Inguinal hernia is one of the most prevalent surgical diagnoses in both primary care and specialist surgical outpatient departments. A man faces a roughly one-in-four lifetime probability of developing an inguinal hernia, while the corresponding figure in women is approximately 3% [1]. Globally, more than 20 million operations are performed annually for groin hernias, placing it firmly among the commonest elective surgical procedures [2]. Over the past four decades, the operative strategy has shifted decisively from tension-dependent tissue approximations toward tension-free reinforcement of the inguinal floor, with Lichtenstein's onlay mesh repair occupying the dominant position endorsed by the European Hernia Society guidelines [3].

The clinical success of mesh-based repair is, however, not without a counterweight. Polypropylene mesh elicits a sustained inflammatory response in host tissue, resulting in fibrosis and stiffness that can manifest clinically as chronic inguinodynia — a syndrome reported in anywhere between 1% and 28.7% of patients after Lichtenstein's repair [4]. Less commonly but more dramatically, mesh has been found to migrate into the bladder, bowel, and scrotal structures; mesh infection, once established, usually mandates complete explantation [5,6]. Dysejaculation, decreased fertility attributable to vas deferens entrapment in fibrous scar tissue, and foreign body sensation further contribute to the morbidity profile of prosthetic repair. In lower-income settings, the expense of the mesh implant itself is a non-trivial barrier to treatment.

Prompted by these shortcomings, Desarda in 2001 described a technique that forsakes synthetic material in favour of the patient's own anatomy [7]. A longitudinal incision within the sutured superior leaf of the external oblique aponeurosis (EOA) creates an undetached, pedicled strip that is interposed behind the spermatic cord to reconstruct the posterior inguinal wall. The strip contracts synchronously with the external and internal oblique musculature, generating lateral and superior tension at moments of increased intra-abdominal pressure — effectively creating a dynamic shield against reherniation [8]. Because aging-related degenerative changes are comparatively minor in tendons and aponeurotic tissue, the EOA strip offers durability without the biological penalties of a foreign implant [7].

Despite a steadily accumulating evidence base, Desarda's technique has not found its deserved foothold in routine surgical practice, particularly across Indian teaching institutions. We therefore undertook this prospective randomized study at a tertiary care centre in Karnataka to formally compare the two procedures across a range of clinically relevant endpoints.

Aims and Objectives

The main objective of this study was to compare the perioperative and postoperative outcomes between Desarda's repair and Lichtenstein's meshplasty. Secondary analysis of the two procedures included total operative time, postoperative pain intensity (VAS) at six specified time points (day 1, 3, 5, 7, 30, and 3 months), length of hospital stay, time to return to normal daily activities, time to return to gainful employment, total postoperative analgesic consumption, and the incidence of wound and scrotal complications including hematoma formation, seroma formation, scrotal edema, and surgical site infection (SSI).

