International Journal of Surgery 12 (2014) 1380e1384

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International Journal of Surgery

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Original research

Standard polypropylene mesh vs lightweight mesh for Lichtenstein

repair of primary inguinal hernia: A randomized controlled trial
Zaza Demetrashvili a, b, *, Kakhi Khutsishvili b, Irakli Pipia b, Giorgi Kenchadze b,
Eka Ekaladze c
a
Department of Surgery of Tbilisi State Medical University, 33, Vazha-Pshavela ave., 0177 Tbilisi, Georgia
b
Department of General Surgery of Kipshidze Central University Hospital, 29, Vazha-Pshavela ave., 0160 Tbilisi, Georgia
c
Department of Biochemistry of Tbilisi State Medical University, 33, Vazha-Pshavela ave., 0177 Tbilisi, Georgia

h i g h l i g h t s

During Lichtenstein with polypropylene mesh, the worst characteristics can be chronic pain.

In order to prevent such kind of difficulties, the usage of lightweight mesh is recommended.

The usage of the LW mesh was associated with less feeling of foreign body than that of the HW mesh.

Thepoint listed above can be considered as an advantage of LW mesh rather than HW mesh.

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: The aim of the present clinical study was to compare early and late outcomes after inguinal
Received 4 August 2014 hernia repair with the heavyweight mesh (HW) and lightweight mesh (LW) during a 3 year follow-up
Received in revised form period. Methods: 226 patients were randomized into LW and HW mesh groups, both of which under-
13 October 2014
went unilateral primary inguinal hernia repair via the Lichtenstein technique. Wound complications
Accepted 25 October 2014
Available online 28 October 2014
(infection, hematoma, seroma), hernia recurrence, pain and feeling of foreign body in inguinal area were
determined in patients. Pain was measured by visual analogue scale. Results: No statistical difference has
been found between LW and HW groups by wound complication (P ¼ 0.80). One case of hernia recur-
Keywords:
Lightweight mesh
rence has been mentioned in both groups one year after hernioplasty. But there was no detectable
Heavyweight mesh difference between the two groups. No significant difference has been found between LW and HW
Lichtenstein groups by frequency of chronic pain 7 days, 1 and 3 months, 1, 2, and 3 years after surgery. As for the
Inguinal hernia feeling of foreign body in groin it is similar in both groups after 1 and 3 months. Level of feeling of foreign
body was significantly lower in LW group 1, 2, and 3 years after surgery, than in HW group (P ¼ 0.03,
P ¼ 0.02, P ¼ 0.02, respectively). Conclusion: Our research shows no significant difference in wound
complications, hernia recurrence and chronic pain after Lichtenstein hernioplasty, by using of LW and
HW meshes. The usage of the LW mesh was associated with less feeling of foreign body than that of the
HW mesh, what can be considered as prevalence of LW mesh hernioplasty.
© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction Lichtenstein method is one of the most popular techniques [1].

Inguinal hernia repair is one of the most frequently performed
operations in general surgery. Tension-free mesh repair currently is
the gold standard in inguinal hernia surgery. Currently the
* Corresponding author. Department of Surgery of Tbilisi State Medical Univer-
sity, 33, Vazha-Pshavela ave., 0177 Tbilisi, Georgia.
E-mail addresses: zdemetr@yahoo.com (Z. Demetrashvili), kkhutsishvili1972@
yahoo.com (K. Khutsishvili), iraklipipia@yahoo.com (I. Pipia), gugken@yahoo.com
(G. Kenchadze), ekaekaladze@yahoo.com (E. Ekaladze).
Usage of prosthetic materials decreased the frequency of hernia
recurrence, although the chronic pain and feeling of a foreign body
in inguinal area after surgery is still considerable problem e it
worsens the level of patients' quality of life [2e4].
The incidence of chronic pain after inguinal hernioplasty varies
from 9 to 52% and the feeling of a foreign body occurs in around 40%
of patients [3,5,6]. The pain may be caused by damage to the
inguinal nerves, but these complications may be due to the foreign
body reaction against the mesh which results in an inflammatory
response and scar tissue formation [5,7]. The reaction on foreign

