Author: Dr Pradeep Saxena, MBBS, MS, FMAS, FACRSI, FHBPS
Professor, Department of Surgery, AIIMS, Bhopal, India.
Synonyms, Key Words, and Related Terms
Lichtenstein hernioplasty, tension-free hernioplasty, open tension-free mesh technique, mesh hernioplasty, hernia mesh surgery, open hernia repair, inguinal hernia surgery
Introduction
Background: The Lichtenstein open tension-free mesh hernioplasty, performed under local anesthesia, is a simple technique to be learned (learning curve = 5 cases), and trained surgical residents are able to perform it without compromising the patient's care and long-term outcome. The procedure is time tested, safe, and economical, as well as being quick and easy to perform. In addition, it carries fewer complications and has become the gold standard in open tension-free hernioplasties. The procedure is well suited for smaller community-based, regional, and teaching hospitals, and it offers good immediate and long-term results. Moreover, the excellent results achieved with the Lichtenstein repair appear to be unrelated to the surgeons’ experience. The technique has been evaluated in large series and has become popular among surgeons all around the world. In a comparative study of open mesh techniques for inguinal hernia repair, Lichtenstein's operation was similar to mesh plug or Prolene Hernia System (PHS) repair in terms of time to return to work, complications, chronic pain, and hernia recurrence in the short term to midterm. Indeed, postoperative pain after a Lichtenstein hernioplasty is minimal; according to a meta-analysis of all reported randomized studies, the pain is comparable to that occurring after laparoscopic repair. Inguinal hernias occur in about 15% of adult population, and mesh hernioplasty is the most common surgical procedure performed by general surgeons. Approximately 800,000 are performed each year in the United States; 100,000 in France; and 80,000 in the United Kingdom. There is morphologic and biochemical evidence that adult male inguinal hernias are associated with altered collagen type I–to–type III ratio. These changes lead to weakening of the fibroconnective tissue of the groin and development of inguinal hernias. Thus the need for prosthetic reinforcement of weakened abdominal wall tissue was recognized. In the past 2 decades, inguinal hernia surgery has gone through several advancements. With ample evidence that the use of mesh is associated with a reduced rate of recurrence, and with the availability of a variety of prosthetic meshes for the reinforcement of the posterior wall of the inguinal canal, most surgeons now preferably perform tension free mesh repair.
Benefits and disadvantages of laparoscopic hernia repair: Laparoscopic hernia surgery is feasible in expert hands, but the learning curve for laparoscopic hernia repair is long (200-250 cases), the severity of complications is greater, detailed analyses of cost effectiveness are lacking, and long-term recurrence rates are not known. The role of laparoscopic inguinal hernia repair in treatment of an uncomplicated, unilateral hernia is still unresolved. However transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) laparoscopic inguinal herniorrhaphy may offer specific benefits in some situations, such as recurrent hernia after conventional anterior open hernioplasty, bilateral hernias, and patients undergoing laparoscopy for other clean operative procedures.
Mesh in hernia repair: Emphasizing the Halstead principle of no tension, the Lichtenstein group advocated the routine use of mesh in 1984. The prosthesis used to reinforce the weakened posterior inguinal wall is placed between the transversalis fascia and the external oblique aponeurosis and extends well beyond the Hesselbach triangle. Mesh implants do not actively shrink, but they are passively compressed by the natural process of wound healing. Shrinkage of mesh occurs only to the extent to which the tissue contracts. A mesh with a small pore size is prone to shrink more. Shrinkage of the different types of mesh in vivo is approximately 20-40%, so the surgeon should ensure that the mesh adequately overlaps the defect on all sides. Use a large sheet of mesh (3 x 6 inches) extending approximately 2 cm medial to the pubic tubercle, 3-4 cm above the Hesselbach triangle, and 5-6 cm lateral to the internal ring to account for mesh shrinkage. Although the use of traditional microporous or heavyweight polypropylene meshes in the last 2 decades have reduced the incidence of recurrence after hernia surgery to less than 1%, a major concern has been the formation of a rigid scar plate causing patient discomfort and chronic pain, impairing quality of life. More than 50% of patients with a large mesh prosthesis in the abdominal wall complain of paresthesia, palpable stiff edges of the mesh, and physical restriction of abdominal wall mobility. It was assumed that flexibility of the abdominal wall is restricted by implantation of excessive foreign material and by excessive scar tissue formation. Better understanding of the biomechanics of the abdominal wall and the influence of mesh on those mechanics has led to our current understanding that “less is more.” In other words, less-dense, lighter-weight mesh of larger pore size, while still stronger than the abdominal wall, will result in less inflammation, better incorporation, better abdominal wall compliance, greater abdominal wall flexibility, less pain, and possibly less scar contraction and will therefore lead to a better clinical outcome. Light-weight, composite mesh thus was developed with the conviction that the ideal mesh should be just strong enough to handle the pressure of the abdominal wall and still be low in mass and as thin as possible. The advantage of large pore size mesh is that tissue is able to grow through the large pores of the mesh and create a thinner, more integrated scar. The new light-weight, composite meshes offer a combination of thinner filament size, larger pore size, reduced mass, and a percentage of absorbable material. Thus, there is less foreign body implanted, the scar tissue has greater flexibility (with almost physiologic abdominal wall mobility), there are fewer patient complaints, and the patient's quality of life is better. The use of light-weight mesh for Lichtenstein hernia repair did not affect recurrence rates, but it did improve some aspects of pain and discomfort 3 years after surgery. According to data from current randomized, controlled trials and retrospective studies, light meshes seem to have some advantages with respect to postoperative pain and foreign body sensation.
Relevant anatomy: The inguinal region is divided into superficial and deep planes by the external oblique aponeurosis. The superficial epigastric and superficial external pudendal vessels lie in the subcutaneous fat and need to be secured. The external oblique is aponeurotic in this region and has a triangular aperture, ie, the superficial inguinal ring on its inferomedial aspect just above the pubic tubercle. The spermatic cord with the ilioinguinal nerve on its anterior aspect can be seen emerging through the superficial ring. On incising the external oblique aponeurosis the inguinal canal is exposed. The lower internal oblique fibers originate from the inner and lateral aspect of the inguinal ligament and arch over to fuse with the transverses abdominis muscle to form the conjoint tendon. The lower muscle fibers of internal oblique are reflected over the spermatic cord as cremaster muscle. The posterior wall of the inguinal canal is formed by the transversus abdominis aponeurosis and fascia transversalis. The floor of the inguinal canal is formed by the reflected part of the inguinal ligament. The deep inguinal ring is an opening in the fascia transversalis about 1 cm above the midinguinal point. The content of the inguinal canal is the spermatic cord in males and the round ligament in females. The spermatic cord consists of the vas deferens, with its artery, testicular artery, pampiniform plexus of veins, lymph vessels, and sympathetic nerves. The nerves of the inguinal region are as follows:
These nerves are mainly sensory, but they also supply a motor component to the internal oblique and cremaster muscles. The nerves may be compromised due to injury by dissection or suture ligation, adherence to overlying mesh, or entrapment by scar tissue. (See the image below.)
Anatomy of nerves of the groin. Iliohypogastric nerve (T12, L1) The iliohypogastric nerve pierces the posterior part of transversus abdominis and divides into lateral and anterior cutaneous nerve of thigh. The anterior branch lies between transversus abdominis and internal oblique muscle and gives motor supply to both of these muscles. It then pierces the internal oblique to emerge in the inguinal canal just superior to the spermatic cord and then pierces the external oblique to innervate the skin of the abdomen above the pubis.
Ilioinguinal nerve (L1) The ilioinguinal nerve perforates the transversus abdominis muscle near the iliac spine and then pierces the internal oblique muscle to overlie the internal oblique and cremaster. It runs medially from the internal ring to the external ring through the inguinal canal to emerge from the superficial inguinal ring, where it can be easily identified. The ilioinguinal nerve innervates the upper and medial parts of the thigh, the anterior scrotum, and the base of the penis. Genitofemoral nerve (L2, L3)
The genitofemoral nerve runs on the anterior surface of the psoas muscle and divides into the genital and femoral branches. The genital branch of the genitofemoral nerve enters the inguinal region lateral to the internal ring and runs in the cremasteric fascia, along with the spermatic vessels. It innervates the cremaster muscle and provides sensory innervation to the scrotum. It may be injured during a tight closure of the internal ring. The femoral branch of genitofemoral nerve passes posterior to the inguinal ligament to enter the anterior thigh lateral to the femoral artery.
Indications and Contraindications
Indications for Lichtenstein hernioplasty: include the following:
Professor, Department of Surgery, AIIMS, Bhopal, India.
