Predictive factors of recurrence and chronic pain in inguinal hernia repair in a tertiary multicenter study: Lichtenstein versus transabdominal preperitoneal versus totallyextraperitoneal approach

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Published Mar 10, 2026
https://doi.org/10.62438/tunismed.v104i01.6006
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Vol. 104 No. 01 (2026): Tunis Med Jan 2026

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Mohamed Ali Chaouch
Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
Mohamed Zayati
Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
Ahmed Saidani
Department of Visceral and Digestive Surgery, Ariana Hospital, Ariana, Tunisia
Ahmed Hadj Taieb
Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
Mohamed Noomen
Department of Anesthesia, Monastir University Hospital, Monastir, Tunisia
Sadok Ben Jabra
Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
Ramzi Ben Letaifa
Department of Anesthesia, Monastir University Hospital, Monastir, Tunisia
Amine Ben Slimane
Department of Anesthesia, Monastir University Hospital, Monastir, Tunisia
Ibtissem Korbi
Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
Besma Gafsi
Department of Anesthesia, Monastir University Hospital, Monastir, Tunisia
Faouzi Ben Salem
Department of Anesthesia, Monastir University Hospital, Monastir, Tunisia
Faouzi Chebbi
Department of Visceral and Digestive Surgery, Ariana Hospital, Ariana, Tunisia
Faouzi Noomen
Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia

Abstract

Objective: To compare the postoperative outcomes of inguinal hernia repair using Lichtenstein, transabdominal preperitoneal(TAPP), and totallyextraperitoneal (TEP) techniques, focusing on the incidence and predictive factors of recurrence and chronic postoperative pain.


Methods: This cohort study included patients operated on for inguinal hernia at Monastir and Ariana University Hospitals between January 2020 and November 2023. The primary outcomes measured were postoperative morbidity and its risk factors, with secondary endpoints including chronic pain and recurrence. Data were analyzed using Pearson's chi² test, Student's t-test, Mann-Whitney test, and multivariate analysis.


Results: This cohort study included 308 patients. The patientswere divided into three groups: Lichtenstein (n=124), TAPP (n=117), and TEP (n=67). The Lichtenstein patients were older (52.02±11.11 years) and had a higher BMI (26.45±3.60 kg/m²) compared to TAPP (48.02±15.62 years, 20.89±5.1 kg/m²), and TEP (46.19±13.52 years, 20.11±2.13 kg/m²). Lichtenstein had the highest morbidity (12.09%) compared to TAPP (8.54%) and TEP (7.46%). Grade II and III complications were significantly more frequent in the Lichtenstein group. Recurrence was higher in the Lichtenstein group (8.06%) compared to TAPP (3.41%) and TEP (2.98%). Chronic pain was more common in Lichtenstein (9.67%) compared to TAPP (1.70%) and TEP (0%). For predictive factors, age >50 years (OR=1.7), BMI >30 kg/m² (OR=1.9), and comorbidities (OR=1.8) were significant predictors of recurrence.  The Lichtenstein technique (OR=5.5), wound complications (OR = 3.2), and smoking (OR=2.0) were key predictors of chronic pain.


Conclusions:In this retrospective study, statistically significant differences were observed between groups: the Lichtenstein ....( abstract truncated at 250 words)

Keywords:

inguinal hernia repair , Lichtenstein procedure, TEP, TAPP, chronic pain, morbidity, recurrence

