Introduction
Inguinal hernia is a prevalent condition in general surgical practice, significantly contributing to morbidity and healthcare utilization globally. It occurs when abdominal or preperitoneal contents protrude through a weakness in the inguinal region. While many inguinal hernias can be asymptomatic, they may lead to complications such as pain, swelling, activity limitations, incarceration, or strangulation [1]. The definitive treatment for symptomatic inguinal hernias is surgical repair, aimed at restoring normal anatomy, alleviating symptoms, preventing recurrence, and ensuring a prompt return to normal activities.
Over the past few decades, the mesh-based tension-free repair, especially the Lichtenstein technique, has gained popularity due to its low recurrence rate and ease of reproduction. This method uses mesh to support the posterior wall of the inguinal canal, minimizing tension on adjacent tissues. However, the use of synthetic foreign materials can lead to complications, including seroma, hematoma, wound infections, discomfort related to the mesh, foreign-body sensations, and chronic pain following surgery [2,3].
Non-mesh tissue repairs, including the Shouldice, Bassini, and Desarda techniques, restore the posterior wall using the patient’s own tissues. These procedures avoid prosthetic material and may therefore reduce mesh-specific complications and costs. The Desarda technique, in particular, uses an undetached strip of external oblique aponeurosis to reinforce the posterior wall and has been proposed as an alternative to mesh repair in selected patients [4]. Nevertheless, concerns regarding tissue tension and potentially higher long-term recurrence have limited widespread adoption of non-mesh techniques.
Comparative evidence remains important because postoperative pain, complications, hospital stay, return to work, and recurrence may vary according to the repair technique and patient characteristics. Meta-analyses have generally demonstrated lower recurrence following mesh repair, although differences in chronic pain and other postoperative outcomes have been less consistent [5,6]. Furthermore, the benefits of mesh must be balanced against complications related to prosthetic implantation.
The prospective observational study aims to compare mesh and non-mesh repair methods for inguinal hernias, focusing on various factors such as pain, infection, complications, hospitalization duration, return to work, and recurrence rates. This comparison seeks to determine the advantages and limitations of each technique to guide the choice of repair strategies for patients.
The study aims to conduct a prospective observational analysis to compare the repair outcomes of inguinal hernias with and without mesh. It focuses on investigating perioperative pain linked to different fixation techniques and assessing postoperative results, including recurrence, pain, wound infection, seroma, scrotal edema, and spinal cord tenderness, for both methods.
Methods
This prospective observational study was conducted at the Department of General Surgery, Prasad Institute of Medical Sciences, Lucknow, over one year, involving 100 patients divided into two groups of 50 each. Group assignments were determined by a surgical team based on either non-mesh (Desarda tissue-based repair) or mesh (Lichtenstein mesh-based repair) techniques. Inclusion criteria encompassed patients aged 18-59, with unilateral indirect inguinal hernias (bubocele and funicular types) or unilateral direct inguinal hernias in primary cases without prior hernia history, classified as ASA Grade I and II for elective hernioplasty. Exclusion criteria included ASA Grade ≥ III, history of recurrence, multiple abdominal surgeries, coagulopathy, significant comorbidities (such as CAD and asthma), requirement for concomitant procedures, chronic analgesic use, alcohol addiction, and patients who declined consent.
The study investigates inguinal hernia surgery, detailing preoperative assessments, surgical techniques, and postoperative outcomes. Patients provided comprehensive medical histories, including age, gender, smoking habits, family history of hernias, and symptoms such as cough and urinary difficulties. Inguinal hernias were diagnosed based on observable enlargements and specific discomfort during physical examination. All patients underwent a pre-anesthesia evaluation, which included additional testing for older individuals. Two surgical approaches were employed: the Desarda repair without mesh and the Lichtenstein tension-free mesh repair. The Desarda technique involved opening the external oblique aponeurosis, localizing the hernia sac, and securing a strip of the aponeurosis to reconstruct the inguinal canal. Conversely, the Lichtenstein method required placing and suturing a polypropylene mesh to reinforce the inguinal canal. Postoperative assessments utilized the Visual Analog Scale (VAS) to evaluate pain and postoperative complications, including hematoma, infection, and recurrence rates. Patients followed a recovery protocol with scheduled follow-up visits from one month to a year after surgery. Main outcomes measured included hernia recurrence, surgical complications, postoperative pain, operational time, and the duration of hospital stay. Results indicated both surgical methods provide significant insights into recovery times and complications. The study also highlights the cost-effectiveness of hernia repairs, especially relevant in low-income areas where access to healthcare may be limited. Overall, the study aims to provide a comprehensive analysis of the effectiveness and safety of inguinal hernia repair techniques.