Synonyms, Key Words, and Related Terms
Lichtenstein hernioplasty, tension-free hernioplasty, open tension-free mesh technique, mesh hernioplasty, hernia mesh surgery, open hernia repair, inguinal hernia surgery
Introduction
Background: The Lichtenstein open tension-free mesh hernioplasty, performed under local anesthesia, is a simple technique to be learned (learning curve = 5 cases), and trained surgical residents are able to perform it without compromising the patient's care and long-term outcome. The procedure is time tested, safe, and economical, as well as being quick and easy to perform. In addition, it carries fewer complications and has become the gold standard in open tension-free hernioplasties. The procedure is well suited for smaller community-based, regional, and teaching hospitals, and it offers good immediate and long-term results. Moreover, the excellent results achieved with the Lichtenstein repair appear to be unrelated to the surgeons’ experience. The technique has been evaluated in large series and has become popular among surgeons all around the world. In a comparative study of open mesh techniques for inguinal hernia repair, Lichtenstein's operation was similar to mesh plug or Prolene Hernia System (PHS) repair in terms of time to return to work, complications, chronic pain, and hernia recurrence in the short term to midterm. Indeed, postoperative pain after a Lichtenstein hernioplasty is minimal; according to a meta-analysis of all reported randomized studies, the pain is comparable to that occurring after laparoscopic repair. Inguinal hernias occur in about 15% of adult population, and mesh hernioplasty is the most common surgical procedure performed by general surgeons. Approximately 800,000 are performed each year in the United States; 100,000 in France; and 80,000 in the United Kingdom. There is morphologic and biochemical evidence that adult male inguinal hernias are associated with altered collagen type I–to–type III ratio. These changes lead to weakening of the fibroconnective tissue of the groin and development of inguinal hernias. Thus the need for prosthetic reinforcement of weakened abdominal wall tissue was recognized. In the past 2 decades, inguinal hernia surgery has gone through several advancements. With ample evidence that the use of mesh is associated with a reduced rate of recurrence, and with the availability of a variety of prosthetic meshes for the reinforcement of the posterior wall of the inguinal canal, most surgeons now preferably perform tension free mesh repair.
Benefits and disadvantages of laparoscopic hernia repair: Laparoscopic hernia surgery is feasible in expert hands, but the learning curve for laparoscopic hernia repair is long (200-250 cases), the severity of complications is greater, detailed analyses of cost effectiveness are lacking, and long-term recurrence rates are not known. The role of laparoscopic inguinal hernia repair in treatment of an uncomplicated, unilateral hernia is still unresolved. However transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) laparoscopic inguinal herniorrhaphy may offer specific benefits in some situations, such as recurrent hernia after conventional anterior open hernioplasty, bilateral hernias, and patients undergoing laparoscopy for other clean operative procedures.
Mesh in hernia repair: Emphasizing the Halstead principle of no tension, the Lichtenstein group advocated the routine use of mesh in 1984. The prosthesis used to reinforce the weakened posterior inguinal wall is placed between the transversalis fascia and the external oblique aponeurosis and extends well beyond the Hesselbach triangle. Mesh implants do not actively shrink, but they are passively compressed by the natural process of wound healing. Shrinkage of mesh occurs only to the extent to which the tissue contracts. A mesh with a small pore size is prone to shrink more. Shrinkage of the different types of mesh in vivo is approximately 20-40%, so the surgeon should ensure that the mesh adequately overlaps the defect on all sides. Use a large sheet of mesh (3 x 6 inches) extending approximately 2 cm medial to the pubic tubercle, 3-4 cm above the Hesselbach triangle, and 5-6 cm lateral to the internal ring to account for mesh shrinkage. Although the use of traditional microporous or heavyweight polypropylene meshes in the last 2 decades have reduced the incidence of recurrence after hernia surgery to less than 1%, a major concern has been the formation of a rigid scar plate causing patient discomfort and chronic pain, impairing quality of life. More than 50% of patients with a large mesh prosthesis in the abdominal wall complain of paresthesia, palpable stiff edges of the mesh, and physical restriction of abdominal wall mobility. It was assumed that flexibility of the abdominal wall is restricted by implantation of excessive foreign material and by excessive scar tissue formation. Better understanding of the biomechanics of the abdominal wall and the influence of mesh on those mechanics has led to our current understanding that “less is more.” In other words, less-dense, lighter-weight mesh of larger pore size, while still stronger than the abdominal wall, will result in less inflammation, better incorporation, better abdominal wall compliance, greater abdominal wall flexibility, less pain, and possibly less scar contraction and will therefore lead to a better clinical outcome. Light-weight, composite mesh thus was developed with the conviction that the ideal mesh should be just strong enough to handle the pressure of the abdominal wall and still be low in mass and as thin as possible. The advantage of large pore size mesh is that tissue is able to grow through the large pores of the mesh and create a thinner, more integrated scar. The new light-weight, composite meshes offer a combination of thinner filament size, larger pore size, reduced mass, and a percentage of absorbable material. Thus, there is less foreign body implanted, the scar tissue has greater flexibility (with almost physiologic abdominal wall mobility), there are fewer patient complaints, and the patient's quality of life is better. The use of light-weight mesh for Lichtenstein hernia repair did not affect recurrence rates, but it did improve some aspects of pain and discomfort 3 years after surgery. According to data from current randomized, controlled trials and retrospective studies, light meshes seem to have some advantages with respect to postoperative pain and foreign body sensation.
Relevant anatomy: The inguinal region is divided into superficial and deep planes by the external oblique aponeurosis. The superficial epigastric and superficial external pudendal vessels lie in the subcutaneous fat and need to be secured. The external oblique is aponeurotic in this region and has a triangular aperture, ie, the superficial inguinal ring on its inferomedial aspect just above the pubic tubercle. The spermatic cord with the ilioinguinal nerve on its anterior aspect can be seen emerging through the superficial ring. On incising the external oblique aponeurosis the inguinal canal is exposed. The lower internal oblique fibers originate from the inner and lateral aspect of the inguinal ligament and arch over to fuse with the transverses abdominis muscle to form the conjoint tendon. The lower muscle fibers of internal oblique are reflected over the spermatic cord as cremaster muscle. The posterior wall of the inguinal canal is formed by the transversus abdominis aponeurosis and fascia transversalis. The floor of the inguinal canal is formed by the reflected part of the inguinal ligament. The deep inguinal ring is an opening in the fascia transversalis about 1 cm above the midinguinal point. The content of the inguinal canal is the spermatic cord in males and the round ligament in females. The spermatic cord consists of the vas deferens, with its artery, testicular artery, pampiniform plexus of veins, lymph vessels, and sympathetic nerves. The nerves of the inguinal region are as follows:
- Iliohypogastric nerve
- Ilioinguinal nerve
- Genitofemoral nerve
These nerves are mainly sensory, but they also supply a motor component to the internal oblique and cremaster muscles. The nerves may be compromised due to injury by dissection or suture ligation, adherence to overlying mesh, or entrapment by scar tissue. (See the image below.)
Anatomy of nerves of the groin. Iliohypogastric nerve (T12, L1) The iliohypogastric nerve pierces the posterior part of transversus abdominis and divides into lateral and anterior cutaneous nerve of thigh. The anterior branch lies between transversus abdominis and internal oblique muscle and gives motor supply to both of these muscles. It then pierces the internal oblique to emerge in the inguinal canal just superior to the spermatic cord and then pierces the external oblique to innervate the skin of the abdomen above the pubis.
Ilioinguinal nerve (L1) The ilioinguinal nerve perforates the transversus abdominis muscle near the iliac spine and then pierces the internal oblique muscle to overlie the internal oblique and cremaster. It runs medially from the internal ring to the external ring through the inguinal canal to emerge from the superficial inguinal ring, where it can be easily identified. The ilioinguinal nerve innervates the upper and medial parts of the thigh, the anterior scrotum, and the base of the penis. Genitofemoral nerve (L2, L3)
The genitofemoral nerve runs on the anterior surface of the psoas muscle and divides into the genital and femoral branches. The genital branch of the genitofemoral nerve enters the inguinal region lateral to the internal ring and runs in the cremasteric fascia, along with the spermatic vessels. It innervates the cremaster muscle and provides sensory innervation to the scrotum. It may be injured during a tight closure of the internal ring. The femoral branch of genitofemoral nerve passes posterior to the inguinal ligament to enter the anterior thigh lateral to the femoral artery.
Indications and Contraindications
Indications for Lichtenstein hernioplasty: include the following:
- Adult patients with uncomplicated inguinal and femoral hernia
- Primary repair of all unilateral and bilateral, adult inguinal hernias
- Recurrent hernias - Recurrence after primary posterior technique (such as laparoscopic TEP, TAPP, or open posterior technique)
Contraindications include complications such as obstruction or strangulation and a history of allergy to local anesthesia or prosthesis. Recurrence after primary anterior technique should preferably be dealt with using laparoscopic TEP, TAPP, or the open posterior technique.