Study Design and Setting This study was designed as a prospective, randomized, open-label comparative trial. It was conducted in the Department of General Surgery at the Karnataka Medical College and Research Institute (KMCRI), Hubballi, Karnataka, over the stipulated study period. The study protocol received approval from the Institutional Ethics Committee before patient recruitment commenced. Each participant provided written informed consent after a detailed explanation of the study procedures, potential risks, and the right to withdraw at any time. Inclusion and Exclusion Criteria Male patients aged 18 years or above who presented with a primary, uncomplicated, reducible inguinal hernia and who were fit for elective surgery were eligible for enrolment. We excluded patients with obstructed, incarcerated, or strangulated hernias; recurrent hernias; bilateral hernias; significant comorbidities including COPD or chronic cough that could predispose to early recurrence; active local wound infection; and ASA physical status grade exceeding III. Randomisation and Allocation Concealment Eligible patients were randomly assigned in a 1:1 ratio to either Group D (Desarda's repair, n=50) or Group L (Lichtenstein's meshplasty, n=50). Randomisation was achieved using computer-generated random numbers, and the allocation sequence was concealed within sequentially numbered, sealed opaque envelopes that were opened only in the operating room immediately before the procedure. Operative Technique All elective cases were performed under spinal anaesthesia. Prophylactic intravenous amoxicillin-clavulanate (1.2 g) was infused 30 minutes before skin incision. Surgeons performing the procedures shared equivalent post-training experience to minimise operator variability. Lichtenstein's Meshplasty The operation was executed as standardised by Amid et al. [9]. A polypropylene mesh measuring 15 × 10 cm was tailored to cover the posterior inguinal floor. The medial corner of the mesh was anchored to the fibro-periosteum overlying the pubic tubercle and anterior rectus sheath with interrupted sutures; the inferior border was then secured to the inguinal ligament using a running non-absorbable monofilament, carried 2 cm lateral to the deep ring. A lateral tail slit accommodated the cord structures. The superior edge was tacked to the internal oblique aponeurosis with interrupted sutures, with deliberate care taken to avoid incorporating any of the three inguinal nerves. Desarda's Repair Following standard groin incision and herniotomy, the superior leaf of the EOA was sutured to the upturned shelving edge of the inguinal ligament with a continuous polypropylene 1-0 suture. The first two bites were taken through the anterior rectus sheath medially, and the last suture was placed to narrow the deep ring snugly around the cord without constriction. A splitting incision was then fashioned within this sutured superior leaf, running from the pubic symphysis to 1–2 cm beyond the deep ring, thereby isolating a strip of EOA whose breadth matched the distance between the conjoint tendon superiorly and the inguinal ligament inferiorly. The free upper border of this strip was sewn to the inferior margin of the conjoint tendon with interrupted polypropylene sutures, positioning it posteriorly as the new floor of the inguinal canal. Finally, the newly formed superior leaf of the EOA was approximated over the cord to the inferior leaf, reconstituting the anterior wall of the canal. Postoperative Management A uniform analgesic regimen was prescribed to all patients. Patients were mobilised on the morning of the first postoperative day. Discharge was authorised once the patient was ambulatory with tolerable discomfort controlled by oral analgesics. Scheduled follow-up visits were conducted at 24 hours, 3 days, 5 days, 1 week, 30 days, and 3 months after surgery. Outcome Measures Primary outcomes were hernia recurrence and chronic inguinodynia, defined as any combination of pain, groin stiffness, or foreign body sensation persisting beyond three months from surgery. Secondary outcomes comprised total operative time (measured from skin incision to skin closure), pain intensity quantified on a 10-point VAS at each of the six follow-up visits, length of in-hospital stay, time to resumption of routine activities of daily living (ADL — bathing, ambulation, household chores), time to full occupational return, cumulative post-discharge analgesic dose requirement, and complications including scrotal oedema, haematoma, seroma, and surgical site infection (SSI, classified per CDC criteria). Statistical Analysis All data were entered and processed in SPSS version 26.0 (IBM, Armonk, USA). Normally distributed continuous variables were summarised as mean ± SD and compared with the independent-samples t-test; normality was confirmed before analysis. Categorical variables were presented as absolute counts and percentages; the chi-square test was employed for group comparisons, with Fisher's exact test substituted where expected cell frequencies were below 5. Statistical significance was defined as a two-tailed p value < 0.05 throughout. Fig. No. 01: Study Flowchart – Patient Allocation and Study Design Patients with inguinal hernia presenting to OPD / Emergency Patients with Inguinal Hernia presenting to OPD/Emergency ▼ Assessment for Inclusion & Exclusion Criteria ▼ 100 Eligible Patients Enrolled Written Informed Consent Obtained ▼ Computer-generated Randomisation ▼ GROUP D Desarda's Repair n = 50 vs GROUP L Lichtenstein's Meshplasty n = 50 ▼ Follow-up at: 24 Hours 3 Days 5 Days 1 Week 30 Days 3 Months ▼ Outcome Assessment •Operative time • VAS Pain • Hospital Stay Return to ADL • Return to Work • Complications • Analgesic Use ▼ Statistical Analysis — SPSS v26.0 | t-test | Chi-square | Fisher's Exact Fig. No. 01: Flowchart depicting study design, inclusion/exclusion criteria, randomisation into Group D (Desarda’s Repair, n=50) and Group L (Lichtenstein’s Meshplasty, n=50), and follow-up schedule

Patient Demographics

One hundred patients were recruited — 50 per arm. Every patient was male. The mean age was 44.78 ± 13.50 years in Group D and 46.42 ± 12.24 years in Group L, a difference that was not significant (p = 0.526). Hernia type and side of presentation were distributed similarly across the two groups (Table 1).

Table No. 01: Baseline Patient and Hernia Characteristics

Table No. 01: Both groups were well matched for age, sex, hernia type, and laterality (all p > 0.05).

Fig. No. 02: Distribution of hernia types (indirect, direct, pantaloon) across Group D (Desarda’s Repair) and Group L (Lichtenstein’s Meshplasty). All differences were not statistically significant (p > 0.05).

Operative Time

Group D required a mean of 39.18 ± 3.32 minutes to complete the repair; Group L required 49.98 ± 3.44 minutes. The difference of approximately 11 minutes was statistically highly significant (p < 0.001). The time saving in Desarda's repair stemmed from the absence of steps specific to mesh repair — cutting the mesh to size, tunnelling a slit for the cord, and placing the mesh flush against multiple anchoring structures (Table 2).

