Inguinal hernias are among the most prevalent surgical conditions worldwide, accounting for over 75% of all abdominal wall hernias. They present a significant healthcare burden, with millions of surgical procedures performed annually. This condition disproportionately affects men, with a lifetime risk of 27% compared to 3% in women. ^[1] Despite advances in surgical techniques and technology, inguinal hernia repair remains a complex procedure requiring a nuanced understanding of anatomy, surgical skill, and patient-specific factors. ^[2]

The term "hernia" originates from the Greek word for bulge or budding, reflecting the condition's hallmark protrusion of a viscous or organ through a weak point in the abdominal wall. Groin hernias, encompassing inguinal and femoral hernias, occur predominantly in the inguinal region. ^[3] They are more common on the right side, and indirect hernias outnumber direct hernias. Various factors contribute to the formation of inguinal hernias, including aging, muscle weakness, chronic cough, obesity, and connective tissue disorders. These factors lead to defects in the myopectineal orifice of Fruchaud, a structurally weak area in the abdominal wall. ^[4]

Historically, hernia repair techniques have evolved significantly, transitioning from tension repairs like Bassini’s and Shouldice techniques to tension-free mesh-based repairs. The introduction of mesh by Lichtenstein in the 1980s revolutionized hernia surgery, offering a less invasive, tension-free solution with reduced recurrence rates. ^[5] Despite its widespread adoption as the gold standard, the Lichtenstein repair has limitations, including chronic post-operative inguinal pain (CPIP), seroma formation, and wound complications. These challenges have prompted the development and adoption of alternative techniques, such as the Open Pre-Peritoneal Approach (TREPP). ^[6]

The Open Pre-Peritoneal Approach (TREPP) represents a paradigm shift in hernia repair. By placing the prosthetic mesh in the pre-peritoneal space, this method minimizes nerve manipulation and exposure within the inguinal canal. ^[7] TREPP is particularly advantageous for recurrent hernias or cases with significant scarring from previous repairs. The technique's primary goal is to reduce complications such as CPIP and recurrence while maintaining the benefits of tension-free repair. ^[8]

This study aims to provide a comparative analysis of clinical outcomes between the TREPP and Lichtenstein techniques. While the Lichtenstein repair remains the cornerstone of hernia surgery, the TREPP approach offers an innovative alternative, particularly in complex or high-risk cases. ^[9] By examining post-operative pain, seroma formation, wound infection, and recurrence rates, this study seeks to determine whether TREPP can provide superior outcomes and potentially establish itself as a standard technique for inguinal hernia repair. ^[10]

This study also explores the historical development of hernia repair techniques and the rationale for the adoption of TREPP. The evolution of surgical methods reflects the ongoing pursuit of reduced morbidity, improved patient outcomes, and greater cost-effectiveness. ^[11] While laparoscopic techniques such as TEP (Total Extra-Peritoneal) and TAPP (Trans-Abdominal Pre-Peritoneal) have gained popularity, they require advanced instrumentation and training, making them less accessible in resource-limited settings. TREPP, by contrast, offers a cost-effective, technically feasible alternative with comparable outcomes. ^[12]

By comparing these two approaches, this study aims to address the clinical and practical considerations of inguinal hernia repair. The findings will provide valuable insights into the advantages and limitations of each technique, guiding surgeons in selecting the most appropriate method for their patients. The study also underscores the need for individualized patient care, considering factors such as age, comorbidities, and hernia characteristics in surgical decision-making.

A Prospective and comparative study was conducted in the Department of General Surgery, SDM College of Medical Sciences and Hospital, Dharwad over a period of 1 year.

Study Sample: 30 cases, divided into two groups by random allocation technique. Groups A and B with 15 patients in each group.

Inclusion criteria:

• Patients of all age groups above the growth period (<20 Years) with inguinal hernia.
• Irrespective of congenital, acquired, direct hernias, Unilateral or bilateral hernias, recurrent inguinal hernias.
• All the patients associated with or without co morbidities, like hypertension, diabetes etc. excluding chronic persistent cough.

Exclusion criteria:

• Patients in growth period (<20 Years).
• Patients with strangulated
• Patient with local
• Patients with obstructive

METHODOLOGY:

Patients who meet the inclusion criteria and willing to give written informed consent are subjected to clinical examination. Demographic data of the patients recorded in the proforma. After preliminary investigations and confirmation of diagnosis and pre-anesthetic check- up, the patients were subjected to the required surgery. These patients were grouped into 2 by Random Allocation Technique.

