Comparative Evaluation of Shouldice and Lichtenstein Methods of Inguinal Canal Plastic Surgery

The dissertation is devoted to a comparative evaluation of two principal methods of inguinal canal plastic surgery — Shouldice and Lichtenstein — in the treatment of inguinal hernias. The investigation aims to determine the most rational surgical method based on a comparative analysis of distant outcomes, including recurrence rates, sexual function status, patients' quality of life in the postoperative period, and the development of chronic neuropathy. The influence of endoprostheses used during hernioplasty on patients' fertility and copulative function has been examined, and an analysis of the causes of recurrences has been conducted. The obtained data have practical significance for selecting the optimal method of inguinal canal plastic surgery in clinical practice.

Relevance of the Problem

Surgical treatment of anterior abdominal wall hernias is a relevant problem of abdominal surgery. More than 20 million hernia operations are performed worldwide annually, accounting for 10 to 15% of all surgical interventions overall [Zhebrovskiy V.V., 1995; Ordyan S.Dj., 2005]. Patients with inguinal hernias constitute up to 80% of the total number of patients with ventral hernas operated in general surgical hospitals [Timoshin A.D., 2003]. Every 3rd to 5th inhabitant of the Earth is a potential hernia carrier [Sakhautdinov V.G., 2002].

The relevance and complexity of the problem lies in the fact that, despite the enormous number of methods of inguinal canal plastic surgery for inguinal hernias (over 300), recurrences are observed in 10–30% of primary inguinal hernias [Myasnikov A.D., 2000; Kuzin N.M., 2002; Bekoyev V.D., 2003; Liem M.S.L., 1997]. Especially large is the number of recurrences in so-called complex forms of inguinal hernias: sliding, combined, extensive and giant, recurrent and repeatedly recurrent. Here the number of recurrences amounts to 40–50% [Saenko V.F., 2002; Slavin L.I., 2005; Korenkov M., 2002]. Only in isolated clinics specializing in hernia surgery is the recurrence rate reduced to a minimum (1–2%) [Zhebrovskiy V.V., 1995; Deryugina M.S., 1998; Shulutko A.M., 2003; Bendavid R.H., 2001], whereas more than 90% of all herniotomies are performed and, apparently, will always be performed in general surgical hospitals.

Approximately 90% of recurrences occur within one year after surgery and 10% at later dates [Nesterko Yu.A., 2005]. Hernia recurrence impairs the work capacity of patients engaged in physical labor and increases the risk of organ incarceration in the abdominal cavity. Identifying the causes of disease recurrence and, consequently, selecting the surgical method depending on the degree of inguinal canal destruction is extremely relevant both in terms of public health and economic considerations.

Unsatisfactory results of treatment of inguinal hernias by "tension" methods served as the reason for the development and introduction into practice of various methods of inguinal canal plastic surgery, among which the Lichtenstein method stands out, consisting in prosthesis of the posterior wall of the inguinal canal with polypropylene mesh using the traditional inguinal approach to the inguinal canal. The results of the application of the specified hernioplasty demonstrated a low percentage of postoperative complications (1–2% recurrences).

At present, surgeons have not abandoned tension methods of inguinal canal plastic surgery, among which the Shouldice method, consisting in multilayer plastic surgery of the inguinal canal using duplication of the transversalis fascia, has gained wide distribution.

The distant results of treatment of patients with inguinal hernias by the Shouldice method are comparable to the results after Lichtenstein plastic surgery [Saybullaev S.A., 2000; Nesterko Yu.A., 2004; Mc.Gillicuddy J.E., 1998; Bendavid R.H., 2001].

At the same time, the introduction of inguinal canal plastic surgery methods by Lichtenstein and Shouldice into surgical hospitals leaves a whole range of questions open regarding their application. Clear indications and contraindications for the application of these techniques have not been established. Despite a large number of works devoted to Lichtenstein plastic surgery, the question of the possibility of its use as the procedure of choice for all forms of inguinal hernias in adults remains unresolved. The questions of the influence of surgical intervention by Lichtenstein and Shouldice methods on patients' quality of life in the postoperative period have not been studied. This question is considered important at least because a significant number of inguinal hernia carriers are elderly and senile patients, and questions of their rehabilitation in the postoperative period acquire special significance.