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References

  1. Aydin M, Fikatas P, Denecke C, Pratschke J, Raakow J. Cost analysis of inguinal hernia repair: the influence of clinical and hernia-specific factors. Hernia. 2021 Oct;25(5):1129–35.
  2. Ghariani W, Dougaz W, Jerraya H, Khalfallah M, Bouasker I, Dziri C. Revue systématique the Recurrence Factors of Groin Hernia: a systematic Review Les facteurs de récidive des hernies de l’aine et leur traitement: une revue systématique. Tunis Médicale. 2019 Dec 23;97:03.
  3. Boudokhane M, Fodha M, Abdekefi MT, Nacef K, Majdoub N, Affes A, et al. Lichtenstein versus Lichtenstein plus Plug dans les cures prothétiques des hernies inguinales : Résultats préliminaires d’une étude contrôlée prospective randomisée. Tunis Med. 2011;90.
  4. Samaali I, Zenaidi HH, Dougaz W, Khalfallah M, Jarraya H, Nouira R, et al. traitement des hernies inguinales par la technique de lichtenstein : une étude prospective ouverte treatment of inguinal hernia by lichtenstein technique: an open prospective study. Tunis Med. 2016;94.
  5. Amid P. The Lichtenstein repair in 2002: an overview of causes of recurrence after Lichtenstein tension-free hernioplasty. Hernia. 2003;7:13–6.
  6. Schultz LS, Cartuill J, Graber JN, Hickok DF. Transabdominal Preperitoneal Procedure. Surg Innov. 1994 Jun 1;1(2):98–105.
  7. Putnis S, Berney CR. Totally extraperitoneal repair of inguinal hernia: techniques and pitfalls of a challenging procedure. Langenbecks Arch Surg. 2012 Dec 1;397(8):1343–51.
  8. Aiolfi A, Cavalli M, Del Ferraro S, Manfredini L, Bonitta G, Bruni PG, et al. Treatment of inguinal hernia: systematic review and updated network meta-analysis of randomized controlled trials. Ann Surg. 2021;274(6):954–61.
  9. Yang C, Deng S. Laparoscopic versus open mesh repair for the treatment of recurrent inguinal hernia: a systematic review and meta-analysis. Ann Palliat Med. 2020;9(3):1164173–1161173.
  10. Huang FH, Cheng PL, Hou WH, Duh YC. Laparoscopic hernia repair with the extraperitoneal approach versus open hernia repair in pediatric inguinal hernia: a systematic review and meta-analysis. J Clin Med. 2022;11(2):321.
  11. Haladu N, Alabi A, Brazzelli M, Imamura M, Ahmed I, Ramsay G, et al. Open versus laparoscopic repair of inguinal hernia: an overview of systematic reviews of randomised controlled trials. Surg Endosc. 2022 Jul;36(7):4685–700.
  12. Bande D, Moltó L, Pereira JA, Montes A. Chronic pain after groin hernia repair: pain characteristics and impact on quality of life. BMC Surg. 2020 Dec;20(1):147.
  13. Olsson A, Sandblom G, Franneby U, Sondén A, Gunnarsson U, Dahlstrand U. Do postoperative complications correlate to chronic pain following inguinal hernia repair? A prospective cohort study from the Swedish Hernia Register. Hernia. 2021 Dec 11;27(1):21–9.
  14. Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, et al. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). pain. 2019;160(1):19–27.
  15. Jenkins JT, O’Dwyer PJ. Inguinal hernias. BMJ. 2008 Jan 31;336(7638):269–72.
  16. Köckerling F, Simons MP. Current concepts of inguinal hernia repair. Visc Med. 2018;34(2):145–50.
  17. Schmedt CG, Sauerland S, Bittner R. Comparison of endoscopic procedures vs Lichtenstein and other open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Surg Endosc Interv Tech. 2005 Feb 1;19(2):188–99.
  18. Forte A, D’Urso A, Palumbo P, Lo Storto G, Gallinaro LS, Bezzi M, et al. Inguinal hernioplasty: the gold standard of hernia repair. Hernia. 2003 Mar 1;7(1):35–8.
  19. Kozol R, Lange PM, Kosir M, Beleski K, Mason K, Tennenberg S, et al. A Prospective, Randomized Study of Open vs Laparoscopic Inguinal Hernia Repair: An Assessment of Postoperative Pain. Arch Surg. 1997 Mar 1;132(3):292–5.
  20. Liem MSL, van Duyn EB, van der Graaf Y, van Vroonhoven TJMV, Group on behalf of the CT. Recurrences After Conventional Anterior and Laparoscopic Inguinal Hernia Repair: A Randomized Comparison. Ann Surg. 2003 Jan;237(1):136.
  21. Memon MA, Cooper NJ, Memon B, Memon MI, Abrams KR. Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair. Br J Surg. 2003 Dec 1;90(12):1479–92.
