Inguinal hernia is a condition that requires surgical correction and is prevalent everywhere in the world and a heavy burden for health systems.[1] It happens when the contents of the abdomen bulge through a weak spot in the groin, leading to a bulge, pain, and restriction of movement.[2] The prevalence of groin hernia is very high, with over 20 million repairs done worldwide each year. Surgical repair is the standard treatment for symptomatic inguinal hernias and is the only treatment that is considered definitive.[3] The main surgical methods used in the treatment of inguinal hernia are open mesh repair and laparoscopy, including totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) repair.[4] The surgical approach varies based on the patient, the presentation of the hernia, the surgeon's experience, and the resources available.[4]

Both open and laparoscopic techniques are effective at repairing hernias, but pain after surgery is a major factor in patient satisfaction and recovery.[5] Chronic postoperative inguinal pain (CPIP), defined as bothersome moderate pain after surgery that interferes with daily activities for at least 3 months, is one of the most notable complications of the surgeries.[6] International guidelines estimate 10-12% of patients will have clinically relevant chronic pain following groin hernia repair, and 0.5-6% will have chronic pain that greatly disrupts their daily activities or work.[7] Open repair is known to be a risk factor for CPIP, possibly due to tissue dissection, nerve injury, and entrapment.[8] Laparoscopic repair can decrease chronic pain through decreased disruption of the inguinal canal, and the mesh can be positioned in the preperitoneal plane.[9]

Surgical effectiveness is also measured by time to normal activity, which directly affects functional recovery, work, daily functioning, and quality of life. While results may depend on the level of surgical expertise, patient-specific factors, and how normal activity is defined, generally, laparoscopic repair is associated with less early postoperative pain and quicker recovery than the conventional open Lichtenstein repair.[10] Data reported in international guidelines suggest that most patients can follow up their normal level of activity about 3-5 days after uncomplicated inguinal hernia repair if comfortable.[11]  However, some recovery may be delayed due to postoperative pain, fatigue, wound issues, and expectations. Evaluating chronic pain together with the time needed to resume normal activities gives a more complete comparison between the two surgical approaches than does a comparison of the two approaches in terms of recurrence or immediate postoperative complications.[11]

Laparoscopic repair has been reported to have promising results in Pakistan with less chronic pain and earlier recovery time, as one of the randomized controlled trials on 100 male patients showed that 4% of patients who underwent laparoscopic repair complained of less postoperative chronic pain than 28% of patients who had open Lichtenstein repair. However, patient populations, surgical methods, follow-up duration, and outcome evaluation vary from one study to another, which restricts the extrapolation of individual results.[12, 13]

The purpose of the current study was to compare in an analytical way both techniques of inguinal hernia repair, laparoscopic repair and open repair, in terms of two patient-centered outcomes, namely chronic postoperative pain and time to return to normal activities. The outcomes of this study will be evaluated in the local clinical context and provide evidence that could be used as part of the surgical decision-making process, for counselling with the patient after surgery, and for informing treatment decisions. Thus, this study is designed to assess and compare the prevalence of chronic postoperative pain and time to regain normal activities after laparoscopic and open inguinal hernia surgeries.

