international journal of surgery 6 (2008) 302–305

www.theijs.com

Tension-free repair versus Bassini technique for strangulated

inguinal hernia: A controlled randomized study

Magdy M.A. Elsebae*, Maged Nasr, Mohamed Said

Department of General Surgery, Theodore Bilharz Research Institute, P.O. Box30, Imbaba, Giza 12411, Egypt

article info abstract

Article history:
Received 29 February 2008
Received in revised form
16 April 2008
Accepted 25 April 2008
Published online 2 May 2008
Keywords:
Incarcerated inguinal hernia
Lichtenstein hernioplasty
By Evidence Based Medicine (EBM) principles, several meta-analyses concluded that use of
mesh is superior to the non-mesh operations in inguinal hernia surgery. Wound infection is
a potential complication of all hernia repairs and deep-seated infection involving an inserted
mesh may result in chronic groin sepsis. In the event of incarcerated or strangulated hernias,
however; placement of prosthetic material is presumed to increase that risk of infection.
Aim: Aim of the study is to compare the outcome of tension-free mesh repair to Bassini
technique used to treat strangulated inguinal hernia.
Patients and methods: In the period from May 2004 to December 2006, 54 patients were sub-
mitted to emergency operation because of strangulated inguinal hernia. The patients were
randomized into two groups (27 patients in each group). Group A patients underwent open
tension-free anterior repair utilizing a monofilament polypropylene mesh according to
Lichtenstein ‘‘tension-free’’ technique, whereas group B patients underwent Bassini tech-
nique. Mesh hernioplasty was not attempted in patients with preoperative peritonitis, in-
flammatory hernia and for those in whom bowel resection was perfumed for ischemic
necrosis caused by strangulated inguinal hernia and they were excluded from the study.
Assessment of the primary outcome included surgical complications and hospital stay
and secondary outcome was the recurrence of hernia.
Results: Postoperative complication rate did not differ significantly between the two groups.
Postoperative hospital stay was also significantly longer in group B compared to group A
(5 ! 3.4 days versus 3 ! 2.1 days, p < 0.01). During the follow-up, (mean 22 ! 6months), three
patients had recurrence after Bassini operation (group B), but there was no recurrent hernia
after mesh herniorrhaphy (group A) (0/27 ¼ 0% versus 3/27 ¼ 7, 11.1%, p < 0.001).
Conclusion: The use of Lichtenstein ‘‘tension-free’’ technique in emergency treatment of
strangulated inguinal hernia is safe, effective with an acceptably low rate of postoperative
complications and without recurrence.
ª 2008 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Background Wound infection is a potential complication of all hernia

By Evidence Based Medicine (EBM) principles, several meta-
analyses concluded that use of mesh is superior to the non-
mesh operations in inguinal hernia surgery.1 Inguinal hernia
repair has been benchmark of clean surgical procedures.
repairs and deep-seated infection involving an inserted
mesh may result in chronic groin sepsis.2 In the event of in-
carcerated or strangulated hernias, however, placement of
prosthetic material is presumed to increase that risk of
infection.3

* Corresponding author. Tel.: þ20 12 7281418; fax: þ20 2 5408125.

E-mail address: magdyelsebae@hotmail.com (M.M.A. Elsebae).
1743-9191/$ – see front matter ª 2008 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijsu.2008.04.006
 international journal of surgery 6 (2008) 302–305 303

for categorical variables. Statistical significance was defined

2. Aim of the study as p < 0.05.

To compare the outcome of ‘‘tension-free’’ mesh repair by

Lichtenstein technique to Bassini technique used to treat
4. Results
strangulated inguinal hernia.