Technical Considerations Lichtenstein hernioplasty is suitable for all adult patients irrespective of age, weight, general health, and the presence of concomitant medical problems. For large scrotal (irreducible) inguinal hernias, after major lower abdominal surgery, and when no general anesthesia is possible, the Lichtenstein repair is the preferred surgical technique.
Complication prevention: The overall risk of complications after inguinal hernia surgery reportedly varies from 15-28% in systematic reviews. Early complications include seroma formation and hematoma (8-22% of cases), urinary retention, and wound infection (1-7% of cases). Late complications include sensory loss, hyperesthesia, chronic inguinal pain, mesh-related problems, hydrocele, testicular pain, testicular swelling, atrophy, and recurrence of hernia. Most seromas disappear spontaneously within a period of 6–8 weeks. Should a seroma persist, it can be aspirated. A small hematoma can be treated conservatively. For larger hematomas, which are asymptomatic, evacuation under anesthesia should be considered. Meticulous dissection with adequate hemostasis will reduce the incidence of seroma and hematoma formation. The surgeon should always be aware of the vas deferens and should protect it from injury. The incidence of vas deferens injury is about 0.3%.
Urinary retention In a meta-analysis of 72 studies, the incidence of urinary retention after herniorrhaphy was 0.37% (33 in 8991 patients) with local anesthesia, 2.42% with regional anesthesia (150 in 6,191 patients), and 3% with general anaesthesia (344 in 11,471 patients). Such retention is said to be due to the inhibitory effect of regional and general anesthesia on bladder function.
Antibiotic prophylaxis: In clinical settings with low rates (<5%) of wound infection, there is no indication for the routine use of antibiotic prophylaxis in low-risk patients. In the presence of risk factors for wound infection (recurrent hernia, advanced age, immunosuppressive conditions, expected prolonged operating times), the use of antibiotic prophylaxis should be considered. Such prophylaxis should also be used at centers where high rates of wound infection are observed in elective settings. Recurrence: The recurrence rate for Lichtenstein hernioplasty at specialist clinics in the United States is consistently less than 1%. In an audit of Lichtenstein hernioplasty performed under local anesthesia by surgical residents, the recurrent rate was 2.1% during a 10-year follow-up. Recurrence in Lichtenstein hernioplasty may be due to inaccurate execution of the technique (inadequate size or improper fixation of the mesh) or to an overlooked hernia at the primary operation. To avoid the latter, the patient should be asked to cough, and the region should be carefully examined for the presence of indirect hernia, direct hernia, femoral hernia, or a combined hernia. Recurrence may occur more frequently in the presence of comorbidities such as chronic cough (chronic obstructive pulmonary disease) or obesity or with the use of steroids. Other contributory factors may be the use of small-sized mesh placed flat under tension, inadequate overlap (medially 2 cm beyond the pubic tubercle and laterally 5-6 cm beyond the internal ring), or failure to cross the tails of the mesh. (See Technique.) A thorough clinical evaluation, a high degree of suspicion, and a diligent follow-up for a long period is advised to keep track of recurrences. Women have a higher risk of recurrence (inguinal or femoral) than do men following an open inguinal hernia operation, due to a higher occurrence of femoral hernias. In female patients, the existence of a femoral hernia should always be excluded by exposing the femoral canal.
Pain: Postoperative chronic pain is more frequent than previously understood and has become one of the most important primary endpoints in hernia surgery. Published reports mention incidence rates for postherniorrhaphy pain ranging from 0% to more than 30%. (Chronic inguinodynia is defined as pain persisting more than 3 months postherniorrhaphy, after the process of wound healing is complete.) Nonfixation or inadequate mesh fixation results in folding and rolling of the mesh, which can cause chronic pain and recurrence of the hernia. Chronic pain after mesh hernioplasty also results from neuroma formation after accidental division of the nerves. The ilioinguinal, iliohypogastric, and genitofemoral nerves are visualized and protected throughout the operation. The nerves should not be dissected free from their natural bed, as that results in perineural fibrosis and chronic pain postoperatively.
Deliberate sectioning of the nerves intraoperatively to prevent chronic groin pain has been described but is still controversial. Current recommendations are nerve identification, minimal handling, and preservation. The prevention of nerve injury is very important, because the treatment of chronic neuralgias may not be successful. Entrapment of a nerve by suture or mesh appears to be an important cause of postoperative pain. The groin nerves should be identified and protected. Fibrin/biologic glues may be used instead of sutures to secure the mesh. It appears that cyanoacrylate glue may be a possible alternative to sutures, and it is anticipated that the use of fewer sutures may be associated with less inguinodynia. Another cause of significant postherniorrhaphy pain is the placement of a stitch into the periosteum at the pubic tubercle for fixation of the mesh medially. This is often the point of maximal tenderness postoperatively, and therefore, one should avoid taking a deep bite through the periosteum of the pubic tubercle. Tough, fibrous tissue in that region should instead be used for fixing the mesh. The use of a novel low-density, macroporous mesh with semiresorbable, self-fixing properties during tension-free repair may be a satisfactory solution to the clinical problems of pain and recurrence following inguinal herniorrhaphy.
Ischemic orchitis and thrombosis: Ischemic orchitis leading to atrophic testicle is a rare, but well-known, complication of inguinal hernia surgery. The patient may complain of pain and testicular swelling postoperatively. Symptoms may last for 2-3 months, and testicular atrophy may occur. Although this complication is rare, there should be a high index of suspicion for it. Testicular ultrasonography and Doppler studies may help in early diagnosis and the avoidance of orchiectomy. Ischemic orchitis is thought to be secondary to venous thrombosis rather than to arterial injury. The thrombosis is caused by surgical trauma to the delicate veins of the pampiniform plexus and disruption of the collateral blood supply to the testes, while the surgeon attempts to completely remove a large hernia sac. It is also more likely in patients undergoing surgery for recurrent hernia. It is thus recommended that one should not try to completely dissect and excise a large hernia sac. The neck of the hernia sac is transacted at the midpoint of the inguinal canal and the distal sac is left in place. However, the anterior wall of the distal sac is incised to prevent postoperative hydrocele formation.
Vascular injury: Vascular injury is a less common, but potentially disastrous, complication. This can be avoided by respecting the proximity of the femoral vessels, particularly when suturing the mesh to the inguinal ligament. Hematoma formation can result from injury of the inferior epigastric vessels or pampiniform plexus veins or from failure to ligate the superficial subcutaneous veins.
Direct and Indirect Hernias An indirect hernia can be congenital or acquired. In indirect hernias, herniation occurs through the deep ring. The sac is anterolateral to the cord structures and follows the spermatic cord in males and the round ligament in females. A direct inguinal hernia occurs through Hesselbach’s triangle, formed by the inferior epigastric vessels laterally, the rectus sheath medially, and the inguinal ligament inferiorly. An indirect hernia is lateral to the inferior epigastric artery and vein, while a direct hernia is medial to these vessels. The sac of direct inguinal hernia emerges from behind the cord structures. In a sliding inguinal hernia, a portion of the wall of the hernia sac is made up of an intra-abdominal organ, such as the urinary bladder, sigmoid colon, or cecum.
Periprocedural Care
Equipment
Anesthetic equipment should include a cardiac monitor and a pulse oximeter for high-risk patients with comorbidities. Synthetic, nonabsorbable flat meshes (or composite meshes with a nonabsorbable component) should be used. The use of light-weight, material-reduced, large-pore (>1000-μm) meshes in open inguinal hernia repair can be considered to decrease long-term discomfort, but possibly at the cost of increased recurrence rate (possibly due to inadequate fixation and/or overlap)
The instruments kept in surgical trolley include the following:
Patient Preparation: The Lichtenstein hernioplasty can be safely performed under local anesthesia. It allows immediate postoperative mobilization and discharge of the patient on a day care basis, so the hospital stay, complications, and cost of treatment are minimized. In addition, a patient under local anesthesia can be asked to cough during the procedure to identify additional hernias and to ensure the adequacy of the prosthetic repair. Anesthesia Commonly used local anesthetics are 0.5-1% lidocaine with epinephrine, 0.25-0.5% bupivacaine, or a combination of these 2 agents in a 50:50 mixture. About 30-45 mL of a 50:50 mixture of 1% lidocaine (Xylocaine) and 0.5% bupivacaine (Marcaine), with 1/200,000 epinephrine, is usually sufficient for a unilateral hernia repair. Lidocaine provides rapid onset, and bupivacaine results in a longer duration of local anesthesia. Epinephrine further prolongs the duration of anesthesia but should be avoided in hypertensive patients and patients with ischemic heart disease. Local infiltration is performed in sequential steps as the operation progresses. As the incision begins at the pubic tubercle and extends 5–6 cm laterally up to the midinguinal point, about 10 mL is infiltrated into the subcutaneous adipose tissue underneath the site of incision, beginning from the lateral end of incision site. The needle is withdrawn until its tip reaches the intradermic level. About 3-5 mL is then infiltrated intradermally along the line of the incision. Another 10 mL is injected deep into the subcutaneous adipose tissue along the line of incision. After incising the skin and subcutaneous tissue, another 10 mL is injected underneath the aponeurosis of the external oblique muscle. This creates plains for dissection underneath the external oblique and anesthetizes all 3 nerves of this region, ie, the ilioinguinal and iliohypogastric nerves and the genital branch of the genitofemoral nerve. A few mL of local anesthetic solution is then infiltrated around the pubic tubercle and the neck of the hernia sac. At the end of surgery, about 10 mL of solution is splashed in the inguinal canal and the subcutaneous tissue for good postoperative analgesia. Sedative drugs and anxiolytic agents may be given by the surgeon as a supplement to local anesthesia in some patients to reduce apprehension. In very large, incarcerated inguinal hernias; apprehensive patients; or patients not willing to undergo the surgery under local anesthesia, the procedure it can be performed under regional or general anesthesia.
