Around 20 million inguinal hernia repairs are performed each year in the entire world. The ideal technique is still a matter of research.
Classically, recurrence rate is used to evaluate outcomes. This is changing... Why? Since recurrence was substantially decreased with the new tension free techniques, pain is nowadays an important factor when evaluating outcome.
In 2013 the Onstep technique for inguinal hernia repair was presented by Lourenço A. et al. with almost 700 patients treated. No chronic pain was reported in any case.
Kristoffer Andresen et al. from the Department of Surgery of the Herlev Hospital in Copenhagen, Denmark, decided to compare the Onstep technique with Lichtenstein technique regarding pain-related impairment of sexual function till 6 months after repair. It was a study included in the "ONLI Trial" (Onstep versus Lichtenstein for inguinal hernia repair). Results were published this year in "Surgery".
A total of 259 patients were randomized for Onstep (130 patients) or Lichtenstein (129 patients) technique. Pain during sexual activity was evaluated for 6 months with a questionnaire:
Onstep - 17 cases of pain (13,1%)
Licthtenstein - 30 cases of pain (23,0%)
p = 0,034
Pain can occur on several locations: scar, scrotum, penis, or during ejaculation (dysejaculation). According to Kristoffer Andresen et al. 20 patients in the Lichtenstein group had pain on the scar compared to only 7 patients in the Onstep group. Dysejaculation was presented in 4 patients and 3 patients in the Lichtenstein group and Onstep group respectively (p=0,72). Another interesting data presented by the authors is that the Onstep technique removed pain during sexual activity in the majority of patients who had preoperative pain during intercourse, with only a few new cases. The authors state that results from the Onset technique are similar to the laparoscopic repair. Additionally, I believe Onstep is cheaper than laparoscopy...
Mesh and sutures around the iliohypogastric and ilioinguinal nerves are presented as possible causes of pain. Because the Onstep technique has no need for stitches, this can be an advantage for reducing postoperative pain. For the authors the Onstep technique might be difficult to perform in obese patients, in scrotal hernias, and extensive fibrosis of preperitoneal space.
Kristoffer Andresen et al. conclude that "the Onstep technique was superior to the Lichtenstein technique in terms of pain during postoperative sexual activity." Additionally it "removed the pain in more patients than the Lichtenstein technique".
A final word of friendship for my friend and fellow surgeon Dr. Augusto Lourenço for giving the worldwide surgical community the Onstep technique. For him and colleague: thank you. "Portugal está (mesmo) na moda!"
Questions to the reader:
What is your experience with the Onstep repair?
Some authors say it is faster. What do you have to say about this?
Onstep or laparoscopy. Which one?
Exchanging ideas makes you stronger! Please comment below...
Link to PubMed:
Andresen K, Burcharth J, Fonnes S, Hupfeld L, Rothman JP, Deigaard S, et al. Sexual dysfunction after inguinal hernia repair with the Onstep versus Lichtenstein technique: a randomized clinical trial. Surgery 2017; 161(6): 1690-1695.
Dr. Carlos Eduardo Costa Almeida
General Surgeon