Group A patients were subjected to Trans rectus sheath pre-peritoneal approach (TREPP).

Group B patients were subjected to Transinguinal Lichtenstein approach.

All the patients were assessed for complications like post-operative pain evaluated using Visual Analogue Scale, seroma formation, wound infection and recurrence in immediate and regular post-operative periods. After discharge patients were asked to regularly follow up in OPD. At the end of the study, Observations in both the groups will be made.After discharge post operatively patients were assessed on 7th day, 1st, 3rd, 6th month.

STATISTICS

Data Entry was done using Microsoft excel 2013 and analysis done using SPSS V 22 version software. Qualitative data was expressed in frequencies and percentages and Quantitative data in mean and standard deviation. Non parametric statistics i.e. Chi-square test/ Fishers exact test was used to find the significant association between the two qualitative variables. Unpaired and paired t test and were used to find the statistical significance between quantitative variables. Graphical representation of data: MS Excel and MS word were used to obtain various types of graphs such as bar diagram and line diagram. p value (Probability that the result is true) of <0.05 was considered as statistically significant after assuming all the rules of statistical tests.

In the open pre peritoneal repair group, the mean age was 52.46 ± 12.29, in the Trans-inguinal Lichtenstein repair group it was 51.60 ± 15.94. There was no statistically significant association observed with relation to Age and Study groups as the p value calculated to be >0.05.

Table No 1: Age distribution comparison between two group

Table No 2: Gender distribution between two groups

Table No 3: Diagnosis comparison between two groups

In the present study, Left Direct inguinal hernia in 13.3% each in open preperitoneal repair group and Trans-inguinal Lichtenstein repair group. Right direct inguinal hernia were 20% of open preperitoneal repair group and 26.7% of Trans-inguinal Lichtenstein repair group. Left inguinal indirect hernia were 20% in open preperitoneal repair group and 26.7% of Trans-inguinal Lichtenstein repair group. Right inguinal indirect hernia were 46.7% in open preperitoneal repair group and 33.3% of Trans-inguinal Lichtenstein repair group.

Table No 4: Pain Severity Distribution in two groups of patients studied

In Lichtenstein group most of the patients had pain in range of 7-10 in POD 1 (66.6%) and in range of 4-6 in POD 2 (100%). However, though the number decreased by POD 7 still most (53.3%) of the patients reported pain in range of 1-3. However, in Open preperitoneal group though most of the patients had pain in range of 4-6 in POD 1 (86.6%) and POD 2 (73.3%). Pain showed significant decrease by POD 7 with most (66.6%) of the patients reported no pain and 33.3%reported pain in range of 1-3.

Table No 5: VAS Score comparison between two groups at different periods of follow-up

In the present study, Mean VAS score was significantly lower in open preperitoneal repair compared to Trans inguinal Lichtenstein repair group at post-operative day 1, day 2, day 7, 1st month, 3rd month as the p value calculated to be <0.05.

Table No 6: Chronic pain comparison between two groups at different periods of follow-up

At 3 months three patients in Lichtenstein group complained of groin pain at site of surgery. while no patient in open preperitoneal group had similar complaint. At 6 months after surgery one patient in Lichtenstein group and no patients in open preperitoneal group complained of groin pain which persisted despite using pain medications. The incidence of chronic groin pain in Lichtenstein group was 20% at 3 months and 6.6% at 6 months. The difference between the two groups is not statistically significant with incidence of chronic groin pain significantly high in Lichtenstein group with a P value of 0.09.

Table no 7: Seroma comparison between two groups at different periods of follow- up

Incidence of seroma at end of post op 7^th day was higher in Trans inguinal Lichtenstein repair group (33.3%) compared to Open pre peritoneal repair group (6.7%).

Table 8: Wound infection comparison between two groups at different periods of follow-up

Incidence of wound infection was observed in Trans- inguinal Lichtenstein repair group to be 20% by the end of 1st month.

Table No 9: Recurrence comparison between 2 groups at different periods of follow- up

There was only one case of recurrence in Transinguinal Lichtenstein group at 6 months. There were no recurrences in the open pre peritoneal repair group.

In Lichtenstein group most of the patients had pain in range of 7-10 in POD 1 (66.6%) and in range of 4-6 in POD 2 (100%). However, though the number decreased by POD 7 still most (53.3%) of the patients reported pain in range of 1-3. However, in Open preperitoneal group though most of the patients had pain in range of 4-6 in POD 1 (86.6%) and POD 2 (73.3%). Pain showed significant decrease by POD 7 with most (66.6%) of the patients reported no pain and 33.3%reported pain in range of 1-3. At the end of 1 month one patient (6.7%) in open preperitoneal group and four patients (26.6%) reported pain.