Statistical analysis
Data analysis utilized Microsoft Excel and SPSS 24th version. Continuous variables were reported as mean ± standard deviation, and categorical variables as frequencies and percentages. The independent Student’s t-test compared continuous variables between mesh and non-mesh repair groups, while categorical variables were evaluated using the Chi-square test or Fisher’s exact test. A two-tailed p-value of <0.05 denoted statistical significance. Postoperative outcomes focused on demographic characteristics, operative parameters, complications, pain levels, hospital stay, return to work, and recurrence rates, highlighting significant differences between the two groups.
Results
Total 100 patients were enrolled, divided between non-mesh repair (50 patients) and mesh repair (50 patients) groups. Gender distribution was comparable, with males making up 70.0% and 72.0% of the non-mesh and mesh groups, respectively, showing no statistically significant difference (p=0.950). Age distribution was similar, with the largest cohort aged 41–50 years; mean ages were 46.50 ± 13.59 years for the non-mesh group and 48.70±12.36 years for the mesh group, which also presented no significant difference (p=0.088). Anthropometric characteristics indicated mean heights of 164.20±7.10 cm and 166.90±7.90 cm for the non-mesh and mesh groups, with a non-significant difference (t=−1.780, p=0.078). Mean weights were 62.80 ± 8.60 kg and 64.10 ± 9.20 kg, also not significant (t = −0.708, p=0.481). Mean Body Mass Index (BMI) was similarly comparable (23.30 ± 2.90 kg/m² vs. 23.20± 2.80 kg/m²; t = 0.076, p = 0.939). Regarding hernia side distribution, in the non-mesh group, left-sided hernias were most common (24 patients, 48%), followed by right-sided (20 patients, 40%) and bilateral hernias (6 patients, 12%). In the mesh group, right-sided hernias were slightly more prevalent (23 patients, 46%), followed by left-sided (22 patients,44%) and bilateral hernias (5 patients, 10%). Overall, hernia side distribution was broadly comparable between the groups, with no significant difference (χ² =1.57, p=0.456), suggesting that hernia laterality did not differ significantly between non-mesh and mesh repair patients (Table 1).
| Non-mesh repair (n=50) n (%) | Mesh repair (n=50) n (%) | Chi-square | p-value | |
| Gender | ||||
| Male | 35 (70.0%) | 36 (72.0%) | 0.04 | 0.950 |
| Female | 15 (30.0%) | 14 (28.0%) | ||
| Age groups | ||||
| 21–30 years | 8 (16.0%) | 5 (10.0%) | 1.476 | 0.831 |
| 31–40 years | 9 (18.0%) | 7 (14.0%) | ||
| 41–50 years | 13 (26.0%) | 15 (30.0%) | ||
| 51–60 years | 10 (20.0%) | 13 (26.0%) | ||
| >60 years | 10 (20.0%) | 10 (20.0%) | ||
| Mean ± SD | 46.50 ± 13.59 | 48.70 ± 12.36 | 0.088 | |
| Anthropometric parameters | ||||
| Height (cm) | 164.20 ± 7.10 | 166.90 ± 7.90 | t=-1.780 | 0.078 |
| Weight (kg) | 62.80 ± 8.60 | 64.10 ± 9.20 | t=-0.708 | 0.481 |
| BMI (kg/m²) | 23.30 ± 2.90 | 23.20 ± 2.80 | t=0.076 | 0.939 |
| Side | ||||
| Left | 24(48.0%) | 22(44.0%) | 0.788 | 0.416 |
| Right | 20(40.0%) | 23(46.0%) | ||
| Both | 6(12.0%) | 5(10.0%) |
Complications revealed that seroma occurred in 5 (10%) of the non-mesh group and 10 (20%) of the mesh group, showing a statistically significant difference (χ² = 4.54, p = 0.033). Wound infections were present in 3 (6%) non-mesh and 6 (12%) mesh patients, with no significant difference (p = 0.488). Hematomas were significantly more common in the mesh group (10 [20%]) compared to the non-mesh group (2 [4%]; χ² = 4.54, p = 0.033). Orchitis was noted in 2 (4%) patients with mesh repair, but not in those without, although this difference was not significant (p = 0.476). Testicular atrophy was absent in both groups. In summary, seroma and hematoma occurrences were significantly higher following mesh repair, while wound infection and orchitis did not show significant differences between the groups (Table 2).