Positioning: The patient is placed straight in a supine position. He/she should be at ease, and the position should be comfortable for the surgical team. The operative field is painted and draped, covering the patient’s upper abdomen and lower limbs. The patient’s head is left open for conversation with the surgeon. The surgeon stands on the side of the patient with the hernia that will be undergoing surgery, and the assistant stands on the opposite side. Monitoring and Follow-Up With the routine use of mesh for hernia surgery recurrence rate has come down to less than 1%. Although some recurrences occur early cases may be reported many years later. A thorough clinical evaluation, high degree of suspicion and a diligent follow up for a long period is advised to keep track of recurrences. Patients with chronic groin pain, postoperative neuralgia, paresthesias, neurapraxia, or hypesthesia for more than 6 months after surgery should be referred for further evaluation, surgical exploration and if required excision of the involved nerve. A multidisciplinary approach at a pain clinic is an option for the treatment of chronic post-herniorrhaphy pain. Surgical treatment of specific causes of chronic post-herniorrhaphy pain includes resection of entrapped nerves, mesh removal in mesh-related pain, removal of fixating sutures and burying the nerve endings in internal oblique muscle.
Operative Technique
The incision is placed about 1 cm above and parallel to the inguinal ligament, beginning from the pubic tubercle and extending 5-6 cm laterally, up to the midinguinal point. The subcutaneous fat is then opened in the length of the incision, and careful hemostasis is achieved by ligating superficial pudendal and superficial epigastric vessels. The Scarpa fascia is similarly opened along the length of the incision, down to the external oblique aponeurosis, and the external inguinal ring and the lower border of the inguinal ligament are visualized. Below the inguinal ligament, on the medial aspect, the deep fascia of the thigh is opened, the femoral canal is exposed, and a check is made for the presence of a concomitant femoral hernia. Although a very low risk, routine exploration of the femoral canal is advised in the absence of an inguinal hernia and in women. (See the images below.)
Draping and incision. External oblique aponeurosis with external inguinal ring. External oblique with external inguinal ring. The external oblique aponeurosis is then opened along the line of incision, starting from the external ring and extending laterally up to 5 cm. The ilioinguinal nerve, lying underneath the aponeurosis, is safeguarded during this procedure. The superior and inferior flaps of the external oblique aponeurosis is then gently freed from the underlying contents of the inguinal canal and overturned to expose the whole of the cremaster with the cord structures, the internal oblique muscle with the iliohypogastric nerve, and the free lower border of the inguinal ligament. Wide separation of the superior and inferior flaps of the external oblique aponeurosis provides good exposure of the inguinal canal, the ilioinguinal and iliohypogastric nerves, the uppermost aponeurotic portion of the internal oblique and conjoint tendon, and the free lower border of the inguinal ligament. It provides ample space in the region for placement of a wide mesh and its fixation to the aponeurotic structures under vision while protecting the nerves. (See the images below.)
Reflected part of inguinal ligament exposed for fixing inferior edge of mesh. Inferior flap of external oblique developed to expose inguinal ligament from pubic tubercle to midinguinal point. The superior flap of external oblique is developed as high as possible to provide ample space for mesh placement. The spermatic cord along with cremaster is then lifted up and separated from the pubic bone for about 2 cm beyond the pubic tubercle to create space for extending the mesh well beyond the pubic tubercle. When lifting the cord, be sure to include the ilioinguinal nerve, the genitofemoral nerve, and the spermatic vessels along with it. All of these structures may then be encircled in a tape for ease of handling. The anatomical plane between cremaster and aponeurotic tissue attached to the pubic bone is avascular and cord structures encircled in the tape can be separated from the floor of the inguinal canal up to the internal ring. A visible landmark for safeguarding the genital nerve is the external spermatic vein, usually referred as the "blue line." If the blue line is kept with the spermatic cord, the surgeon can be sure that the genital branch of the genitofemoral nerve, which is always adjacent to this vein, is well protected. (See the images below.)
Exposure of inguinal canal. Lifting up cord with hernia sac medial to external inguinal ring. Avascular plane between posterior inguinal wall and cord structures. Cord structures and hernia sac looped along with ilioinguinal and genitofemoral nerve Hernia Sac Management Having visualized the cord structures and all of the nerves of the inguinal canal, the hernia sac must now be identified and isolated. The patient is asked to cough, and the region is examined for the presence of an indirect hernia, a direct hernia, a femoral hernia, a combined hernia, or a spigelian hernia.
A hernia sac can be managed by inversion, division, resection, or ligation. Resection and ligation of a small hernia sac should not be performed unnecessarily, as it causes postoperative pain. However the hernia sac must be well separated from the internal ring before it is invaginated. The risk of recurrence is not increased when a small or medium-sized, indirect hernia sac is not ligated. A study found that excision of an indirect hernia sac in inguinal hernia repair is associated with a lower risk of hernia recurrence than is division or invagination.When the hernia sac is excised or divided, the proximal sac should never be left open, because that may lead to recurrence. The proximal sac is dissected free of cord structures well above the internal ring, and a high ligation of the neck of the sac should be performed. (See the images below.) Cremaster muscle picked up to be incised longitudinally between hemostats. Indirect hernia sac dissected and being separated from lipoma of cord and cord structures. Lipoma of cord dissected free and excised.
The indirect hernia sac lies anterolateral to the cord structures and is visualized by dividing the cremaster muscle longitudinally. The cremaster muscle should not be divided transversely or excised, as it may result in low-lying testes and dysejaculation. The peritoneal sac is identified and separated from the spermatic vessels and vas deferens high unto its neck. A small or medium-sized hernia sac is isolated and inverted into the preperitoneal space without suture ligation. For a voluminous scrotal hernia sac, one should not try to completely dissect and excise it, since this can result in ischemic orchitis. The neck of a large hernia sac is transected at the midpoint of the inguinal canal, and the proximal part is suture ligated. A high ligation of the proximal sac is recommended and the stump is reduced deep underneath the internal ring. The distal sac is left in place; however, the anterior wall of the distal sac is incised to prevent postoperative hydrocele formation. (See the images below.) Indirect hernia sac separated from cord structures in midinguinal region towards the neck of sac. Voluminous indirect hernia sac separated from the cord structures in the midinguinal region up to the neck of the sac.
Hernia sac being divided near the neck. Contents of hernia sac reduced and proximal end to be sutured closed. Anterior wall of distal sac incised to prevent hydrocele formation. A direct inguinal hernia lies posteromedial to the cord structures. The direct hernia sac is isolated and dissected free. Its contents are reduced, and the peritoneal sac is inverted and maintained in position by purse string suture. If there is suspicion of a femoral hernia, the femoral ring should be evaluated by incising the medial part of the iliopubic tract. If a sac is seen entering the femoral ring, it is reduced and dealt with by inverting or ligating the neck of the sac. Spigelian hernias are managed in a similar manner. A sliding hernia is simply dissected free and inverted in the preperitoneal space. Mesh Placement and Fixation A 15 x 8–cm polypropylene mesh is more commonly used in the Lichtenstein hernioplasty. On the medial side, the sharp corners of the mesh are trimmed to conform to the patient’s anatomy. The mesh should be wide enough to extend 3-4 cm beyond the boundary of the inguinal triangle, to compensate for future shrinkage of the mesh. It should be placed lax in the posterior wall of the inguinal canal so as to form a domelike wrinkle in the mesh, to compensate for increased intra-abdominal pressure when the patient stands up. For a femoral hernia, the mesh is tailored to have a triangular extension from its lower edge on its medial side. The first medial-most stitch in the mesh fixes it 2 cm medial to the pubic tubercle, where the anterior rectus sheath inserts into the pubic bone. Care should be taken not to pass the needle through the periosteum of the bone or through the pubic tubercle, because this is one of the most common causes of chronic postoperative pain.