Postoperative Pain — VAS Scores

Pain intensity was recorded on the VAS at six postoperative time points. At every assessment, patients in Group D reported lower scores than those in Group L, and all comparisons reached significance at p < 0.001 (Table 2). The highest readings in both groups occurred at postoperative day 5, mirroring the inflammatory peak, though Group L scores at this point (5.50 ± 0.81) were nearly double those in Group D (3.04 ± 0.81). By three months, mean VAS in the Desarda group had fallen to 0.08 ± 0.27, compared with 0.92 ± 0.88 in the Lichtenstein group.

Table No. 02: Operative Duration and Postoperative VAS Pain Scores (mean ± SD)

Table No. 02: VAS = Visual Analogue Scale (0–10). All comparisons: p < 0.001.

Fig. No. 03: Mean operative time (minutes) for Group D (Desarda’s Repair) vs. Group L (Lichtenstein’s Meshplasty). Error bars represent ±1 SD. Group D was significantly faster (39.18 ± 3.32 min vs. 49.98 ± 3.44 min; p < 0.001).

Fig. No. 04: Postoperative VAS pain scores (scale 0–10) at six follow-up time points (24 h, Day 3, Day 5, Week 1, Day 30, 3 Months). Group D recorded significantly lower scores at all intervals (p < 0.001). Shaded bands represent ±1 SD.

Chronic Inguinodynia

At the three-month visit, 6 of the 50 Desarda patients (12%) reported some degree of persistent groin discomfort, compared with 10 of 50 in the Lichtenstein group (20%). Despite this numerically higher rate in Group L, the chi-square test did not yield statistical significance (p = 0.413) (Table 3).

Table No. 03: Chronic Inguinodynia at 3 Months

Table No. 03: NS = Not Significant. p = 0.413 (chi-square test).

Fig. No. 05: Chronic inguinodynia at 3 months — grouped bar chart and proportional pie charts comparing Group D (12%, n=6) vs. Group L (20%, n=10). Difference was not statistically significant (p = 0.413, NS).

Hospital Stay and Recovery Parameters

Patients in Group D were discharged after a mean of 2.32 ± 0.55 days, against 3.64 ± 0.53 days in Group L (p < 0.001). Return to normal ADL did not differ significantly between the groups (4.24 ± 0.77 vs. 4.44 ± 0.73 days; p = 0.187). Return to work was meaningfully earlier in Group D: 15.56 ± 2.74 days versus 17.50 ± 1.91 days in Group L (p < 0.001). Total analgesic doses consumed were comparable in both groups (4.36 ± 1.14 vs. 4.42 ± 1.16; p = 0.795) (Table 4).

Table No. 04: Postoperative Recovery Outcomes

Table No. 04: NS = Not Significant. ADL = Activities of Daily Living.

Fig. No. 06: Postoperative recovery outcomes — hospital stay, return to ADL, return to work, and analgesic doses consumed — comparing Group D and Group L. Error bars represent ±1 SD. *** p < 0.001; NS = Not Significant.

Postoperative Complications

Neither group showed statistically significant differences in any individual complication (Table 5). Scrotal oedema was the most frequently encountered problem in both arms — 8 patients (16%) in Group D versus 10 (20%) in Group L (p = 0.795). A single haematoma was recorded in each group. Seroma developed in 4 patients (8%) after Desarda repair and 5 patients (10%) after Lichtenstein repair. Two patients in each group sustained surgical site infections. No hernia recurrence was recorded in either group throughout the observation period.

Table No. 05: Postoperative Complication Profile

Table No. 05: All differences NS (p > 0.05). SSI = Surgical Site Infection.

Fig. No. 07: Postoperative complication rates (%) comparing Group D (Desarda’s Repair) and Group L (Lichtenstein’s Meshplasty). All differences were not statistically significant (p > 0.05). SSI = Surgical Site Infection.