A study done by G.G.KONING et al in 2011 regarding the first 50 cases of TREPP - mean postoperative pain did not exceed a visual analog scale (VAS) Score of 4 (1–10 scale) in the first 14 days. Postoperative pain was controlled easily with paracetamol. [13] A study conducted by J. L. Faessen et al in 2020 regarding the efficacy and safety of TREPP - The reported post-operative pain at the follow-up control between 6 and 8 weeks was the highest in the Lichtenstein group (21.2%) compared with the TREPP (10.7%) and the TEP (13.8%) group, but did not significantly differ (P = 0.466). [14]

Chronic (postoperative) pain has been defined as pain lasting at least 2–3 months (after surgery), but modifications are proposed to this timeframe. [15] A group of experts in hernia surgery and chronic pain has suggested modifying the definition for chronic pain after hernia repair as pain lasting at least 6 months after operation. [16] The reason for this extended period of time is because the inflammation around the mesh is still ongoing after 3 months, and there is a chance that some patients will improve substantially from 3 to 6 months postoperatively.

In the present study, the difference between the two groups is not statistically significant with incidence of chronic groin pain significantly high in Lichtenstein group (20% at 3 months and 6.6% at 6 months). None of the patients who underwent TREPP had CPIP. A study done by G.G.KONING et al in 2011 regarding the first 50 cases of TREPP – none of the patients complained chronic pain. [17] A study done by J.F.M.Lange et al in 2014 regarding the 1st 1000 cases of TREPP - total of 49 patients reported experiencing CPIP (5.3 %). [18]

Seroma are a known postoperative occurrence after laparoscopic and open inguinal hernia repairs, especially in patients with large scrotal hernias. The Incidence varies between 0.5 and 12%. Park et al. suggest that a seroma should be considered a complication only if it persisted for more than six weeks, presents continuous growth, or becomes symptomatic. [19] A study conducted by Suryaram Aravind et al in 2018 compared Lichtenstein repair versus open preperitoneal repair - 2 (6.7%) patients had seroma in Lichtenstein repair whereas none of the patients in open preperitoneal repair had seroma. [20]

In present study, Incidence of seroma at end of post op 7th day was higher in Trans inguinal Lichtenstein repair group (33.3%) compared to Open pre peritoneal repair group (6.7%), which were managed conservatively. The incidence was high in the present study may be due to more tissue dissection and smaller sample size.

In present study, Incidence of wound infection in Trans- inguinal Lichtenstein repair group is 20% and none of patients in open preperitoneal repair (TREPP) had wound infection which was not statistically significant. But clinically Lichtenstein repair group had higher incidence. All three patients reported were superficial infections were managed with regular dressing and oral antibiotics. No cases of mesh infections were reported.

A study done by G.G.KONING et al in 2011 regarding the first 50 cases of TREPP – none of the patients had wound infection. [21] Study done by W.J.V William Bokkerink et al in 2020 – Surgical site infection in TREPP - 14 (3.6%) and in TIPP - 17 (4.3%) (p value 0.592). [22] Study done by J. L. Faessen et al in 2020 regarding the efficacy and safety of TREPP - Wound infection rates showed a significantly lower rate in favor of TEP when compared with TREPP and Lichtenstein (TREPP: 4 (6.9%); TEP: 3 (1.6%); Lichtenstein: 4 (7.7%), P = 0.040). [23]

In present study incidence of wound infection in open preperitoneal approach (TREPP) is 0% which is less compared to available studies, whereas higher in Lichtenstein group due to smaller sample size.

From the study it can be concluded that inguinal hernia repair with open pre peritoneal approach (Trans rectus sheath pre peritoneal approach TREPP) has resulted in better patient comfort with low post- operative pain and also few complications. There was no recurrence observed in my study, the follow up period was only 6 months. TREPP seems to be an effective and safe technique which gives an approach to inguinal, femoral and obturator hernias and shares the same anatomical relationship in TEP and TAPP approaches which gives a better understanding of the TEP and TAPP procedures. It has been developed to avoid mesh placement in the inguinal canal in a primary repair. There is no contact of mesh with the cord structures and nerve which reduces the postoperative pain (Inguinodynia), and sensory loss. Hence the Trans rectus sheath pre peritoneal approach (TREPP) is a simple alternative technique to the Trans inguinal Lichtenstein approach which can be used for treating inguinal hernia.

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