First medial-most stitch in the mesh fixing it about 2 cm medial to pubic tubercle, where anterior rectus sheath inserts into pubis. Fixation of the lower edge of the mesh. The same suture serves as a continuous suture to fix the lower edge of the mesh to the free lower border of inguinal ligament up to a point just lateral to the internal ring. No more than 4-5 passes are required. For a femoral hernia, the medial portion of the iliopubic tract is excised and Cooper ligament is exposed. The lower triangular extension on the medial side of the mesh is stitched to the Cooper ligament and is continued to suture the lower edge of the mesh to the inguinal ligament, as above. The same suture is utilized as a continuous suture to fix the lower edge of mesh to the reflected part of inguinal ligament up to the internal ring. A slit is then made in the lateral end of the mesh, creating a narrower lower tail (lower one third) and a wider upper tail (upper two thirds). The slit extends up to a point just medial to the internal inguinal ring. The upper tail is passed underneath the cord so as to place the mesh posterior to the cord in the inguinal canal, and the spermatic cord is placed between the 2 tails of the mesh. The upper tail is then crossed over the lower one and the 2 tails are held in an artery forceps.
Lower edge of mesh sutured to inguinal ligament up to the internal inguinal ring. To accommodate the cord structures, the lateral end of mesh is divided into a wider upper (two thirds) and narrower lower (one third) tail. Wider upper tail of mesh passed underneath the cord, and mesh is placed posteriorly in the inguinal canal behind spermatic cord. Keeping the mesh lax, the upper edge of the mesh is then fixed to the rectus sheath and internal oblique aponeurosis by 2 or 3 interrupted, nonabsorbable sutures. The iliohypogastric nerve may sometimes come in the way of upper edge of the mesh. In such cases, the mesh may be split to accommodate the nerve. Slit made in the mesh to accommodate the iliohypogastric nerve. Two interrupted sutures are taken under vision to fix the upper edge of mesh while safeguarding the iliohypogastric nerve.
Fixation of the upper edge of the mesh. The 2 tails are then tucked together and fixed to the inguinal ligament just lateral to the internal ring, thus creating a new internal ring made of mesh. The tails are trimmed 5 cm beyond the internal ring and placed underneath the external oblique aponeurosis. Suturing the mesh beyond the internal ring is unnecessary and may injure the femoral nerve. Similarly, fixation of the tails of the mesh to the internal oblique muscle, lateral to the internal ring, may cause entrapment of the ilioinguinal nerve. Trying to suture the 2 tails without crossing or trimming the tails shorter than 5-6 cm beyond the internal ring may result in recurrence at the deep inguinal ring.18 The upper tail is crossed over the lower tail around the spermatic cord, thus creating an internal ring. The lower edges of the 2 tails are tucked together to the inguinal ligament just lateral to the internal ring. The 2 tails are then passed underneath the external oblique aponeurosis to give an overlap of about 5 cm beyond internal ring.
If any of the nerves are injured or integrity is doubtful, the nerve can be resected and the proximal end ligated and buried within the fibers of the internal oblique muscle to keep the stump of the nerve away from scarring. In male patients, always gently pull the testes back down to their normal scrotal position
after fixation of the mesh. The external oblique aponeurosis is reapproximated with 2-0 polypropylene and the skin is closed with staples or subcuticular stitches. External oblique aponeurosis sutured with 2-0 Prolene. Subcutaneous tissue approximated with 3-0 plain catgut. Skin approximated with 2-0 Prolene subcuticular suture.
Postoperative Care: Patient is asked to rest for few hours. He or she may be discharged on the same day on a day care basis. Early mobilization is the key to rapid convalescence. If general or regional anesthesia is used, the patient may be hospitalized for few days. There is some pain in the postoperative period, and suitable analgesics should be prescribed. The dressing is removed on the fifth postoperative day, and stitches are removed on seventh postoperative day. Light work can be resumed after a week, and heavier jobs after 6 weeks.
REFERENCES
1. Paajanen H, Varjo R. Ten-year audit of Lichtenstein hernioplasty under local anaesthesia performed by surgical residents. BMC Surg. Aug 4 2010;10:24. [Medline]. [Full Text].
2. Wiese M, Kaufmann T, Metzger J, et al. Learning curve for Lichtenstein hernioplasty. Open Access Surgery. Jul 2 2010;3:43-6. [Full Text].
3. {Guideline} Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. Aug 2009;13(4):343-403. [Medline]. [Full Text].
4. Kark AE, Kurzer M, Waters KJ. Tension-free mesh hernia repair: review of 1098 cases using local anaesthesia in a day unit. Ann R Coll Surg Engl. Jul 1995;77(4):299-304. [Medline]. [Full Text].
5. Gianetta E, Cuneo S, Vitale B, et al. Anterior tension-free repair of recurrent inguinal hernia under local anesthesia: a 7-year experience in a teaching hospital. Ann Surg. Jan 2000;231(1):132-6. [Medline]. [Full Text].
6. Zhao G, Gao P, Ma B, et al. Open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Ann Surg. Jul 2009;250(1):35-42. [Medline].
7. Chung RS. Meta-analysis of randomized controlled trials of laparoscopic versus conventional inguinal hernia repair. Surg Endosc. 1999;7:68-94.
8. Junge K, Klinge U, Prescher A, et al. Elasticity of the anterior abdominal wall and
impact for reparation of incisional hernias using mesh implants. Hernia. Sep 2001;5(3):113-8. [Medline].
9. Fingerhut A, Millet B, Veyrie N, et al. Inguinal hernia repair, update 2006. In: Edmund AM, Neugebauer S, Fingerhut A, et al. EAES Guidelines for Endoscopic Surgery. vol 1. Springer; 2006:294-307.
10. DeBord JR, Whitty LA. Biomaterials in hernia repair. In: Fischer JE. Mastery of Surgery. vol 2. 5th ed. Lippincott Williams & Wilkins; 2007:1965-8.
11. Bringman S, Wollert S, Osterberg J, et al. Three-year results of a randomized clinical trial of lightweight or standard polypropylene mesh in Lichtenstein repair of primary inguinal hernia. Br J Surg. Sep 2006;93(9):1056-9. [Medline].
12. Weyhe D, Belyaev O, Muller C, et al. Improving outcomes in hernia repair by the use of light meshes--a comparison of different implant constructions based on a critical appraisal of the literature. World J Surg. Jan 2007;31(1):234-44. [Medline].
13. Sanchez-Manuel FJ, Lozano-Garcia J, Seco-Gil JL. Antibiotic prophylaxis for hernia repair. Cochrane Database Syst Rev. Jul 18 2007;CD003769. [Medline].
14. Shankar VG, Srinivasan K, Sistla SC, et al. Prophylactic antibiotics in open mesh repair of inguinal hernia - a randomized controlled trial. Int J Surg. 2010;8(6):444-7. [Medline].
15. Hakeem A, Shanmugam V. Inguinodynia following Lichtenstein tension-free hernia repair: a review. World J Gastroenterol. Apr 14 2011;17(14):1791-6. [Medline]. [Full Text].
16. Chastan P. Tension-free open hernia repair using an innovative self-gripping semi-resorbable mesh. Hernia. Apr 2009;13(2):137-42. [Medline].
17. Amid PK, Shulman AG, Lichtenstein IL. Local anesthesia for inguinal hernia repair step-by-step procedure. Ann Surg. Dec 1994;220(6):735-7. [Medline]. [Full Text].
18. Amid PK. Lichtenstein tension-free hernioplasty. In: Fischer JE. Mastery of Surgery. vol 2. 5th ed. Lippincott Williams & Wilkins; 2007:1933-9.
19. Stylianidis G, Haapamaki MM, Sund M, et al. Management of the hernial sac in inguinal hernia repair. Br J Surg. Mar 2010;97(3):415-9. [Medline].
20. Treadwell J, Tipton K, Oyesanmi O, Sun F, Schoelles K. Surgical Options for Inguinal Hernia: Comparative Effectiveness Review [Internet]. Effective Healthcare Program. Aug 2012;[Medline]. [Full Text].
Author Information: Dr Pradeep Saxena, M.S [Surgery], F.MAS, FACRSI, FHBPS
Professor, Department of Surgery, AIIMS, Bhopal
Website: https://www.bhopalsurgery.com/home/Dr-Pradeep-Saxena
Email: pradeep@bhopalsurgery.com
Dr Pradeep Saxena is a member of the following medical societies: Association of Colon and Rectal Surgeons of India and Association of Surgeons of India.