The history of inguinal hernia surgery is, in many ways, the history of surgery itself — a succession of technique refinements driven by the twin imperatives of durability and patient safety. Bassini's anatomical repair set the foundation; Shouldice's multilayer technique improved upon it; and Lichtenstein's mesh onlay eliminated the tension that had caused much of the earlier failure. Today, however, mesh-related long-term complications have become the central problem, drawing surgeons back toward the biological principles that Bassini first articulated [9,10]. Our two study groups were well balanced at baseline — no significant difference in age, hernia type, or laterality. Any outcome disparity between groups can therefore reasonably be attributed to the operative technique rather than to patient-level characteristics. The finding that attracted most attention was the 11-minute reduction in mean operative time with Desarda's repair (39.18 vs. 49.98 min; p < 0.001). This aligns with observations in the RCT by Jain et al., where the saving was even more pronounced (31.39 vs. 65.55 min) [11], and with Youssef et al., who recorded 59.4 versus 72.3 minutes in favour of Desarda [12]. The shorter duration directly reflects the technical simplicity of the Desarda procedure, which eliminates the need to fashion, slit, and meticulously anchor a polypropylene mesh — translating to reduced anaesthetic exposure, lower theatre utilisation cost, and enhanced feasibility as a day-care procedure [11]. Pain scores at every follow-up interval were significantly lower in the Desarda group (p < 0.001 throughout). The pain peak at day 5 in both groups was expected, corresponding to the height of the inflammatory phase; but the magnitude of this peak differed substantially — VAS 3.04 in Group D versus 5.50 in Group L. We attribute this to the more extensive tissue dissection required to seat the mesh and the polypropylene-driven foreign body response that amplifies local inflammation. By three months, Group D had virtually no measurable pain (VAS 0.08), whereas Group L retained a mean score of 0.92. These data are consistent with Jain et al. [11] but diverge from Youssef et al. [12] and Ramesh Kumar et al. [13], likely due to heterogeneous analgesic protocols and patient selection across trials. Chronic inguinodynia was present in 12% of Group D and 20% of Group L patients at three months. Although clinically notable, the chi-square test returned p = 0.413. Our study was not powered to detect differences in this outcome at this sample size. The mechanistic basis for a higher rate in the Lichtenstein group is well established: progressive mesh fibrosis creates a rigid scar plate within which inguinal nerves become entrapped, sustaining a chronic nociceptive milieu [4,11]. In Jain et al.'s RCT, the difference was striking — 9.1% vs. 62.5% (p < 0.001) [11]; Szopinski et al. [14] and Youssef et al. [12], however, found no significant divergence. The wide variation in reported rates (1.5%–63%) underscores the sensitivity of this outcome to the definition used and duration of follow-up. Hospital stay was shorter by over a day in the Desarda group (2.32 vs. 3.64 days; p < 0.001), mirroring Jain et al. (2.34 vs. 4.88 days) [11]. Return to full occupational duties was also earlier (15.56 vs. 17.50 days; p < 0.001). In the Indian context, where a significant proportion of working-age patients are daily wage earners, even a two-day difference in return to work carries material economic significance. The absence of a significant difference in return to basic ADL (p = 0.187) suggests both techniques allow similar timelines for light activities; the Desarda advantage is most apparent when higher physical demands — those associated with employment — are considered. Analgesic consumption was statistically identical (p = 0.795), attributable to the uniform prescribing protocol applied in our unit. Complication rates were reassuringly low and comparable between groups. Scrotal oedema, the commonest complication, was managed conservatively in all cases. Neither group sustained wound dehiscence or mesh infection. Zero recurrences were recorded across 100 patients at three months, consistent with short-term results from Manyilirah et al. [15] and Ramesh Kumar et al. [13]. However, the true test of any hernioplasty lies in recurrence data beyond one year [14]. The cost argument for Desarda's repair is practical rather than theoretical. Eliminating the polypropylene mesh from the operative budget — without compromising outcomes — is a genuine advantage in district hospital and public sector settings where most inguinal hernia surgeries in India are performed [16]. Limitations of this study include a three-month follow-up period insufficient for long-term recurrence data, a sample size potentially underpowered for detecting modest differences in complication rates or chronic pain incidence, an open-label design where surgeons could not be blinded, and exclusion of patients with thin or mechanically deficient EOA in whom Desarda's repair may not be applicable,

Desarda's repair, performed with no foreign material, is a technically sound and clinically reliable option for the operative management of uncomplicated inguinal hernia. In our series of 100 randomised patients, it consistently outperformed Lichtenstein's meshplasty in operative speed, early and late pain control, hospital stay, and time to return to work, while matching it on complications and recurrence. These findings support a broader adoption of Desarda's technique in routine surgical practice — particularly for younger patients with indirect hernias, in resource-constrained environments, and wherever avoiding the long-term sequelae of mesh implantation is a clinical priority. Long-term multicentre trials with follow-up beyond three years will be required to definitively settle the question of comparative recurrence.

Desarda's repair, performed with no foreign material, is a technically sound and clinically reliable option for the operative management of uncomplicated inguinal hernia. In our series of 100 randomised patients, it consistently outperformed Lichtenstein's meshplasty in operative speed, early and late pain control, hospital stay, and time to return to work, while matching it on complications and recurrence. These findings support a broader adoption of Desarda's technique in routine surgical practice — particularly for younger patients with indirect hernias, in resource-constrained environments, and wherever avoiding the long-term sequelae of mesh implantation is a clinical priority. Long-term multicentre trials with follow-up beyond three years will be required to definitively settle the question of comparative recurrence.

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