Research Spotlight: An Alternative Approach to the Lichtenstein Repair for Hernia Results in Improved Patient Quality of Life and Less Opioid Use Post Surgery

Divyansh Agarwal, MD, a physician-scientist in the Department of Surgery at Massachusetts General Hospital and Michael Reinhorn, MD, a physician-scientist in the Department of Surgery at Newton-Wellesley Hospital are co-authors of a new study published in the journal Hernia, Improved patient-reported outcomes after open preperitoneal inguinal hernia repair compared to anterior Lichtenstein repair: 10-year ACHQC analysis

What was the question you set out to answer with this study?

The Lichtenstein repair is one of the most popular techniques for repair of inguinal hernias and has been synonymous with “open” inguinal hernia repair (IHR) for 40 years.

However, international guidelines have suggested that an alternative approach, posterior mesh placement, results in advantageous biomechanics and reduced risk of nerve-related chronic pain.

Additionally, the use of local anesthetics has been shown to reduce postoperative pain and complication risks.

An open trans-rectus pre-peritoneal/open pre-peritoneal (TREPP/OPP) repair combines posterior mesh placement with the use of local anesthetic and as such could be the ideal repair for primary inguinal hernia.

Using the Abdominal Core Health Quality Collaborative (ACHQC) registry, we compared open anterior mesh (the Lichtenstein repair) with open posterior mesh repairs (TREPP/OPP0 to assess patient quality of life, hernia recurrence and postoperative opioid use.

What Methods or Approach Did You Use?

We performed a propensity score matched analysis of patients undergoing open IHR between 2012 and 2022 in the ACHQC. After 1:1 optimal matching, both the TREPP/OPP and Lichtenstein cohorts were balanced with 451 participants in each group.

What Did You Find?

• Improvement was seen after TREPP/OPP in EuraHS QoL score at 30 days (OR 0.558 [0.408, 0.761]; p=0.001), and the difference persisted at 1 year (OR 0.588 [0.346, 0.994]; p=0.047).
• Patient-reported opioid use at 30-day follow up was significantly lower in the TREPP/OPP cohort (OR 0.31 [0.20, 0.48]; p<0.001).
• 30-day frequency of surgical-site occurrences was significantly higher in the Lichtenstein repair cohort (OR 0.22 [0.06–0.61]; p =0.007).
• There were no statistically significant differences in hernia recurrence risk at 1 year, or rates of postoperative bleeding, peripheral nerve injury, DVTs, or UTIs

What are the Implications?

Our analysis demonstrates a benefit of posterior mesh placement (TREPP/OPP) over anterior mesh placement (Lichtenstein) in open inguinal hernia repair in patient-reported quality of life and reduced opioid use.

What are the Next Steps?

From the research perspective, we want to compare TREPP to Shouldice repair, considered the gold standard for the prosthesis-free treatment of inguinal hernias, and to create a teaching atlas that can help more surgeons learn the TREPP/OPP repair technique.

We are hoping to use our data and publications to educate the next generation of surgeons on a better alternative to inguinal hernia repair with the ultimate goal of eliminating chronic postoperative inguinal pain.

About the Massachusetts General Hospital

Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The Mass General Research Institute conducts the largest hospital-based research program in the nation, with annual research operations of more than $1 billion and comprises more than 9,500 researchers working across more than 30 institutes, centers and departments. In July 2022, Mass General was named #8 in the U.S. News & World Report list of "America’s Best Hospitals." MGH is a founding member of the Mass General Brigham healthcare system.