  22. Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R, Dunlop D, Gibbs J, et al. Open Mesh versus Laparoscopic Mesh Repair of Inguinal Hernia. N Engl J Med. 2004 Apr 29;350(18):1819–27.
  23. Pokorny H, Bischof G. Open mesh versus laparoscopic mesh repair of inguinal hernia. Eur Surg. 2004 Sep 1;36(4):262–3.
  24. de Geus SWL, Geary AD, Arinze N, Ng SC, Carter CO, Sachs TE, et al. Resident involvement in minimally-invasive vs. open procedures. Am J Surg. 2020 Feb;219(2):289–94.
  25. Gignoux B, Bayon Y, Martin D, Phan R, Augusto V, Darnis B, et al. Incidence and risk factors for incisional hernia and recurrence: Retrospective analysis of the French national database. Colorectal Dis. 2021;23(6):1515–23.
  26. Köckerling F, Koch A, Lorenz R, Schug-Pass C, Stechemesser B, Reinpold W. How Long Do We Need to Follow-Up Our Hernia Patients to Find the Real Recurrence Rate? Front Surg [Internet]. 2015 Jun 16 [cited 2024 Nov 3];2. Available from: https://www.frontiersin.org/journals/surgery/articles/10.3389/fsurg.2015.00024/full
  27. Andresen K, Bisgaard T, Rosenberg J. Sliding inguinal hernia is a risk factor for recurrence. Langenbecks Arch Surg. 2015 Jan;400(1):101–6.
  28. Matthews RD, Anthony T, Kim LT, Wang J, Fitzgibbons RJ, Giobbie-Hurder A, et al. Factors associated with postoperative complications and hernia recurrence for patients undergoing inguinal hernia repair: a report from the VA Cooperative Hernia Study Group. Am J Surg. 2007 Nov 1;194(5):611–7.
  29. Bay-Nielsen M, Perkins FM, Kehlet and H. Pain and Functional Impairment 1 Year After Inguinal Herniorrhaphy: A Nationwide Questionnaire Study. Ann Surg. 2001 Jan;233(1):1.
  30. Poobalan AS, Bruce J, Smith WCS, King PM, Krukowski ZH, Chambers WA. A Review of Chronic Pain After Inguinal Herniorrhaphy. Clin J Pain. 2003 Feb;19(1):48.
  31. Nienhuijs S, Staal E, Strobbe L, Rosman C, Groenewoud H, Bleichrodt R. Chronic pain after mesh repair of inguinal hernia: a systematic review. Am J Surg. 2007 Sep 1;194(3):394–400.
  32. Konschake M, Zwierzina M, Moriggl B, Függer R, Mayer F, Brunner W, et al. The inguinal region revisited: the surgical point of view. Hernia. 2020 Aug 1;24(4):883–94.
  33. Tinelli A. Laparoscopic entry: Traditional methods, new insights and novel approaches [Internet]. Springer Science & Business Media; 2011 [cited 2024 Nov 4]. Available from: https://books.google.com/books?hl=fr&lr=&id=hnEdMJIkHQQC&oi=fnd&pg=PR3&dq=,+the+laparoscopic+approach+places+the+mesh+within+the+preperitoneal+space,+away+from+these+superficial+nerves,+reducing+direct+contact+with+and+potential+injury+to+these+&ots=eD5YGHEnwy&sig=AYcc_rTE94pU7TSuCp0Q6LLcrzc
  34. Kokotovic D, Burcharth J, Helgstrand F, Gögenur I. Systemic inflammatory response after hernia repair: a systematic review. Langenbecks Arch Surg. 2017 Nov 1;402(7):1023–37.
  35. Mundal I, Gråwe RW, Bjørngaard JH, Linaker OM, Fors EA. Prevalence and long-term predictors of persistent chronic widespread pain in the general population in an 11-year prospective study: the HUNT study. BMC Musculoskelet Disord. 2014 Jun 20;15(1):213.
  36. Elliott AM, Smith BH, Hannaford PC, Smith WC, Chambers WA. The course of chronic pain in the community: results of a 4-year follow-up study. PAIN. 2002 Sep 1;99(1):299–307.
  37. Alfieri S, Amid PK, Campanelli G, Izard G, Kehlet H, Wijsmuller AR, et al. International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia J Hernias Abdom Wall Surg. 2011 Jun;15(3):239–49.
  38. Dahlstrand U, Sandblom G, Nordin P, Wollert S, Gunnarsson U. Chronic pain after femoral hernia repair: a cross-sectional study. Ann Surg. 2011 Dec;254(6):1017–21.
  39. Saad CA, Kim DS, Solnik MJ, Towfigh S. Inguinal Hernia as a Cause of Chronic Pelvic Pain: A Key Sign to Make the Diagnosis: [215]. Obstet Gynecol. 2015 May;125:70S.
  40. Tabbara M, Genser L, Bossi M, Barat M, Polliand C, Carandina S, et al. Inguinal Hernia Repair Using Self-adhering Sutureless Mesh: AdhesixTM: A 3-Year Follow-up with Low Chronic Pain and Recurrence Rate. Am Surg. 2016 Feb;82(2):112–6.
  41. Teng YJ, Pan SM, Liu YL, Yang KH, Zhang YC, Tian JH, et al. A meta-analysis of randomized controlled trials of fixation versus nonfixation of mesh in laparoscopic total extraperitoneal inguinal hernia repair. Surg Endosc. 2011 Sep 1;25(9):2849–58.