All patients were males. Their mean age was 34.6 years (range
21–68 years). All patients included in the study had unilateral
3. Patients and methods inguinal hernia. Patients were presented to us and admitted af-
ter 6–12 h of strangulation. Demographic and other character-
The study included consecutive cases who were 18 years of
istic of patients in the two groups B (¼ Bassini operation) and A
age or older, who were submitted to emergency operation be-
(¼ Lichtenstein herniorrhaphy) were comparable Table 1.
cause of strangulated inguinal hernia in the period from May
Mean operative time was significantly longer for group B
2004 to December 2006. Urgent preoperative workup was done
(¼ Bassini operation) than group A (¼ Lichtenstein herniorrha-
for all of the patients. It included full history taking, clinical
phy) (91.5 ! 9.3 min versus 65.7 ! 10.5 min, p < 0.05).
examination, and laboratory testing by blood picture, liver
There was no postoperative mortality in this study. Postop-
and kidney function tests, blood sugar and abdominal sonog-
erative complication rate did not differ significantly between
raphy. Patients with a recurrent hernia, patients with preoper-
both groups ( p > 0.05). Complications following Lichtenstein
ative peritonitis, inflammatory hernia and/or associated other
‘‘tension-free’’ technique were groin swelling and ecchymosis
hernias or intraabdominal masses or ascites were excluded
and seroma in one patient and seroma formation and wound
from the study.
infection in another patient. The latter was a superficial inci-
The study included 54 patients. Patients were in American
sion site infection and was treated in a conservative way. Post-
Society of Anesthesiologists (ASA) class I–II. Selected patients
operative wound sepsis occurred in three cases following
who gave a written fully informed consent were eligible for
Bassini operation. Escherichia coli were the main isolated
the study. They were randomized into two groups A and B
bacterium.
(27 patients in each group) depending on whether the
Postoperative hospital stay was also significantly longer in
patient’s registration number was odd or even, respectively.
group B compared to group A Table 2.
The study, however, was controlled so that mesh hernioplasty
During the follow-up, (mean 22 ! 6 months), three patients
was not attempted in for those in whom bowel resection was
had hernia recurrence after Bassini operation (group B), but
performed and they were excluded from the study. Group A
there was no recurrent hernia after Lichtenstein herniorrha-
patients underwent open tension-free anterior repair utilizing
phy (group A) Table 3.
a monofilament polypropylene mesh according to Lichten-
stein ‘‘tension-free’’ technique, whereas group B patients un-
derwent Bassini technique. All the patients underwent
standardized repairs by attending surgeons. The open proce-
5. Discussion
dure was performed according to the Lichtenstein method,
In recent years, use of prosthetic material for inguinal hernia
as described by Amid et al., 1996.4
repair has increased dramatically. Tension-free repairs have
Regarding postoperative care of the patient in this study,
gained popularity not only for primary or recurrent hernias
prophylactic daily single oral dose of 500 mg ciprofloxacin
but also for complicated inguinal hernia repairs as well.
was given for five days after the operation in all patients. In
high-risk patients (i.e., obese patients), low molecular weight
heparin is usually administered to prevent deep venous
thrombosis the night before surgery and its administration Table 1 – The demographic and characteristics of patients
is continued during the hospitalization of the patient. The pa- in the two groups
tient is mobilized about 6 h after surgery. Postoperative anes- Lichtenstein Bassini
thesia consists in the administration of NSAIDS analgesics. herniorrhaphy technique
When a closed suction drainage was used, it is removed on (group A) (group B)
the day of discharge. Postoperative course of the patients n ¼ 27 n ¼ 27
was closely monitored and documented. Bacteriological cul- Age (mean and range) years 34.6 (21–63) 43.2 (36–68)
ture and sensitivity studies were done for cases with wound
ASA score
sepsis. Outpatient follow-up visits were also documented. As- Class I 18 16
sessment of the primary outcome included surgical complica- Class II 9 11
tions and hospital stay and secondary outcome was the
Duration of strangulation 6.7 5.8
recurrence of hernia. (mean/hours)
Associated DM 11 8
3.1. Statistical analysis Associated hypertension 9 13
Associated chronic 4 3
liver disease
Statistical analysis was performed with the aid of the SPSS
Direct/indirect hernia 3/24 2/25
computer program (version 6.0 windows). Statistical compar-
Inguinoscrotal hernia 15 13
isons between the two groups were made with Student’s t test
304 international journal of surgery 6 (2008) 302–305