A prospective comparative study was performed to determine the postoperative pain and time to recovery to normal activities after laparoscopic and open inguinal hernia repair. The study was carried out at People's University of Medical and Health Sciences for Women (PUMHSW), Nawabshah, Pakistan, within the Department of General Surgery. The study was carried out for a six-month period starting from 1st December 2025 to 31st May 2026. The sample size was calculated using the OpenEpi online sample size calculator for comparing two independent proportions. A previous Pakistani randomized controlled trial by Aslam et al. reported chronic postoperative pain in 4% of patients undergoing laparoscopic mesh repair and 28% of patients undergoing open Lichtenstein mesh repair.[12] With these proportions, a two-sided 95% confidence level, 80% statistical power, and a 1:1 allocation ratio, the estimated sample size was about 42 patients per group, totaling 84 patients. The final sample size was set at 94 patients (47 per group) after allowing for a 10% loss to follow-up. A non-probability consecutive sampling technique was used. All patients aged 18-65 years with clinically diagnosed, first, unilateral or bilateral inguinal hernia undergoing elective laparoscopic or open mesh inguinal hernia repair were included. The participants were selected if they gave informed consent and were willing to undergo postoperative follow-up. Patients who had a previous major surgery in the lower abdomen or pelvis that made the planned approach impossible, had tried inguinal hernia repairs and ended up with a recurrent inguinal hernia, had experienced incarcerated or strangulated hernias that required emergency surgery, had a femoral hernia, or had chronic pain in the groin area before surgery, or had a documented chronic pain disorder were excluded. Patients with severe mental retardation or other factors that made it difficult to assess pain and follow-up were also excluded. Demographic and clinical data were obtained by means of an informed consent form with approval from the institutional ethics review committee and written informed consent from each participant. Demographic data recorded were age, sex, body mass index (BMI), job, smoking, comorbidities, hernia side, time of symptoms, and type of surgery performed. Patients were divided into two groups: Group A consisted of patients who were repaired laparoscopically, including TAPP or TEP repairs, and Group B consisted of patients who underwent open Lichtenstein mesh repair. Clinical records were obtained, and operative details and complications were recorded. A follow-up evaluation was performed to assess postoperative pain, and chronic postoperative inguinal pain was defined as pain that affected the activities of daily living and was present for at least 3 months after surgery. The level of pain using a numerical rating scale (NRS) of 0 to 10, with higher scores denoting increased pain intensity, was measured. Time to normal activity was measured in days between the day of surgery and the day the patient returned to his/her pre-surgical functional levels of usual daily activities and occupational function. Outpatient evaluations or telephone contacts were used to conduct follow-up evaluations with a standardized questionnaire. Patients not completing follow-up were documented, and reasons for failure to complete follow-up were recorded when available. The IBM SPSS Statistics version 26 software was used to analyze the data. All quantitative variables were tested for normality by the Shapiro-Wilk test, such as age, BMI, pain scores, and time to return to normal activity. Data from the normally distributed variables were reported as mean±SD and compared between groups using the independent-samples t-test. The categorical variables (sex, laterality of herniorrhaphy, chronic postoperative pain, and postoperative complications) were presented as frequencies and percentages and compared by chi-square test and Fisher's exact test. The two surgical groups were compared for the frequency of chronic postoperative pain, and the time to return to normal activity was compared for differences in functional recovery. A p-value of less than 0.05 was considered statistically significant.

A total of 94 patients were included in the study, with 47 patients in each surgical group. There were no statistically significant differences between the groups in age, body mass index, sex distribution, and occupation (p > 0.05). There was a preponderance of male patients in both groups, and manual labour was the most prevalent occupational group (Table 1).

The clinical parameters were also similar in both groups. There was no statistically significant difference in the duration of symptoms associated with hernia, smoking, comorbidities, or hernia laterality (p > 0.05). The most frequently seen hernias were right-sided, left-sided, and bilateral hernias (Table 2).

Among patients undergoing laparoscopic repair, TAPP was performed in 61.7% and TEP in 38.3%, whereas all patients in the open group underwent Lichtenstein mesh repair. The mean operative duration for the laparoscopic group (72.4 ± 15.8 minutes) was significantly longer than that for the open group (54.6 ± 12.9 minutes). The laparoscopic group stayed in hospital for a significantly shorter period of time (1.5 ± 0.7 days vs 2.1 ± 0.8 days; both differencesere statistically significant, p < 0.001) (Table 3).

The laparoscopic group experienced fewer complications after surgery (8.5%) compared to the open group (21.3%). The incidence of seroma, hematoma, surgical site infection, and urinary retention was higher after open repair. However, neither the overall complication rate nor the individual complications differed significantly between the groups (p > 0.05) (Table 4).

Laparoscopic repair had significantly fewer patients with chronic postoperative inguinal pain at 3 months (6.4%) than open repair (25.5%). The laparoscopic group experienced a lower rate of chronic postoperative pain than the open group, but this difference was not statistically significant (p = 0.022) (Table 5).