The influence of the inguinal canal plastic surgery method on patients' sexual function has been insufficiently studied, which is relevant given the large number of childless marriages — up to 15%, including 30–60% due to male infertility [Kirillov Yu.B., 2006]. The presence of an inguinal hernia is a factor negatively affecting spermatogenesis and the functional state of the testicle, but even greater harm is caused by herniotomy. The situation is further aggravated by the fact that prolonged obstruction of the vas deferens, whether due to ligation or transection, as well as due to the inflammatory-scarring process around the duct, leads to impaired testicular function not only on the affected side but also contralaterally [Stekhun F.I., 1987]. Concern about the fate of the spermatic cord in connection with its possible involvement in the scarring process caused by the mesh implant placed in the inguinal canal is expressed by many authors. Some even propose relocating the spermatic cord into the subcutaneous tissue with the aim of excluding its contact with the polypropylene prosthesis [Gvenetadze T.K., 2003; Demidov D.G., 2003]. Thus, the question of the application of Lichtenstein plastic surgery in young men remains unresolved. In connection with this, the present investigation was conducted.

Goal of the Investigation

Determination of the most rational type of plastic surgery based on a comparative evaluation of the distant results of inguinal canal plastic surgery by Lichtenstein and Shouldice methods.

To achieve this goal, the following tasks were set.

Tasks of the Investigation

1. To study the distant results of surgical treatment in groups of patients who underwent inguinal canal plastic surgery by Lichtenstein and Shouldice methods.

2. To study the influence of operative treatment of inguinal hernias by Lichtenstein and Shouldice methods on patients' quality of life.

3. To study the sexual function status of patients after hernioplasty by Lichtenstein and Shouldice.

Scientific Novelty

When studying the distant results in patients after herniotomy by Lichtenstein and Shouldice, the quality of life of patients in the postoperative period was studied for the first time using the SF-36 scale, which is distinguished by a significant degree of universality.

The importance of the quality of life question in terms of rehabilitation of patients after operative treatment of inguinal hernias has been demonstrated.

Attention has been devoted to the question of chronic neuropathy in the postoperative period.

The sexual function status of patients after operative treatment by Lichtenstein and Shouldice has been studied, and in this connection the influence of the implant used in Lichtenstein plastic surgery on the state of fertility and copulative function of patients has been investigated. An analysis of the causes of inguinal hernia recurrences has been conducted.

Practical Significance

When comparing inguinal canal plastic surgery methods by Lichtenstein and Shouldice, it has been shown that the most rational method is Lichtenstein, since it allows avoiding hernia recurrence, and the prosthesis used does not affect the sexual function status of patients. At the same time, it has been established that patients' quality of life is higher with Lichtenstein plastic surgery.

Work Validation

The main results of the work were reported and discussed at the Scientific-Practical Conference of Physicians of Russia in Tver on December 20, 2006, at the 239th Meeting of Outpatient Surgeons of Moscow on May 24, 2007, and at the Joint Meeting of the Surgical Clinic of City Clinical Hospital No. 64 of Moscow and the Department of Faculty Surgery of Peoples' Friendship University of Russia on June 28, 2007. Five printed works on the dissertation topic have been published, including one in a publication included in the Higher Attestation Commission list.

Implementation and Introduction of Results

The results of the investigation and developments have been introduced into the practical activities of the surgical departments of City Clinical Hospital No. 64 of Moscow, and are also used in teaching fourth-year students at the Department of Faculty Surgery of Peoples' Friendship University of Russia.

Structure and Volume of the Dissertation

The dissertation is presented on 98 pages of typed text and consists of an introduction, 3 chapters, conclusion, conclusions, practical recommendations. The bibliography contains 181 titles, including 83 works by foreign authors. The text is illustrated with 10 tables, 16 diagrams, and 2 microf photographs.