| Complications | Non-mesh repair (n=50) | Mesh repair (n=50) | Chi-square | p-value | ||
| N | % | N | % | |||
| Seroma | 5 | 10% | 10 | 20% | 4.54 | 0.033* |
| Wound infection | 3 | 6% | 6 | 12% | 0.48 | 0.488 |
| Hematoma | 2 | 4% | 10 | 20% | 4.54 | 0.033* |
| Orchitis | 0 | 0% | 2 | 4% | 0.51 | 0.476 |
| Testicular atrophy | 0 | 0% | 0 | 0% | – | – |
* Significant at p < 0.05
Compares the frequencies of early postoperative pain, late postoperative pain, and chronic pain between the non-mesh repair and mesh repair groups, with 50 patients in each group. Early postoperative pain (<3 days) was reported in 47 (94%) patients in the non-mesh group and 45 (90%) patients in the mesh group. The difference was statistically significant (χ² = 13.50, p < 0.001). Late postoperative pain (>3 days) was present in 46 (92%) patients undergoing non-mesh repair compared with 42 (84%) patients undergoing mesh repair, and this difference was also statistically significant (χ² = 11.31, p = 0.001). Chronic pain was reported in 10 (20%) patients in the non-mesh group and 17 (34%) patients in the mesh group. Although chronic pain appeared more frequent following mesh repair, the difference was not statistically significant (χ² = 1.65, p = 0.1595). Overall, the findings indicate significant differences in early and late postoperative pain between the groups, while chronic pain did not differ significantly (Table 3).
| Pain | Non-mesh repair (n=50) | Mesh repair (n=50) | Chi-square | p-value | |||
| N | % | N | % | ||||
| Early post-op pain (<3 days) | No | 2 | 4% | 5 | 10% | 13.50 | <0.001* |
| Yes | 47 | 94% | 45 | 90% | |||
| Late post-op pain (>3 days) | No | 4 | 8% | 8 | 16% | 11.31 | 0.001* |
| Yes | 46 | 92% | 42 | 84% | |||
| Chronic pain | Yes | 10 | 20% | 17 | 34% | 1.65 | 0.1595 |
| No | 40 | 80% | 33 | 66% |
* Significant at p < 0.05
The comparison showed that the mean duration of hernia disease was slightly longer in the non-mesh repair group (7.8 ± 5.0 years) compared to the mesh repair group (6.5 ± 5.0 years), though this difference was not statistically significant (t = 1.30, p = 0.202). The mean duration of surgery was similar between both groups (non-mesh: 49.5 ± 5.6 minutes; mesh: 48.9 ± 5.2 minutes), with a statistically significant difference (t = 2.50, p = 0.014). Patients who underwent mesh repair experienced a significantly shorter hospital stay, averaging 3.4±0.8 days, compared to 4.2 ± 1.0 days for the non-mesh group (t = 4.42, p<0.001). However, return to work was significantly faster after non-mesh repair (9.88 ± 3.95 days) than after mesh repair (11.55±3.25 days; t = 3.85, p<0.001). These findings indicate that while mesh repair may enable earlier discharge, non-mesh repair might promote quicker functional recovery and return to work (Table 4).