Complication prevention: The overall risk of complications after inguinal hernia surgery reportedly varies from 15-28% in systematic reviews. Early complications include seroma formation and hematoma (8-22% of cases), urinary retention, and wound infection (1-7% of cases). Late complications include sensory loss, hyperesthesia, chronic inguinal pain, mesh-related problems, hydrocele, testicular pain, testicular swelling, atrophy, and recurrence of hernia. Most seromas disappear spontaneously within a period of 6–8 weeks. Should a seroma persist, it can be aspirated. A small hematoma can be treated conservatively. For larger hematomas, which are asymptomatic, evacuation under anesthesia should be considered. Meticulous dissection with adequate hemostasis will reduce the incidence of seroma and hematoma formation. The surgeon should always be aware of the vas deferens and should protect it from injury. The incidence of vas deferens injury is about 0.3%.
Urinary retention In a meta-analysis of 72 studies, the incidence of urinary retention after herniorrhaphy was 0.37% (33 in 8991 patients) with local anesthesia, 2.42% with regional anesthesia (150 in 6,191 patients), and 3% with general anaesthesia (344 in 11,471 patients). Such retention is said to be due to the inhibitory effect of regional and general anesthesia on bladder function.
Antibiotic prophylaxis: In clinical settings with low rates (<5%) of wound infection, there is no indication for the routine use of antibiotic prophylaxis in low-risk patients. In the presence of risk factors for wound infection (recurrent hernia, advanced age, immunosuppressive conditions, expected prolonged operating times), the use of antibiotic prophylaxis should be considered. Such prophylaxis should also be used at centers where high rates of wound infection are observed in elective settings. Recurrence: The recurrence rate for Lichtenstein hernioplasty at specialist clinics in the United States is consistently less than 1%. In an audit of Lichtenstein hernioplasty performed under local anesthesia by surgical residents, the recurrent rate was 2.1% during a 10-year follow-up. Recurrence in Lichtenstein hernioplasty may be due to inaccurate execution of the technique (inadequate size or improper fixation of the mesh) or to an overlooked hernia at the primary operation. To avoid the latter, the patient should be asked to cough, and the region should be carefully examined for the presence of indirect hernia, direct hernia, femoral hernia, or a combined hernia. Recurrence may occur more frequently in the presence of comorbidities such as chronic cough (chronic obstructive pulmonary disease) or obesity or with the use of steroids. Other contributory factors may be the use of small-sized mesh placed flat under tension, inadequate overlap (medially 2 cm beyond the pubic tubercle and laterally 5-6 cm beyond the internal ring), or failure to cross the tails of the mesh. (See Technique.) A thorough clinical evaluation, a high degree of suspicion, and a diligent follow-up for a long period is advised to keep track of recurrences. Women have a higher risk of recurrence (inguinal or femoral) than do men following an open inguinal hernia operation, due to a higher occurrence of femoral hernias. In female patients, the existence of a femoral hernia should always be excluded by exposing the femoral canal.
Pain: Postoperative chronic pain is more frequent than previously understood and has become one of the most important primary endpoints in hernia surgery. Published reports mention incidence rates for postherniorrhaphy pain ranging from 0% to more than 30%. (Chronic inguinodynia is defined as pain persisting more than 3 months postherniorrhaphy, after the process of wound healing is complete.) Nonfixation or inadequate mesh fixation results in folding and rolling of the mesh, which can cause chronic pain and recurrence of the hernia. Chronic pain after mesh hernioplasty also results from neuroma formation after accidental division of the nerves. The ilioinguinal, iliohypogastric, and genitofemoral nerves are visualized and protected throughout the operation. The nerves should not be dissected free from their natural bed, as that results in perineural fibrosis and chronic pain postoperatively.
Deliberate sectioning of the nerves intraoperatively to prevent chronic groin pain has been described but is still controversial. Current recommendations are nerve identification, minimal handling, and preservation. The prevention of nerve injury is very important, because the treatment of chronic neuralgias may not be successful. Entrapment of a nerve by suture or mesh appears to be an important cause of postoperative pain. The groin nerves should be identified and protected. Fibrin/biologic glues may be used instead of sutures to secure the mesh. It appears that cyanoacrylate glue may be a possible alternative to sutures, and it is anticipated that the use of fewer sutures may be associated with less inguinodynia. Another cause of significant postherniorrhaphy pain is the placement of a stitch into the periosteum at the pubic tubercle for fixation of the mesh medially. This is often the point of maximal tenderness postoperatively, and therefore, one should avoid taking a deep bite through the periosteum of the pubic tubercle. Tough, fibrous tissue in that region should instead be used for fixing the mesh. The use of a novel low-density, macroporous mesh with semiresorbable, self-fixing properties during tension-free repair may be a satisfactory solution to the clinical problems of pain and recurrence following inguinal herniorrhaphy.
Ischemic orchitis and thrombosis: Ischemic orchitis leading to atrophic testicle is a rare, but well-known, complication of inguinal hernia surgery. The patient may complain of pain and testicular swelling postoperatively. Symptoms may last for 2-3 months, and testicular atrophy may occur. Although this complication is rare, there should be a high index of suspicion for it. Testicular ultrasonography and Doppler studies may help in early diagnosis and the avoidance of orchiectomy. Ischemic orchitis is thought to be secondary to venous thrombosis rather than to arterial injury. The thrombosis is caused by surgical trauma to the delicate veins of the pampiniform plexus and disruption of the collateral blood supply to the testes, while the surgeon attempts to completely remove a large hernia sac. It is also more likely in patients undergoing surgery for recurrent hernia. It is thus recommended that one should not try to completely dissect and excise a large hernia sac. The neck of the hernia sac is transacted at the midpoint of the inguinal canal and the distal sac is left in place. However, the anterior wall of the distal sac is incised to prevent postoperative hydrocele formation.
Vascular injury: Vascular injury is a less common, but potentially disastrous, complication. This can be avoided by respecting the proximity of the femoral vessels, particularly when suturing the mesh to the inguinal ligament. Hematoma formation can result from injury of the inferior epigastric vessels or pampiniform plexus veins or from failure to ligate the superficial subcutaneous veins.
Direct and Indirect Hernias An indirect hernia can be congenital or acquired. In indirect hernias, herniation occurs through the deep ring. The sac is anterolateral to the cord structures and follows the spermatic cord in males and the round ligament in females. A direct inguinal hernia occurs through Hesselbach’s triangle, formed by the inferior epigastric vessels laterally, the rectus sheath medially, and the inguinal ligament inferiorly. An indirect hernia is lateral to the inferior epigastric artery and vein, while a direct hernia is medial to these vessels. The sac of direct inguinal hernia emerges from behind the cord structures. In a sliding inguinal hernia, a portion of the wall of the hernia sac is made up of an intra-abdominal organ, such as the urinary bladder, sigmoid colon, or cecum.
Periprocedural Care
Equipment
Anesthetic equipment should include a cardiac monitor and a pulse oximeter for high-risk patients with comorbidities. Synthetic, nonabsorbable flat meshes (or composite meshes with a nonabsorbable component) should be used. The use of light-weight, material-reduced, large-pore (>1000-μm) meshes in open inguinal hernia repair can be considered to decrease long-term discomfort, but possibly at the cost of increased recurrence rate (possibly due to inadequate fixation and/or overlap)
The instruments kept in surgical trolley include the following:
- Syringe
- 25-gauge needle
- Surgical knife with blade
- Mosquito forceps
- Dissecting scissors
- Prolene mesh
- Langenbeck retractors
- Adson thumb forceps
- Needle holder
- 2-0 Prolene and plain catgut sutures
Patient Preparation: The Lichtenstein hernioplasty can be safely performed under local anesthesia. It allows immediate postoperative mobilization and discharge of the patient on a day care basis, so the hospital stay, complications, and cost of treatment are minimized. In addition, a patient under local anesthesia can be asked to cough during the procedure to identify additional hernias and to ensure the adequacy of the prosthetic repair. Anesthesia Commonly used local anesthetics are 0.5-1% lidocaine with epinephrine, 0.25-0.5% bupivacaine, or a combination of these 2 agents in a 50:50 mixture. About 30-45 mL of a 50:50 mixture of 1% lidocaine (Xylocaine) and 0.5% bupivacaine (Marcaine), with 1/200,000 epinephrine, is usually sufficient for a unilateral hernia repair. Lidocaine provides rapid onset, and bupivacaine results in a longer duration of local anesthesia. Epinephrine further prolongs the duration of anesthesia but should be avoided in hypertensive patients and patients with ischemic heart disease. Local infiltration is performed in sequential steps as the operation progresses. As the incision begins at the pubic tubercle and extends 5–6 cm laterally up to the midinguinal point, about 10 mL is infiltrated into the subcutaneous adipose tissue underneath the site of incision, beginning from the lateral end of incision site. The needle is withdrawn until its tip reaches the intradermic level. About 3-5 mL is then infiltrated intradermally along the line of the incision. Another 10 mL is injected deep into the subcutaneous adipose tissue along the line of incision. After incising the skin and subcutaneous tissue, another 10 mL is injected underneath the aponeurosis of the external oblique muscle. This creates plains for dissection underneath the external oblique and anesthetizes all 3 nerves of this region, ie, the ilioinguinal and iliohypogastric nerves and the genital branch of the genitofemoral nerve. A few mL of local anesthetic solution is then infiltrated around the pubic tubercle and the neck of the hernia sac. At the end of surgery, about 10 mL of solution is splashed in the inguinal canal and the subcutaneous tissue for good postoperative analgesia. Sedative drugs and anxiolytic agents may be given by the surgeon as a supplement to local anesthesia in some patients to reduce apprehension. In very large, incarcerated inguinal hernias; apprehensive patients; or patients not willing to undergo the surgery under local anesthesia, the procedure it can be performed under regional or general anesthesia.