Surgical techniques and implanted materials are crucial to

Table 2 – Postoperative complications
the results and costs associated with hernia repair. Specific
Lichtenstein Bassini technique mesh materials are related to specific complications.12 Poly-
herniorrhaphy (group B)
propylene meshes are ideal for use in contaminated or poten-
(group A) n ¼ 27
n ¼ 27 tially contaminated fields (i.e., with incarcerated/strangulated
bowel within the hernia). The macroporous structure of the
Groin ecchymosis 1 0 meshes of polypropylene, with pores of diameter larger than
and seroma
70 microns, allows contact among the bacteria, which mea-
Wound sepsis: sures one micron in diameter, and the cells of the immune
Superficial 1 2 system, granulocytes and macrophages, with a diameter of
Deep infection 0 1
15–20 microns, allowing the recovery from infections.5,13
Total 2 (7.4%) 3 (11.1%) Although routine use of prophylactic antibiotics is not rec-
ommended for open nonimplant herniorrhaphy, there is little
Inguinal hernia mesh repair according to Lichtenstein ‘‘ten- direct clinical evidence supporting the use of antibiotic pro-
sion-free’’ technique has gained great acceptance worldwide, phylaxis for tension-free mesh herniorrhaphy.14,15 The use
showing efficacy to consolidate the posterior wall of the ingui- of prophylactic antibiotics in our study was empirical.
nal canal and to reduce recurrence risk because of tension on Review of literature by Medline search from 1995 to 2007; it
suture lines and postoperative pain.5 The clinical results of ten- was found no single randomized study compares tension-free
sion-free anterior repair of inguinal hernia using a mesh mesh repair like Lichtenstein technique and other classic tis-
revealed that the immediate complications were rare and al- sue repairs like Bassini operation. One comparative non-
ways minor, and rate of long-term recurrence is very low randomize study by Papaziogas et al., 2005 came to results
(0.5%).6 similar to our study. Mean operative time and postoperative
The presence of a strangulated inguinal hernia cannot be hospital stay were significantly longer for modified Bassini
considered a contraindication for the use of a prosthetic technique in comparison with tension-free repair. Postopera-
mesh. Lichtenstein hernioplasty can be successfully used tive complication rate and recurrence rate did not differ signif-
not only as an elective operation but also as an emergency op- icantly between the two operations. No mesh had to be
eration for incarcerated inguinal hernia with a good outcome removed. It was concluded that the presence of a simple
and an acceptably low rate of postoperative complications, strangulated inguinal hernia cannot be considered a contrain-
and the risk of the local infectious complications is low.7–9 dication for the use of a prosthetic mesh.16
However, the outcomes of emergency Lichtenstein hernio- In our study postoperative wound infection rate following
plasty were inferior to the outcomes of elective Lichtenstein Lichtenstein technique was not different from that following
hernioplasty.10 Bassini technique. In one case of infection of the surgical
However, wound infection is a potential complication of all wound, removal of the mesh was never required. It can be
hernia repairs and deep-seated infection involving an inserted considered as mesh infection (type I), which never involves
mesh may result in chronic groin sepsis, which usually neces- its body, but it is present around sutures and bended edges
sitates complete removal of mesh to produce resolution.2,3 Re- and the prosthesis can be saved.17
moval of mesh would potentially result in a weakness of the Hospital stay is longer in the group B than group A because
repair and subsequent hernia recurrence. However, hernia re- of wound infection that necessitated in-hospital management
currence was found uncommon following mesh removal for in two cases and the need for medical control of ascites which
chronic groin sepsis, suggesting that the strength of a mesh was rapidly accumulating postoperatively in another two cir-
repair lies in the fibrous reaction evoked within the transver- rhotic patients. Otherwise the longer hospital stay was due to
salis fascia by the prosthetic material rather than in the phys- causes unrelated to surgery. Wound sepsis in Bassini group in
ical presence of the mesh itself. When there is established three cases (11.1%) is unfortunate incident which is difficult to
deep infection, there should be no unnecessary delay in re- be explained. However, it can be attributed to uncontrolled
moving an infected mesh in order to allow resolution of type DM at time of presentation to ER in one of those three
chronic groin sepsis.11 However, that procedure is not without cases.
a risk of bowel injury. Recurrence rate in Bassini group of 11.1% is actually not
more than other studies reported in literature. Mittelstaedt
et al., 1999 in a prospective, randomized trial comparing three
operative techniques: Bassini, Shouldice and McVay found
that among the Bassini recurrences, the worst results were ob-
Table 3 – Hospital stay and recurrence
served with direct hernias (29% recurrence) when compared
Lichtenstein Bassini p with indirect ones (16% recurrence). They concluded that a re-
herniorrhaphy technique currence rate of 35.7% for inguinal herniorrhaphy with the
(group A) (group B)
Bassini technique was surprising and obliged them to inter-
n ¼ 27 n ¼ 27
rupt the trial. They pointed to a prohibitive high failure rate
Postoperative hospital 5 ! 3.4 3 ! 2.1 <0.01 when dealing with the Bassini technique, which was, over
stays (mean days). a century, the most popular treatment of inguinal hernia all
Hernia recurrence. 0 (0%) 3 (11.1%) 1 <0.001
over the world.18 In another study, recurrence rate was found
(no. and % of cases)
21.6% in Bassini repair after a mean observation period of 48
 international journal of surgery 6 (2008) 302–305
months.19 The use of slowly absorbable suture material in the
Bassini technique was reported to result in a high recurrence
rate of 12.8%.20 Of course, this does comply with our study be-
cause we did use a monofilament polypropylene no. 0 in Bas-
sini herniorrhaphy. Also, long-term (12–15 years) recurrence
rate following Bassini repair was found 33% by Beets et al.,
1997.21 However, recurrence in Bassini group in our study
was attributed to the occurrence of predisposing factors to
hernia recurrence namely; chronic cough due to chronic asth-
matic bronchitis in two cases and chronic straining due to be-
nign prostate hyperplasia (BPH) which received no treatment
after hernia surgery in another case. Its worth mentioning
that the higher incidence of hernia recurrence in those pa-
tients could be reduced by applying mesh repair.
6. Conclusion
The use of Lichtenstein ‘‘tension-free’’ technique in emer-
gency treatment of strangulated inguinal hernia is safe, effec-
tive with an acceptably low rate of postoperative
complications and without recurrence.
Conflict of interest
None.
Funding
None.
Ethical approval
Local ethical committee, Theodore Bilharz Research Institute.
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