http://dx.doi.org/10.1016/j.ijsu.2014.10.025
1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
 Z. Demetrashvili et al. / International Journal of Surgery 12 (2014) 1380e1384
body is depend on the type and volume, as well as the size of pores
and web-structure of synthetic prosthesis. Taking into consider-
ation this fact, nowadays partially absorbable lightweight meshes
(LW) are being used instead of heavyweight polypropylene meshes
(HW). Low mass, decreased content of foreign body and large pores
are characteristic for LW [8e10].
According to the current researches usage of LW meshes for
inguinal hernioplasty decreases the frequency of chronic pain
[11e13], at the same time several articles don't confirm the fact
[14,15]. It's worth mentioning, that the risk of hernia recurrence
might be increased in case of using LW meshes [16].
The aim of the present clinical study was to compare early and
late outcomes after inguinal hernia repair via the Lichtenstein
technique with the heavyweight mesh (HW) and lightweight mesh
(LW) during a 3 year follow-up period.
2. Methods
From January 2008 to April 2011 patients over 18 years of age
who underwent elective surgery for unilateral primary inguinal
hernia via the Lichtenstein technique were enrolled in the study.
The patients were operated at the General Surgery Department of
Kiphshidze Central University Hospital. The inclusion criteria were
a unilateral primary inguinal hernia requiring operative treatment
and patient's approval to participate in the study. The exclusion
criteria were bilateral hernia, irreducible hernia, recurrent hernia,
strangulated hernia, a patient's preference for either mesh type, or
a patient's refusal to participate in the study. The basic principle for
this study was one unit, one surgeon trained in the standard
Lichtenstein technique and the use of LW and HW meshes. The
patients were assigned to one of the two groups: the LW group or
the HW group. The randomization (by simple random sampling) of
patients to each of the two groups described above was done before
the surgical intervention. The assignment of patients to the specific
groups was performed by the clinical manager not involved in the
surgical procedures. The study participants were blinded regarding
the type of the mesh used in the surgical intervention. The Lich-
tenstein hernioplasty was performed according to the original
description of the technique [17]. The nerves in inguinal canal were
identified and preserved when possible. In the HW group, a
monofilament polypropylene mesh with a weight of 82 g/m2 and
pore size 0.8 mm (Prolene, Ethicon, Somerville, New Jersey) was
used. The LW mesh in this study was Ultrapro (Ultrapro, Ethicon,
Somerville, New Jersey), a large pore composite mesh (poly-
propylene and poliglecaprone, Monocril) (weight ¼ 28 g/m2, pore
size 3 mm). In both groups, 8  12 cm mesh was applied. Poly-
propylene 2/0 monofilament suture material was used for mesh
implantation.
Several preoperative factors were studied, which included sex,
age, body mass index, occupation, tobacco use, risk groups by
American Society of Anesthesiologists (ASA) and comorbidities, and
site of hernia. Patients with ASA groups 4 and 5 were excluded from
the study.
Among the intraoperative factors, the following were evaluated:
type of hernia, anesthesia method (local, general), and duration of
the operation. Prophylactic antibiotics were not used in all patients.
We were using it only in patients with concurrent disorders. In
these instances, 1.5 g cefuroxime was used intravenously 30 min
before the operation.
Among the postoperative data, the following were studied:
postoperative days at the ward (hospital stay), sick-leave days, and
complications. The latter were divided into two groups: early and