| Parameter | Non-mesh repair (n=50) Mean ± SD | Mesh repair (n=50) Mean ± SD | t | p-value |
| Duration of hernia disease (years) | 7.8 ± 5.0 | 6.5 ± 5.0 | 1.30 | 0.202 |
| Surgery duration (min.) | 49.5 ± 5.6 | 48.9 ± 5.2 | 2.50 | 0.014* |
| Hospital stay (days) | 4.2 ± 1.0 | 3.4 ± 0.8 | 4.42 | <0.001* |
| Return to work (days) | 9.88 ±3.95 | 11.55±3.25 | 3.85 | <0.001* |
*Statistically significant
The study compares recurrence rates in non-mesh repair and mesh repair groups, finding no recurrences: 0% in each group, with all 50 patients remaining recurrence-free. Consequently, the chi-square test and p-value were irrelevant, indicating both repair methods had comparable outcomes regarding recurrence (Table 5).
| Non-mesh repair (n=50) | Mesh repair (n=50) | Chi sq. | p-Value | ||||
| N | % | N | % | ||||
| Recurrence | Yes | 0 | 0.0 | 0 | 0.0 | - | - |
| No | 50 | 100 | 50 | 100 |
Discussion
The surgical correction of inguinal hernias is the most frequently performed general surgical operation today. Achieving a tension-free closure of the hernia defect is essential for minimizing recurrence rates. The American College of Surgeons endorses mesh as the standard care for adult inguinal hernia repair [7]. Ongoing research aims to enhance surgical techniques and lower complication rates, with a new mesh-free approach emerging that requires no synthetic material, leading to lower costs. A 3-year follow-up of adult male patients receiving either the Desarda (no mesh) or Lichtenstein (mesh) techniques showed no significant differences in clinical outcomes, except for a higher incidence of seromas in one group [8]. Recurrence rates for hernia repairs are about 1% in specialized hospitals, while in general settings, they can reach 18%. Different mesh procedures show varying rates, with transabdominal preperitoneal repair presenting rates from 1.6% to 19%. Additionally, 15% to 28% of patients experience postoperative complications, potentially rising to nearly 50% with careful monitoring. Common issues include seroma, infection, discomfort, and recurrence; rare cases of death and significant quality of life decline have also been reported, indicating a need for further clinical research [9][10].
In the present study, 100 patients with hernia were enrolled, with 50 patients each undergoing non-mesh repair and mesh repair. The two groups were comparable with respect to baseline demographic characteristics. Males predominated in both groups (70.0% in the non-mesh group and 72.0% in the mesh group), with no statistically significant difference (p=0.950). This male predominance is consistent with the established epidemiology of inguinal hernia. Constance et al. reported a substantially higher cumulative incidence of inguinal hernia among men (13.9%) compared with women (2.1%) [11].
The mean age was 46.50 ± 13.59 years in the non-mesh group and 48.70 ± 12.36 years in the mesh group, with no significant difference (p=0.088), suggesting adequate age comparability. These findings are broadly consistent with Kamat and Shinde, who reported mean ages of 33.24 and 33.56 years in non-mesh and mesh groups, respectively [12]. Sinha et al. reported an age range of 29–45 years among patients with hernia, while their mean age was 36.62 years in the non-mesh group compared with 37 years in the mesh group [13]. Similarly, Sakamoto et al. observed broadly comparable age distributions between mesh and non-mesh groups [14].
Anthropometric parameters were also comparable. Mean BMI was 23.30 ± 2.90 kg/m² in the non-mesh group and 23.20 ± 2.80 kg/m² in the mesh group (p=0.939). This finding agrees with Van Veen et al., who reported an identical median BMI of 24.4 in both mesh and non-mesh groups [15]. Hernia laterality was likewise comparable, with no significant difference between groups (χ²=1.57, p=0.456). Overall, the similarity in demographic and anthropometric characteristics indicates that the two treatment groups were well matched at baseline, strengthening the validity of subsequent comparison of surgical outcomes.