The laparoscopic group had less pain at three months, with a median NRS of 0 (IQR 0-1) versus 1 (IQR 0-3) in the open group. Laparoscopic patients were more likely to have no pain than were open repair patients, while moderate and severe pain were more prevalent in open repair patients (Table 6).

The mean time to return to normal activity was significantly lower after laparoscopic repair than after open repair (p < 0.001). In addition, 72.3% of patients who were treated with laparoscopy were able to return to normal activities within 7 days, whereas 19.1% of those treated with open repair were able to return to normal activities within 7 days. There was a significant difference between recovery times in the groups (p < 0.001) (Table 7).

Table 1. Demographic characteristics of study participants (n = 94)

Table 2. Clinical characteristics of study participants (n = 94)

Table 3. Distribution of surgical procedures and operative outcomes (n = 94)

Table 4. Comparison of postoperative complications between laparoscopic and

open inguinal hernia repair

Table 5. Comparison of chronic postoperative inguinal pain at three months

Table 6. Comparison of postoperative pain intensity at three-month follow-up

Table 7. Comparison of time to return to normal activity

This study compared the outcomes of laparoscopic inguinal hernia repair with open inguinal hernia repair in 94 patients, focusing on chronic pain after surgery and the time it takes for the patient to return to normal activities. The results indicated that the incidence of chronic pain was significantly lower after the laparoscopic repair (p = 0.022), and the time to return to normal activities was significantly shorter (p <0.001). The operative time was longer in laparoscopic surgery, but the hospital stay was shorter. The results are similar to several recent studies, but the comparison should be interpreted with caution due to the differences in study design, patient population, surgical procedures, and outcome definitions. In a prospective comparative study of 100 patients, Choudhary et al. (2021) found significantly less postoperative pain with earlier recovery after laparoscopic repair. The laparoscopic group had a mean time to resume usual activity of 16.23 days, while the open repair group had a mean of 41.10 days. The laparoscopic surgery was also linked to a shorter hospital stay and longer operative time. These observations are consistent with the findings of the present study, but the much longer recovery periods reported by Choudhary et al. may be a reflection of the differences in the patient populations, postoperative instructions, work demands, and definition of normal activity.[14] A prospective randomized study was published in 2022 that compared 174 patients with laparoscopically performed totally extraperitoneal repair with open Lichtenstein repair. Return to normal activities occurred earlier after TEP repair (13.6 ± 6.8 days) than after Lichtenstein repair (19.8 ± 4.6 days). Chronic groin pain also occurred less frequently after laparoscopic repair (3.4%) than after open repair (22.09%). These results are similar to those seen in the current study. The earlier study evaluated TEP; however, the current laparoscopic group included both TAPP and TEP.[15] In 2022, a systematic review and meta-analysis of 22 randomized trials was published in the American Journal of Surgery that looked into chronic groin pain. The analysis also revealed that there was a decreased risk of chronic pain after TEP compared to open mesh repair at multiple follow-up periods. However, the difference was not statistically significant when chronic pain was specifically defined as moderate or interfering with daily activities (p = 0.08). This is important, since the current study used daily activity as the criterion for chronic pain. Despite the result of the present study being in favor of laparoscopy, the result of the meta-analysis suggests that the differences in pain and functional impairment are not necessarily the same as the difference in the overall incidence of postoperative pain.[16] Haladu et al. (2022) performed an overview of systematic reviews of randomized controlled trials (RCTs) that compared open versus laparoscopic inguinal hernia repair. They concluded that there was no consistent difference in recurrence rates, but laparoscopic methods showed a reduced incidence of chronic groin pain. This is supported by the lower prevalence of chronic pain in the present study. The current study, however, was not designed to address the relative long-term success of either procedure in regard to recurrence, and no conclusions can be drawn about the relative long-term durability.[17] Hakeem et al. (2023) performed a prospective cohort study of 65 patients with unilateral inguinal hernia at Aga Khan University Hospital, Karachi, to compare the laparoscopic TAPP with open Lichtenstein repair. Patients had a slightly shorter time to return to work after laparoscopic repair, but this was not statistically significant. This compares with a much greater difference in return to normal functioning that was found in the present study. The difference may partly be due to differing sample sizes, expectations of jobs, and outcome measures since returning to work and returning to normal, everyday activities are not synonymous. Thus, the shorter recovery time after laparoscopy should not be automatically assumed to be a similar reduction in work absence for all patients.