The Modified Iliopubic Tract Repair—A Pain-Free Alternative

Background  The open preperitoneal repair offers the benefits of placing the mesh in the preferred position while avoiding the disadvantages of laparoscopic repair. Methods  A total of 60 patients with bilateral inguinal hernias were randomized to undergo either the standard Lichtenstein meshplasty or the modified iliopubic tract repair in a teaching hospital. Outcomes measured were immediate postoperative pain, return to activity, and delayed neurological complications. Results  Patients who underwent the iliopubic tract repair walked out of bed faster than the Lichtenstein group (6.3 hours vs 7.4 hours, p  < 0.0001) and experienced significant lower pain as charted by visual analogue scale scores (3.28 vs 2.71 on day 1, 2.16 vs 1.71 on day 2, 1.92 vs 1.08 on day 3; p  < 0.05). Delayed complications like chronic inguinal pain and numbness were not seen in the iliopubic tract group. However, this difference was not statistically significant ( p  > 0.05). Conclusion  The iliopubic tract repair offers an excellent alternative to the Lichtenstein meshplasty, and is associated with lower postoperative pain, earlier return to work, and lower delayed neurological complications.

CONSORT criteria. The sample size was calculated using the formula: n ¼ z 2 x P(100-P)/d 2 Where: P was the anticipated prevalence d was the desired precision z was the appropriate value from the normal distribution for the desired confidence, which was 95% in our study (z ¼ 1.960).
Demographic details of all patients were recorded. Patients between ages 18 and 80, with bilateral uncomplicated inguinal hernias, were randomized into two groups: one undergoing the Lichtenstein meshplasty, and the other, the modified iliopubic tract repair. Patients with unilateral, complicated, congenital, and recurrent hernias were excluded from the study (►Table 1) Institute Ethics Committee clearance was obtained prior to initiation of the study. Informed consent was obtained from all patients after explaining the nature of the study, and the advantages and disadvantages associated with both procedures.
All the patients in the study were operated upon by the same team of surgeons comprising experienced consultants, as well as surgery residents.
Both groups received inj. cefotaxime 1 g intravenously (IV) at the time of induction of anesthesia as per our institute protocol.
Patients in Group A underwent the standard Lichtenstein meshplasty repair as described in literature. A 3"x 6" lightweight Prolene mesh was fixed over the posterior wall of the inguinal canal using interrupted Prolene sutures, and the procedure repeated on the opposite side after repair of one side.
Patients in Group B underwent the modified iliopubic tract repair, wherein the preperitoneal space was accessed using a lower midline incision, extending from below the umbilicus to the pubic symphysis. The hernia sac was then identified. In case of indirect inguinal hernia, the sac was ligated and divided at the level of the deep ring, with the distal part of the sac remaining within the canal. In case of a direct hernia, the sac was inverted with a running pursestring suture. Repair was then done by approximating the arching fibers of the transversalis fascia superiorly to the iliopubic tract (►Fig. 1) inferiorly with interrupted Prolene sutures (►Fig. 2). A small mesh (3"x 6" lightweight Prolene mesh cut in half) was then sutured placed over the repair, and secured superiorly to the transversalis arch, and inferiorly to the pectineal ligament, thus eliminating possibility of future femoral hernias as well (►Fig. 3). The contralateral hernia was similarly repaired through the same incision. The incision was then closed in layers over a suction drain.
Both groups received inj. cefotaxime 1 g IV 12 hourly for 3 days as per institute protocol for antibiotic prophylaxis, and inj. paracetamol 1 g IV 8 hourly for analgesia postoperatively.
Main outcome assessed was postoperative pain, with time taken to walk out of bed, long-term pain, and numbness being secondary outcomes assessed.
Patients were assessed immediately postoperatively for pain. Pain was charted using the 10-point numerical visual analogue scale (VAS) every 8 hours until discharge. Time   The Modified Iliopubic Tract Repair Ali et al. e83 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
taken to walk out of bed was defined as the time taken for the patient to independently stand and walk out of bed. Patients were additionally followed up 3 monthly, for a period of up to 2 years. They were asked about inguinal pain and history of consuming analgesics. Patient were also subjected to a physical examination to assess numbness and paraesthesia. Follow-up examinations were conducted by a member of the team who was not the operating surgeon for the particular case to avoid bias.
Tabulated VAS scores were assessed for significance using the Mann-Whitney U test. Time taken to walk out of bed, and chronic pain was compared using the unpaired t-test. A p value less than 0.05 was considered statistically significant.