In the present study, postoperative complications differed between the non-mesh and mesh repair groups. Seroma occurred in 5 (10%) patients in the non-mesh group compared with 10 (20%) in the mesh group, and this difference was statistically significant (χ²=4.54, p=0.033). This finding is consistent with Liu et al. (2023), who identified seroma as one of the most common early complications following laparoscopic hernia repair and reported an incidence of 16.4% [16]. The present findings are also supported by Smith et al. (2022), whose meta-analysis demonstrated a significantly higher risk of seroma following mesh repair than non-mesh repair (RR 1.63; 95% CI: 1.03–2.59; p=0.04) [17]. The increased seroma formation may be related to inflammatory response and dead-space formation associated with mesh placement.
Hematoma was also significantly more frequent in the mesh group, occurring in 10 (20%) compared with 2 (4%) patients in the non-mesh group (χ²=4.54, p=0.033). However, this finding differs from Smith et al. (2022), who reported no significant difference in hematoma or bleeding between mesh and non-mesh repairs (OR 1.05; 95% CI: 0.95–1.17) [17]. The higher incidence observed in the present study may reflect differences in operative technique, patient characteristics, or postoperative monitoring.
Wound infection occurred in 6% and 12% of non-mesh and mesh patients, respectively, without significant difference (p=0.488). This agrees with Smith et al., who found no discernible difference in wound infection between mesh and non-mesh techniques [17]. Orchitis was uncommon and statistically comparable, while testicular atrophy was absent in both groups. Overall, the findings indicate that mesh repair was associated particularly with seroma and hematoma, whereas infectious and testicular complications remained comparable.
In the present study comparing mesh and non-mesh repair of inguinal hernia, postoperative pain was an important outcome. Early postoperative pain (<3 days) was reported in 94% of patients in the non-mesh group compared with 90% in the mesh group, with a statistically significant difference (χ²=13.50, p<0.001). Similarly, late postoperative pain (>3 days) occurred in 92% of patients following non-mesh repair compared with 84% following mesh repair (χ²=11.31, p=0.001). These findings indicate that non-mesh repair was associated with a greater frequency of pain during the early postoperative period and beyond the first three days.
The present findings are partly consistent with previous comparative studies. Szopiński et al. (2012) used a definition of chronic pain persisting for ≥6 months, considering the possibility of prolonged inflammatory response to synthetic materials used in mesh repair [8]. Other studies have similarly adopted longer follow-up periods when assessing chronic postoperative pain [18,19]. Studies comparing Desarda non-mesh repair with Lichtenstein mesh repair found slightly greater discomfort in the non-mesh group during the early postoperative period; however, these differences were not statistically significant. Furthermore, no significant differences in pain were observed during six-month follow-up [20]. These observations suggest that early pain may vary according to tissue handling, tension, fixation technique and individual patient factors rather than mesh use alone.
In the present study, chronic pain was more frequent after mesh repair (34%) than non-mesh repair (20%), although the difference was not statistically significant (χ²=1.65, p=0.1595). Similarly, persistent pain was higher following mesh repair (28.33% vs. 16.67%) without statistical significance. These findings are consistent with previous studies indicating that chronic postoperative pain may be influenced by mesh-related foreign-body reaction, fibrosis, nerve irritation, and fixation techniques [8,18,19]. Szopiński et al. defined chronic pain as persisting for ≥6 months, considering the prolonged inflammatory response associated with synthetic mesh [8]. Other comparative studies have also reported no significant long-term pain differences between mesh and non-mesh repairs [20].
In the present study, the mean duration of hernia disease was slightly longer in the non-mesh group (7.8 ± 5.0 years) than in the mesh group (6.5 ± 5.0 years), although the difference was not statistically significant (p=0.202), indicating comparable disease duration. The mean operative duration was also similar, although a statistically significant difference was observed (49.5 ± 5.6 vs. 48.9 ± 5.2 minutes; p=0.014). The relatively small difference in operative time may have limited clinical relevance.
Mesh repair was associated with a significantly shorter hospital stay (3.4 ± 0.8 vs. 4.2 ± 1.0 days; p<0.001). This finding is consistent with Sinha et al., who reported significantly shorter hospitalization following mesh repair (3.8 vs. 5.4 days; p=0.003) [13]. However, Elsebae et al. reported prolonged hospitalization in some mesh patients because of wound infection and medical complications, suggesting that postoperative morbidity and patient-related factors can influence hospital stay [21].