late complications. The early complications included wound
infection, hematoma, and seroma. The late complications included
chronic pain in the inguinal region, the feeling of a foreign body and
1381
hernia recurrence. Pain scores were measured on a Visual Analogue
Scale (VAS), ranging from 0 (no pain) to 10 (worst imaginable pain).
After discharge from the hospital, all patients were examined
after 1 week, 15 days, and 1 month at the outpatient department by
the same surgeon who performed the operation. Also, these pa-
tients were examined 3 month, 1, 2, and 3 years after the operation
date. The examinations were performed by surgeons who had not
been participating previously in this study. They were paying
attention to the pain in the inguinal region, to the feeling of a
foreign body and the presence of hernia recurrence. The pain
questionnaire included questions regarding pain at rest, on
coughing, while climbing steps and during physical activity.
3. Statistical methods
Descriptive statistics methods were used to characterize each
variable. Comparison of continuous variables was performed by
independent samples t-test or the ManneWhitney U test according
to the normality of the variables. Categorical variables were eval-
uated by two-tailed Chi-square test or Fisher's exact test where
appropriate. The threshold for statistical significance was set to
P < 0.05. Statistical tests were performed by SPSS 16.00 (SPSS Inc.,
Chicago, IL).
4. Results
From January 2008 to April 2011, 328 patients underwent
inguinal hernia repair via Lichtenstein technique. Among these
patients, 226 were randomized in two groups equally (113 patients
in each group). All of these patients underwent the allocated op-
erations. Information about 28 patients was lost during the time
observation: among them e 19 patients were not coming for ex-
amination, 7 patients were died during observation period (the
causes of death were all non-hernia surgery related), in 2 patients
developed recurrence of hernia. Subsequently 102 patients from
HW group and 96 e from LW group were consecutively examined
during 3 years after surgical operation. The data of this investiga-
tion is analyzed on this article (Fig. 1).
Both groups were similar by preoperative (sex, age, body mass
index, tobacco use, American Society of Anesthesiologists risk
groups, comorbidities, site of hernia, and occupation) and intra-
operative (type of hernia, anesthesia, prophylactic antibiotics, and
operation time) factors. No statistically significant differences were
found between the groups by these factors (Table 1, Table 2).
Regarding the postoperative data, no statistical difference has
been found (P ¼ 0.35) between groups by postoperative time spent
at the ward (hospital stay), and by sick-leave days (P ¼ 0.15). In the
LW group, 8 early complications (wound infection, hematoma,
seroma) were observed (8.3%), in the HW group e 10 early com-
plications (9.8%). The difference did not statistical significant
(P ¼ 0.80). One case of hernia recurrence was marked in each group
after 1 year of surgery. But there was no detectable difference be-
tween the two groups (Table 3).
As for frequency of inguinal pain the difference was not statis-
tically significant between LW and HW groups 7 days, 1 and 3
month and 1, 2 and 3 years after surgery. There was no detectable
difference between the two groups according to average VAS scores
too (Table 4).
The difference was not statistically detectable between LW and
HW groups concerning the feeling of a foreign body 7 days, 1 and 3
months after operation. Statistical significant difference (P ¼ 0.03)
was found in the data of feeling of a foreign body 1 year after
surgery: the symptom was mentioned in 6 (6.3%) patients in LW
group and 17 (16.7%) patients in HW group. 2 years after surgery