Positioning: The patient is placed straight in a supine position. He/she should be at ease, and the position should be comfortable for the surgical team. The operative field is painted and draped, covering the patient’s upper abdomen and lower limbs. The patient’s head is left open for conversation with the surgeon. The surgeon stands on the side of the patient with the hernia that will be undergoing surgery, and the assistant stands on the opposite side. Monitoring and Follow-Up With the routine use of mesh for hernia surgery recurrence rate has come down to less than 1%. Although some recurrences occur early cases may be reported many years later. A thorough clinical evaluation, high degree of suspicion and a diligent follow up for a long period is advised to keep track of recurrences. Patients with chronic groin pain, postoperative neuralgia, paresthesias, neurapraxia, or hypesthesia for more than 6 months after surgery should be referred for further evaluation, surgical exploration and if required excision of the involved nerve. A multidisciplinary approach at a pain clinic is an option for the treatment of chronic post-herniorrhaphy pain. Surgical treatment of specific causes of chronic post-herniorrhaphy pain includes resection of entrapped nerves, mesh removal in mesh-related pain, removal of fixating sutures and burying the nerve endings in internal oblique muscle.
Operative Technique
The incision is placed about 1 cm above and parallel to the inguinal ligament, beginning from the pubic tubercle and extending 5-6 cm laterally, up to the midinguinal point. The subcutaneous fat is then opened in the length of the incision, and careful hemostasis is achieved by ligating superficial pudendal and superficial epigastric vessels. The Scarpa fascia is similarly opened along the length of the incision, down to the external oblique aponeurosis, and the external inguinal ring and the lower border of the inguinal ligament are visualized. Below the inguinal ligament, on the medial aspect, the deep fascia of the thigh is opened, the femoral canal is exposed, and a check is made for the presence of a concomitant femoral hernia. Although a very low risk, routine exploration of the femoral canal is advised in the absence of an inguinal hernia and in women. (See the images below.)
Draping and incision. External oblique aponeurosis with external inguinal ring. External oblique with external inguinal ring. The external oblique aponeurosis is then opened along the line of incision, starting from the external ring and extending laterally up to 5 cm. The ilioinguinal nerve, lying underneath the aponeurosis, is safeguarded during this procedure. The superior and inferior flaps of the external oblique aponeurosis is then gently freed from the underlying contents of the inguinal canal and overturned to expose the whole of the cremaster with the cord structures, the internal oblique muscle with the iliohypogastric nerve, and the free lower border of the inguinal ligament. Wide separation of the superior and inferior flaps of the external oblique aponeurosis provides good exposure of the inguinal canal, the ilioinguinal and iliohypogastric nerves, the uppermost aponeurotic portion of the internal oblique and conjoint tendon, and the free lower border of the inguinal ligament. It provides ample space in the region for placement of a wide mesh and its fixation to the aponeurotic structures under vision while protecting the nerves. (See the images below.)
Reflected part of inguinal ligament exposed for fixing inferior edge of mesh. Inferior flap of external oblique developed to expose inguinal ligament from pubic tubercle to midinguinal point. The superior flap of external oblique is developed as high as possible to provide ample space for mesh placement. The spermatic cord along with cremaster is then lifted up and separated from the pubic bone for about 2 cm beyond the pubic tubercle to create space for extending the mesh well beyond the pubic tubercle. When lifting the cord, be sure to include the ilioinguinal nerve, the genitofemoral nerve, and the spermatic vessels along with it. All of these structures may then be encircled in a tape for ease of handling. The anatomical plane between cremaster and aponeurotic tissue attached to the pubic bone is avascular and cord structures encircled in the tape can be separated from the floor of the inguinal canal up to the internal ring. A visible landmark for safeguarding the genital nerve is the external spermatic vein, usually referred as the "blue line." If the blue line is kept with the spermatic cord, the surgeon can be sure that the genital branch of the genitofemoral nerve, which is always adjacent to this vein, is well protected. (See the images below.)
Exposure of inguinal canal. Lifting up cord with hernia sac medial to external inguinal ring. Avascular plane between posterior inguinal wall and cord structures. Cord structures and hernia sac looped along with ilioinguinal and genitofemoral nerve Hernia Sac Management Having visualized the cord structures and all of the nerves of the inguinal canal, the hernia sac must now be identified and isolated. The patient is asked to cough, and the region is examined for the presence of an indirect hernia, a direct hernia, a femoral hernia, a combined hernia, or a spigelian hernia.
A hernia sac can be managed by inversion, division, resection, or ligation. Resection and ligation of a small hernia sac should not be performed unnecessarily, as it causes postoperative pain. However the hernia sac must be well separated from the internal ring before it is invaginated. The risk of recurrence is not increased when a small or medium-sized, indirect hernia sac is not ligated. A study found that excision of an indirect hernia sac in inguinal hernia repair is associated with a lower risk of hernia recurrence than is division or invagination.When the hernia sac is excised or divided, the proximal sac should never be left open, because that may lead to recurrence. The proximal sac is dissected free of cord structures well above the internal ring, and a high ligation of the neck of the sac should be performed. (See the images below.) Cremaster muscle picked up to be incised longitudinally between hemostats. Indirect hernia sac dissected and being separated from lipoma of cord and cord structures. Lipoma of cord dissected free and excised.
The indirect hernia sac lies anterolateral to the cord structures and is visualized by dividing the cremaster muscle longitudinally. The cremaster muscle should not be divided transversely or excised, as it may result in low-lying testes and dysejaculation. The peritoneal sac is identified and separated from the spermatic vessels and vas deferens high unto its neck. A small or medium-sized hernia sac is isolated and inverted into the preperitoneal space without suture ligation. For a voluminous scrotal hernia sac, one should not try to completely dissect and excise it, since this can result in ischemic orchitis. The neck of a large hernia sac is transected at the midpoint of the inguinal canal, and the proximal part is suture ligated. A high ligation of the proximal sac is recommended and the stump is reduced deep underneath the internal ring. The distal sac is left in place; however, the anterior wall of the distal sac is incised to prevent postoperative hydrocele formation. (See the images below.) Indirect hernia sac separated from cord structures in midinguinal region towards the neck of sac. Voluminous indirect hernia sac separated from the cord structures in the midinguinal region up to the neck of the sac.
Hernia sac being divided near the neck. Contents of hernia sac reduced and proximal end to be sutured closed. Anterior wall of distal sac incised to prevent hydrocele formation. A direct inguinal hernia lies posteromedial to the cord structures. The direct hernia sac is isolated and dissected free. Its contents are reduced, and the peritoneal sac is inverted and maintained in position by purse string suture. If there is suspicion of a femoral hernia, the femoral ring should be evaluated by incising the medial part of the iliopubic tract. If a sac is seen entering the femoral ring, it is reduced and dealt with by inverting or ligating the neck of the sac. Spigelian hernias are managed in a similar manner. A sliding hernia is simply dissected free and inverted in the preperitoneal space. Mesh Placement and Fixation A 15 x 8–cm polypropylene mesh is more commonly used in the Lichtenstein hernioplasty. On the medial side, the sharp corners of the mesh are trimmed to conform to the patient’s anatomy. The mesh should be wide enough to extend 3-4 cm beyond the boundary of the inguinal triangle, to compensate for future shrinkage of the mesh. It should be placed lax in the posterior wall of the inguinal canal so as to form a domelike wrinkle in the mesh, to compensate for increased intra-abdominal pressure when the patient stands up. For a femoral hernia, the mesh is tailored to have a triangular extension from its lower edge on its medial side. The first medial-most stitch in the mesh fixes it 2 cm medial to the pubic tubercle, where the anterior rectus sheath inserts into the pubic bone. Care should be taken not to pass the needle through the periosteum of the bone or through the pubic tubercle, because this is one of the most common causes of chronic postoperative pain.
