Group I (n = 176) Group II (n = 130) P-value

Mean age (years) SD 53.82 17.37 51.96 16.17 NS (0.339)a

Mean follow-up time (months) SD 24.63 13.65 23.23 12.65 NS (0.359)b
Mean operation time (min) SD* 44.83 4.49 44.80 4.69 NS (0.947)c
Sex (male/female) 146/30 (83%/17%) 102/28 (78.5%/21.5%) NS (0.322)
Side of hernia (right/left/bilateral) 73/82/21 53/55/22 NSd
Type of hernia (indirect/direct/pantaloon) 101/58/17 73/45/12 NSe
NS not signiWcant; Group I: darn repair; Group II: Lichtenstein repair
* Two surgeons performed bilateral hernia repair at the same time
a
t = 0.957
b
t = 0.918
c
t = 0.066
d
P = 0.901/0.456/0.214
e
P = 0.830/0.761/0.899

Table 2 Early and late postoperative complications after inguinal her- the side-loop to prevent the rupture of Wbrils. They claim
nia repair that this method is superior to the original darn method.
n = 306 Group I Group II P-value There was no recurrence in their modiWed darn method and
(n = 176) (n = 130) a complication rate of only 1.9%. The duration of opera-
tions were also similar between the groups in our study, as
Early
in the studies of Zeybek et al. and Kaynak et al. [6, 10].
Hematoma 2 (1.1%) 0 (0%) NS (0.223)
Recurrence seen 6 months after the surgery was evalu-
Seroma 3 (1.7%) 3 (2.3%) NS (0.707)
ated as late recurrence in our study. Although there is no
Wound infection 9 (5.1%) 7 (5.4%) NS (0.916)
consensus on this issue, we believe that recurrence within
Late 6 months after the operation may be due to technical insuY-
Sensory loss 1 (0.6%) 1 (0.8%) NS (0.829) ciency. There were no recurrences in our patients, as all of
Chronic pain 1 (0.6%) 0 (0%) NS (0.389) the patients had inguinal hernia as a primary disease and
Rejection 0 (0%) 3 (2.3%) 0.043 recurrent hernia and incarcerated hernias were not included.
NS not signiWcant; Group I: darn repair; Group II: Lichtenstein repair Both methods were also tension-free. Gentle and meticulous
surgery is another reason for decreased recurrence. On the
other hand, our mean follow-up time was around 24 months.
these patients were similar to the Wndings in the study of
Bisgaard et al. [11] followed primary Lichtenstein mesh and
Hofbauer et al. [7]. The rejection can be due to chronic for-
sutured inguinal repair patients for 8 years and observed that
eign body reactions of the prosthesis used in the surgery.
cumulative recurrence was increasing in the mesh group
Wang et al. [8] suggested that host versus mesh reaction is
until 5 years postoperatively. In conclusion, the Moloney
the cause of rejection. Koukourou et al. [9] compared poly-
darn repair method is simple, safe, and has similar recur-
prolene mesh with the nylon darn hernia repair method and
rence rates when compared to the Lichtenstein method in
they observed an early complication rate of 28% in the
inguinal hernia patients. On the other hand, in the Lichten-
mesh group versus 33% in the darn group and, also, the late
stein method, there is risk of rejection of the mesh which
complication rates were 15 and 20% in mesh and darn
requires its removal as result. Although there are a limited
groups, respectively; there was no statistically signiWcant
number of similar studies comparing the above-mentioned
diVerence between the groups. The recurrence rates were
methods, the Moloney darn repair method can be used in the
similar after 1 year, being 4%. The mean follow-up times
treatment of primary inguinal hernia.
were 24.63 13.65 and 23.23 12.65 months in the darn
group and Lichtenstein group, respectively, in our study
and there was no recurrence in the groups. Kaynak et al.
[10] compared the Lichtenstein hernioplasty and Moloney References
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