the same symptom was detected in 2 (2.1%) patients in LW group
1382 Z. Demetrashvili et al. / International Journal of Surgery 12 (2014) 1380e1384
Fig. 1. Study flow chart. A randomized trial of lightweight vs. heavyweight mesh in Lichtenstein primary inguinal hernia repair.
and 11 (10.8%) e in HW group e difference is statistical significant
(P ¼ 0.02). 3 years after surgery the feeling of a foreign body was
marked in 1 (1.05%) patient in LW group and 9 (9.4%) in HW group e
difference is statistical significant (P ¼ 0.02) (Table 5).
5. Discussion
A tension-free operation with mesh has become the standard
technique for inguinal hernia surgery [1]. According to the scientific
literature the frequency of hernia recurrence is considerably low
after mesh repair [1,2,18,19]. Although chronic pain and feeling of a
foreign body in inguinal area is the main problems of mesh repair
surgery. These complications significantly effect on the quality of
patients life [3e6,12,20]. Several investigators confirm that the
main reasons of these complications are the reaction of organism
on a foreign body (polypropylene). Thus, a lightweight mesh with a
reduced weight of non-absorbable components has been devel-
oped to minimize foreign body reactions after surgery [7e10,21].
The purpose of our clinical study was to evaluate the outcomes
of Lichtenstein hernioplasty by using light and heavy weight
meshes and to compare them to the results of analogs researches.
According to our research frequency of early postoperative
complications (infection, hematoma, seroma) in both groups were
the same. These results are in accordance to other investigations
[13,22e24].
There was no detectable difference by of hernia recurrence be-
tween the two groups. Our results did not differ from results of
other investigations [11,14,15,25,26]. Different kinds of meta-
analysis found no statistical difference in overall hernia
recurrence between LW and HW mesh in inguinal hernia repair
[13,23,24,27,28]. It's worth to mention the work of O'Dwyer et al.
[29], where hernia recurrence was statistically significantly higher
in LW group compared to HW group. The authors don't correlate
the increase of frequency of recurrence of the type of mesh. Ac-
cording to their opinion the cause of this difference is technical
errors of mesh fixation. We think particular attention have to paid
to lightweight mesh fixation to avoid hernia recurrence in Lich-
tenstein hernioplasty. We completely agree the authors' opinion
about three additional modification of LW mesh fixation to be
considered during Lichtenstein hernioplasty [25,27,29]. Importance
of lightweight mesh fixation for prevention of hernia recurrence is
emphasized also in European Hernia Society guidelines update
[30].
Chronic pain is one of the most serious long-term complications
following groin hernia repair [1,3,5,6,20,30]. No statistical differ-
ence has been found between LW and HW groups by chronic pain 1,
2, and 3 years after surgery. Several scientific articles confirm our
result [14,15,25,26]. Otherwise some scientific results show the
chronic pain is significantly decreased in LW group
[11e13,16,22e24,28,29]. According to the European Hernia Society
guidelines on treatment of inguinal hernia in adult patients, the risk
factors for chronic pain are preoperative pain, younger age and
severe early postoperative pain [1]. We mentioned an interesting
fact: acute severe pain was observed on 7th day after surgery in
patients of both groups who 1, 2 or 3 years after hernioplasty had
chronic pain.
Based on our results the feeling of a foreign body in groin is
similar in both groups after 1 and 3 month. Significant decrease of
 Z. Demetrashvili et al. / International Journal of Surgery 12 (2014) 1380e1384 1383