[18] In 2023, another study in the journal Cureus compared two different types of inguinal hernia repair (laparoscopic and open) in 84 patients to see how safe and effective each procedure was. The investigators reported a longer operative time, but good outcomes in terms of postoperative discomfort, hospital stay, and resumption of normal activities with laparoscopy. These findings are consistent with those of the operative and functional recovery of the present study. However, the previous study mainly focused on short-term results and, apart from the three-month follow-up, failed to extensively assess chronic postoperative pain, which prevented direct comparisons with the current study's three-month evaluation of pain.[19] The authors of the study, Lyra et al., conducted a systematic review and meta-analysis of 13 studies that compared laparoscopic TAPP or TEP with open Lichtenstein repair. Their analysis showed that the risk of chronic postoperative inguinal pain after laparoscopic repair was significantly reduced (RR = 0.49, 95% CI: 0.32-0.75). This is consistent with the current results, which saw a decrease in chronic pain following laparoscopic surgery. However, the certainty of evidence was rated as low, and significant heterogeneity (I²=66%) was observed. Therefore, the apparent advantage of laparoscopy must be viewed in light of variations in surgical techniques and pain evaluation between studies.[20] In this study, Avci et al. (2025) compared open inguinal hernia surgery and laparoscopic inguinal hernia surgery in 128 patients in Türkiye, half of whom underwent each type of surgery. In contrast to this current study, they did not see any statistically significant differences between the surgical procedures in terms of chronic pain, postoperative complications, or overall quality of life outcomes. They conclude that the benefits that have been seen after laparoscopic repair may not be generalizable to all clinical situations. Variability in patient characteristics, follow-up assessment, and the level of surgical expertise might explain the differences in outcomes reported in the literature, but these were not studied directly to determine if they were the source of the variations in the present study.[21] Al-Sharabi et al. (2025) compared laparoscopic and open inguinal hernia repairs in patients ≥65 years. The chronic postoperative pain incidence was 2.5% (laparoscopic) versus 9.6% (open repair) (p=0.003). The direction of this difference was similar to the present results, except that the absolute frequencies were reduced in both groups. Due to age distribution and patient selection, there is a limitation to direct comparison, especially for the present study's patient population, which consisted of adults between 18 and 65 years old. However, the lower overall complication rate seen following laparoscopy in the present study was not statistically significant and so cannot be interpreted as a sign of decreased complications.[22] More recently, Butt et al. (2026) carried out a systematic review and meta-analysis of 17 studies that compared the laparoscopic TAPP with open Lichtenstein repair for primary unilateral inguinal hernia. They found a much reduced risk of chronic pain after TAPP (RR=0.42, 95% CI: 0.20 - 0.88), corroborating the chronic pain results of the current study. However, their pooled analysis found no statistically significant difference in return to normal activity or hospital stay. The result is contrary to the findings of significant differences in recovery and hospitalization found in the present investigation. This discrepancy suggests that the amount of functional recovery benefit could be different among patients and in clinical environments.[23] Several limitations should be noted in the present study. However, its prospective comparative design enables evaluation of postoperative results but cannot prove causality, as the patients were not randomly allocated but instead recruited from a non-probability consecutive sampling. The relatively small sample size, single-centre setting, and the inclusion of both TAPP and TEP in one laparoscopic group may hamper the interpretation and generalizability of the results. Also, chronic pain was measured at 3 months, which would not allow conclusions to be drawn regarding the persistence of the symptoms. Other factors such as expectations, postoperative advice, and occupation may have influenced return to normal activity.

Laparoscopic inguinal hernia repair had fewer incidences of chronic postoperative pain and a faster return to activity than open Lichtenstein repair. Patients had shorter hospital stay, but longer operative time for laparoscopic repair. However, there was no significant difference in the postoperative complication rates between the groups. These results indicate possible benefits of laparoscopic repair in recovery after surgery, but larger randomized trials with more follow-up are necessary.