Results
All 60 (30 in Lichtenstein group, 30 in iliopubic tract group) patients completed the study. None were lost to follow-up (►Fig. 4).
Majority of the patients were in the 61 to 70 years bracket (Group A: 36.67%, Group B: 40%). The youngest patient in the study was 24 years old, while the oldest was 80 years old. Both groups were comparable, with no statistical difference in age (p value ¼ 0.49). All patients in the study were males.
Patients in the iliopubic tract repair group walked out of bed faster than those after Lichtenstein repair (6.33 AE 0.488 hours vs 7.4 AE 0.85 hours). This difference was significant at 95% confidence interval (p < 0.0001) (►Table 2).
Patients in the Lichtenstein group had higher VAS pain scores postoperatively compared with the iliopubic tract repair group up to the third post-op day (p < 0.05). Difference in pain was not significant on days 4 and 5 (p > 0.05) (►Fig. 5)  More patients in the Lichtenstein repair group experienced delayed complications (numbness, chronic pain) as compared with the iliopubic tract repair group. However, this difference was statistically insignificant (p > 0.05) (►Table 3).

Discussion
The ideal method of hernia repair would cause minimal discomfort to the patient, both during the surgical procedure and in the postoperative course. It would be technically simple to perform, and easy to learn, would have a low rate of complications and recurrence, and would require only a short period of convalescence.
Most modern studies compare the standard Lichtenstein meshplasty to laparoscopic techniques, and few directly compare it to open preperitoneal methods. This makes it difficult to assess the impact of the posterior approach itself in the surgical outcome, factoring in the minimal trauma caused by laparoscopic methods. The present study design makes it possible to directly study the role of the posterior approach alone in outcome of hernia repair by comparing it to the current gold standard.
The results can vary widely among different centers, and the results from specialized centers are often good. For example, very low recurrence rates have been reported from the Shouldice Hospital using their eponymous technique, even <1%, 3 with some authors suggesting it be used as a gold standard when evaluating new herniorrhaphy techniques. 4 However, there exists a steep learning curve for the technique, 5 which has resulted in other centers failing to reproduce the Shouldice Hospital's stellar recurrence rates. 6 Our study was conducted in a general surgical teaching center, which far better mimics clinical reality.
The Nyhus repair is considered the standard open preperitoneal repair. Our study focused on our modification of the same, tailored specifically to bilateral inguinal hernias. This choice was also relevant as it considered the cost of the repair, which is sensitive in a developing country like ours.
The iliopubic tract repair showed significantly shorter time taken to walk out of bed among patients as compared with the Lichtenstein meshplasty (6.33 hours vs 7.4 hours). Multiple studies also demonstrated the same, clearly giving the open preperitoneal approach the advantage. [7][8][9][10][11] Lower pain in the iliopubic tract group might probably explain the same.
The most significant advantage for the iliopubic tract group was in terms of postoperative pain. Mean VAS scores for the iliopubic tract repair group following surgery were significant lower than those for the Lichtenstein group in the immediate postoperative period, until the third postoperative day (3.28 vs 2.71 on day 1, 2.16 vs 1.81 on day 2, 1.92 vs 1.08 on day 3). Mean VAS scores showed no statistical difference toward the end of day 4 and on day 5.
Postoperative pain following hernia repair has extensively been studied, and most reports show a distinct advantage with the posterior preperitoneal approach, as employed by the iliopubic tract repair. A meta-analysis of over 500 patients showed significantly higher pain following Lichtenstein repair as compared with preperitoneal repair. Late complications are a bane of hernia repair. Our study assessed patients for groin numbness, chronic pain, recurrence, and late infection at 3 monthly intervals for a maximum period of 2 years. Long-term pain was measured based on a history of analgesic use, and restriction of daily activities. While other indices are available, we found their application difficult with our patients, who mostly are illiterate and come from poor backgrounds. Late complications were encountered more in the Lichtenstein group, with five patients reporting numbness, one each reporting chronic groin pain and recurrence. None of the patients who underwent the iliopubic tract repair suffered any delayed complication. However, this was not statistically significant, and a more extensive study would be required to confirm statistical advantage.
Our findings, however, were in contrast to others, who have reported significantly higher rates of groin numbness and chronic inguinal pain among patients undergoing the Lichtenstein meshplasty as compared with preperitoneal repairs. It has been postulated that this may be due to the greater chances of nerve damage in the anterior approach employed by the Lichtenstein repair. 6-9,11-13 Modified iliopubic tract repair 6.33 The Modified Iliopubic Tract Repair Ali et al. e85