Table 1 Table 4
Preoperative factors in two treatment groups. Pain and visual analogue scale (VAS) at follow-up.

Characteristics Lightweight mesh Heavyweight mesh P Value Characteristics Lightweight mesh Heavyweight mesh P Value

(n ¼ 96) (n ¼ 102) (n ¼ 96) (n ¼ 102

Sex 7 days
Male 90 92 0.44 Pain 13(13.5) 17(16.7) 0.56
Female 6 10 VAS 3.2 ± 2.3 3 ± 1.7 0.84
Age (years) 54.7(14.3) 51.3 (17.5) 0.14 1 month
BMI, kg/m2 24.4(1.7) 24.6(1.8) 0.42 Pain 12(12.5) 15(14.7) 0.68
Site of hernia VAS 3.2 ± 1.8 2.6 ± 1.3 0.37
Right 56 64 0.56 3 month
Left 40 38 Pain 10(10.4) 12(11.8) 0.82
Comorbidities VAS 2.5 ± 1.4 2.4 ± 1.3 0.82
Cardiovascular 11 10 0.82 1 year
Respiratory system 4 5 0.75 Pain 6(6.3) 9(8.8) 0.60
Diabetes 3 5 0.72 VAS 2.2 ± 1.2 2.4 ± 1.4 0.70
ASA risk group 2 year
1 36 42 0.67 Pain 3(3.1) 6(5.9) 0.50
2 50 54 0.67 VAS 2.3 ± 1.5 2.5 ± 1.1 0.85
3 10 6 0.30 3 year
Current smoker 41 47 0.74 Pain 2(2.1) 5(4.9) 0.45
Occupation Vas 2 ± 1.4 2.4 ± 1.1 0.71
Light work 54 48 0.25
VAS e Visual Analogue Scale.
Physical work 42 54
Data are expressed as absolute number of patients (%) or as mean and SD.
ASA e American Society of Anesthesiologists; BMI e Body mass index.
Data are expressed as mean (SD) or absolute number of patients (%).
Table 5
Identifying feeling of foreign body.
Table 2
Characteristics Lightweight mesh Heavyweight mesh P Value
Intraoperative factors in two treatment groups.
(n ¼ 96) (n ¼ 102)
Characteristics Lightweight mesh Heavyweight mesh P Value
Feeling of foreign body
(n ¼ 96) (n ¼ 102) 7 days 33(34.4) 30(29.4) 0.54
Type of hernia 1 month 24(25) 27(26.5) 0.87
Indirect 62(64.6) 71(69.6) 0.54 3 month 19(19.8) 23(22.5) 0.73
Direct 30(31.3) 27(26.5) 0.53 1 year 6(6.3) 17(16.7) 0.03
Combined 4(4.1) 4(3.9) 0.99 2 year 2(2.1) 11(10.8) 0.02
Anesthesia 3 year 1(1.05) 9(9.4) 0.02
Local 76 78 0.73 Data are expressed as absolute number of patients (%).
General 20 24
Prophylactic antibiotic 28 26 0.63
Operation time, min. 58.7(13.3) 61.2(9.9) 0.13
body than that of the HW mesh. That can be considered as an
Data are expressed as mean (SD) or absolute number of patients (%). advantage of LW mesh rather than HW mesh.

Ethical approval
Table 3
Surgical outcomes in two treatment groups.
None.
Characteristics Lightweight mesh Heavyweight mesh P Value

(n ¼ 96) (n ¼ 102) Sources of funding

Hospital stay (days) 1.4(0.8) 1.5(0.7) 0.35
Sick leave (days) 8.4(2.1) 8.8(1.8) 0.15 None.
Primary complication 8 10 0.80
Wound infection 3 3 1.0
Hematoma 1 1 1.0 Author contribution
Seroma 4 6 0.75
Recurrence 1(1.04) 1(0.98) 0.99 Zaza Demetrashvili participated in the design and coordination
Data are expressed as mean (SD) or absolute number of patients (%). of the study, collected the data, analysed the data, carried out the
statistical analysis and wrote the manuscript. Kakhi Khutsishvili,
Irakli Pipia, Giorgi Kenchadze and Eka Ekaladze developed the
the symptom has been found is in LW group 1, 2 or 3 years after literature search, collected the data and assisted in writing up. All
surgery (P ¼ 0.03, P ¼ 0.02, P ¼ 0.02, respectively). Several in- authors read and approved the final manuscript.
vestigations confirm our results underlining the prevalence of
lightweight mesh concerning feeling of a foreign body Conflicts of interest
[11,13,16,22e28], but work of Nikkolo et al. [15] shows no difference
in this indicator between compared groups. The authors declare that they have no conflict of interests.
In conclusion, based on our observational study comparison of
LW and HW meshes usage in Lichtenstein hernioplasty in primary Acknowledgments
inguinal hernia, indicated no significant difference in terms of
wound complications, hernia recurrence and chronic pain. The We are thankful to Dr George Kamkamidze for the help he
usage of the LW mesh was associated with less feeling of foreign provided during the writing of the article.
1384 Z. Demetrashvili et al. / International Journal of Surgery 12 (2014) 1380e1384

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