A comparison of hernia sac ligation versus invagination in Lichtenstein tension-free mesh hernioplasty: does the type of hernia play a role in outcomes?

Background Management of the indirect hernial sac in inguinal hernia repairs has long been a subject of debate among general surgeons. Although hernial sac high ligation (HL) is a time-honored concept in groin hernia surgery, non-ligation/ invagination is gaining popularity. This study was intended to compare the effects of hernia sac ligation and invagination in patients undergoing Lichtenstein mesh hernioplasty (LMH). Another aim was to investigate the possible association between the hernial defect size and postoperative early pain in both groups. Methods Patients with indirect inguinal hernia undergoing elective LMH under spinal anesthesia were included in this prospective randomized study. Patients were classified according to European Hernia Society (EHS) criteria and were randomized into two groups, HL and non-HL/invagination. Postoperative pain levels at 6, 12, and 24 h, 7 days, and 1 year were compared using a ten-point visual analog scale (VAS). In addition, recurrence was examined in the postoperative first year. Postoperative complications, length of hospital stay, drain use, and surgery times were evaluated as secondary outcomes. This study was registered at www.clinicaltrials.gov. (The clinicaltrials.gov ID number is: NCT05308251). Results Ninety-three out of a total of 108 patients were included in the study between January 2020 and January 2021 (HL group n = 44, non-HL group n = 49). Demographic characteristics were comparable between the groups. Mean VAS scores were significantly higher in the HL group at 6 and 12 h postoperatively (p < 0.05 and p = 0.036 respectively). While there was no difference in pain levels between the groups in EHS 1 and EHS 2 hernias (p> 0.05 for all), VAS scores were significantly higher in the ligation group in EHS 3 hernias (p < 0.05 for all). Recurrence and complication rates were unaffected with non-ligation at a median 18 months follow-up. Conclusion Hernia sac invagination was superior to ligation in patients who underwent LMH, as it reduced early postoperative pain levels without disturbing repair integrity. We therefore recommend that ligating the hernial sac be avoided, especially in EHS 3 patients who undergo LMH.