First medial-most stitch in the mesh fixing it about 2 cm medial to pubic tubercle, where anterior rectus sheath inserts into pubis. Fixation of the lower edge of the mesh. The same suture serves as a continuous suture to fix the lower edge of the mesh to the free lower border of inguinal ligament up to a point just lateral to the internal ring. No more than 4-5 passes are required. For a femoral hernia, the medial portion of the iliopubic tract is excised and Cooper ligament is exposed. The lower triangular extension on the medial side of the mesh is stitched to the Cooper ligament and is continued to suture the lower edge of the mesh to the inguinal ligament, as above. The same suture is utilized as a continuous suture to fix the lower edge of mesh to the reflected part of inguinal ligament up to the internal ring. A slit is then made in the lateral end of the mesh, creating a narrower lower tail (lower one third) and a wider upper tail (upper two thirds). The slit extends up to a point just medial to the internal inguinal ring. The upper tail is passed underneath the cord so as to place the mesh posterior to the cord in the inguinal canal, and the spermatic cord is placed between the 2 tails of the mesh. The upper tail is then crossed over the lower one and the 2 tails are held in an artery forceps.
Lower edge of mesh sutured to inguinal ligament up to the internal inguinal ring. To accommodate the cord structures, the lateral end of mesh is divided into a wider upper (two thirds) and narrower lower (one third) tail. Wider upper tail of mesh passed underneath the cord, and mesh is placed posteriorly in the inguinal canal behind spermatic cord. Keeping the mesh lax, the upper edge of the mesh is then fixed to the rectus sheath and internal oblique aponeurosis by 2 or 3 interrupted, nonabsorbable sutures. The iliohypogastric nerve may sometimes come in the way of upper edge of the mesh. In such cases, the mesh may be split to accommodate the nerve. Slit made in the mesh to accommodate the iliohypogastric nerve. Two interrupted sutures are taken under vision to fix the upper edge of mesh while safeguarding the iliohypogastric nerve.
Fixation of the upper edge of the mesh. The 2 tails are then tucked together and fixed to the inguinal ligament just lateral to the internal ring, thus creating a new internal ring made of mesh. The tails are trimmed 5 cm beyond the internal ring and placed underneath the external oblique aponeurosis. Suturing the mesh beyond the internal ring is unnecessary and may injure the femoral nerve. Similarly, fixation of the tails of the mesh to the internal oblique muscle, lateral to the internal ring, may cause entrapment of the ilioinguinal nerve. Trying to suture the 2 tails without crossing or trimming the tails shorter than 5-6 cm beyond the internal ring may result in recurrence at the deep inguinal ring.18 The upper tail is crossed over the lower tail around the spermatic cord, thus creating an internal ring. The lower edges of the 2 tails are tucked together to the inguinal ligament just lateral to the internal ring. The 2 tails are then passed underneath the external oblique aponeurosis to give an overlap of about 5 cm beyond internal ring.
If any of the nerves are injured or integrity is doubtful, the nerve can be resected and the proximal end ligated and buried within the fibers of the internal oblique muscle to keep the stump of the nerve away from scarring. In male patients, always gently pull the testes back down to their normal scrotal position
after fixation of the mesh. The external oblique aponeurosis is reapproximated with 2-0 polypropylene and the skin is closed with staples or subcuticular stitches. External oblique aponeurosis sutured with 2-0 Prolene. Subcutaneous tissue approximated with 3-0 plain catgut. Skin approximated with 2-0 Prolene subcuticular suture.
Postoperative Care: Patient is asked to rest for few hours. He or she may be discharged on the same day on a day care basis. Early mobilization is the key to rapid convalescence. If general or regional anesthesia is used, the patient may be hospitalized for few days. There is some pain in the postoperative period, and suitable analgesics should be prescribed. The dressing is removed on the fifth postoperative day, and stitches are removed on seventh postoperative day. Light work can be resumed after a week, and heavier jobs after 6 weeks.
REFERENCES
1. Paajanen H, Varjo R. Ten-year audit of Lichtenstein hernioplasty under local anaesthesia performed by surgical residents. BMC Surg. Aug 4 2010;10:24. [Medline]. [Full Text].
2. Wiese M, Kaufmann T, Metzger J, et al. Learning curve for Lichtenstein hernioplasty. Open Access Surgery. Jul 2 2010;3:43-6. [Full Text].
3. {Guideline} Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. Aug 2009;13(4):343-403. [Medline]. [Full Text].
4. Kark AE, Kurzer M, Waters KJ. Tension-free mesh hernia repair: review of 1098 cases using local anaesthesia in a day unit. Ann R Coll Surg Engl. Jul 1995;77(4):299-304. [Medline]. [Full Text].
5. Gianetta E, Cuneo S, Vitale B, et al. Anterior tension-free repair of recurrent inguinal hernia under local anesthesia: a 7-year experience in a teaching hospital. Ann Surg. Jan 2000;231(1):132-6. [Medline]. [Full Text].
6. Zhao G, Gao P, Ma B, et al. Open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Ann Surg. Jul 2009;250(1):35-42. [Medline].
7. Chung RS. Meta-analysis of randomized controlled trials of laparoscopic versus conventional inguinal hernia repair. Surg Endosc. 1999;7:68-94.
8. Junge K, Klinge U, Prescher A, et al. Elasticity of the anterior abdominal wall and
impact for reparation of incisional hernias using mesh implants. Hernia. Sep 2001;5(3):113-8. [Medline].
9. Fingerhut A, Millet B, Veyrie N, et al. Inguinal hernia repair, update 2006. In: Edmund AM, Neugebauer S, Fingerhut A, et al. EAES Guidelines for Endoscopic Surgery. vol 1. Springer; 2006:294-307.
10. DeBord JR, Whitty LA. Biomaterials in hernia repair. In: Fischer JE. Mastery of Surgery. vol 2. 5th ed. Lippincott Williams & Wilkins; 2007:1965-8.
11. Bringman S, Wollert S, Osterberg J, et al. Three-year results of a randomized clinical trial of lightweight or standard polypropylene mesh in Lichtenstein repair of primary inguinal hernia. Br J Surg. Sep 2006;93(9):1056-9. [Medline].
12. Weyhe D, Belyaev O, Muller C, et al. Improving outcomes in hernia repair by the use of light meshes--a comparison of different implant constructions based on a critical appraisal of the literature. World J Surg. Jan 2007;31(1):234-44. [Medline].
13. Sanchez-Manuel FJ, Lozano-Garcia J, Seco-Gil JL. Antibiotic prophylaxis for hernia repair. Cochrane Database Syst Rev. Jul 18 2007;CD003769. [Medline].
14. Shankar VG, Srinivasan K, Sistla SC, et al. Prophylactic antibiotics in open mesh repair of inguinal hernia - a randomized controlled trial. Int J Surg. 2010;8(6):444-7. [Medline].
15. Hakeem A, Shanmugam V. Inguinodynia following Lichtenstein tension-free hernia repair: a review. World J Gastroenterol. Apr 14 2011;17(14):1791-6. [Medline]. [Full Text].
16. Chastan P. Tension-free open hernia repair using an innovative self-gripping semi-resorbable mesh. Hernia. Apr 2009;13(2):137-42. [Medline].
17. Amid PK, Shulman AG, Lichtenstein IL. Local anesthesia for inguinal hernia repair step-by-step procedure. Ann Surg. Dec 1994;220(6):735-7. [Medline]. [Full Text].
18. Amid PK. Lichtenstein tension-free hernioplasty. In: Fischer JE. Mastery of Surgery. vol 2. 5th ed. Lippincott Williams & Wilkins; 2007:1933-9.
19. Stylianidis G, Haapamaki MM, Sund M, et al. Management of the hernial sac in inguinal hernia repair. Br J Surg. Mar 2010;97(3):415-9. [Medline].
20. Treadwell J, Tipton K, Oyesanmi O, Sun F, Schoelles K. Surgical Options for Inguinal Hernia: Comparative Effectiveness Review [Internet]. Effective Healthcare Program. Aug 2012;[Medline]. [Full Text].
Author Information: Dr Pradeep Saxena, M.S [Surgery], F.MAS, FACRSI, FHBPS
Professor, Department of Surgery, AIIMS, Bhopal
Website: https://www.bhopalsurgery.com/home/Dr-Pradeep-Saxena
Email: pradeep@bhopalsurgery.com
Dr Pradeep Saxena is a member of the following medical societies: Association of Colon and Rectal Surgeons of India and Association of Surgeons of India.
No comments:
Post a Comment