Interestingly, patients undergoing non-mesh repair returned to work significantly earlier (9.88 ± 3.95 vs. 11.55 ± 3.25 days; p<0.001). This contrasts with the meta-analysis by Lockhart et al., which found that mesh repair was associated with earlier return to activities of daily living by approximately 2.87 days, although substantial heterogeneity was noted [4]. Situma et al. found no significant difference between Desarda and modified Bassini repairs regarding pain or resumption of normal activities [22]. Furthermore, laparoscopic approaches such as TAPP and TEP have demonstrated faster return to work compared with Lichtenstein repair [23]. Overall, the present findings suggest that mesh repair may facilitate earlier discharge, whereas non-mesh repair may allow earlier occupational recovery in this cohort.
In the present study, no recurrence was observed in either the non-mesh or mesh repair group during the follow-up period, with 0 (0.0%) cases in each group. Thus, both techniques demonstrated comparable recurrence outcomes in this cohort. Similar findings were reported by Mitura and Roman-czuk, who observed no recurrence at 6 months and comparable pain scores between mesh and non-mesh repairs [84]. Situma et al. also found no significant difference between non-mesh and mesh techniques regarding pain and functional recovery [22].
However, these findings should be interpreted cautiously because recurrence may become apparent only after longer follow-up. Evidence from larger comparative studies and meta-analyses generally favors mesh repair for reducing recurrence. Four meta-analyses reported significantly lower recurrence with mesh repair, with odds ratios as low as 0.26 (95% CI: 0.25–0.28; p<0.0001) and risk ratios of 0.46 (95% CI: 0.26–0.80; p=0.006) [4,24,25]. Conversely, another meta-analysis found no significant difference between open mesh and non-mesh repairs (RD=0.00; 95% CI: −0.01 to 0.01; p=0.93) [24]. Registry-based studies have also demonstrated a significantly lower risk of recurrence and reoperation following mesh repair [26]. Therefore, although the present study found no recurrence in either group, the relatively small sample and limited follow-up may explain the absence of observed recurrence and do not necessarily establish equivalence between the two techniques.
The present study highlights several limitations, including a prospective observational design without randomization, potentially leading to selection bias due to patient and surgeon factors. Additionally, the small sample size of 100 patients may limit statistical power and the generalizability of the results. Furthermore, the short follow-up period may inadequately reflect long-term outcomes such as chronic postoperative pain and hernia recurrence, which typically manifest years later. Previous meta-analyses stress the necessity of long-term follow-up in assessing outcomes related to mesh and non-mesh repairs. In clinical practice, older patients with direct hernias generally require mesh repair for effective treatment, while younger patients with good muscle tone can be treated adequately with herniorrhaphy.
Conclusion
The present prospective observational study comparing mesh and non-mesh repair of inguinal hernia demonstrated that both techniques provided satisfactory postoperative outcomes. The two groups were comparable with respect to age, gender, anthropometric characteristics, and hernia laterality, minimizing baseline differences between the groups. Mesh repair was associated with a significantly shorter hospital stay, whereas non-mesh repair resulted in significantly earlier return to work. Early and late postoperative pain were significantly more frequent following non-mesh repair, while chronic pain was numerically higher after mesh repair but did not differ significantly. Seroma and hematoma occurred significantly more frequently in the mesh group, whereas wound infection and orchitis showed no significant differences. Importantly, no recurrence was observed in either group during the study follow-up. Overall, mesh repair appeared advantageous for reducing early postoperative pain and hospital stay, while non-mesh repair offered earlier functional recovery. The choice of repair should therefore be individualized based on patient characteristics, surgeon expertise, and expected postoperative outcomes.
Declaration
Acknowledgements
None
Conflict of interest
All authors have no conflict of interest to declare.
Funding/ financial support
No external funding was received.
Contributors
All authors have equal contribution.
Ethical Clearance
Taken from the ethical committee.