|Year : 2022 | Volume
| Issue : 4 | Page : 221-228
Some more time with an old friend: Small details for better outcomes with Lichtenstein repair for inguinal hernias
Ankara Hernia Center, Department of Surgery, Ankara, Turkey
|Date of Submission||23-Aug-2022|
|Date of Decision||29-Aug-2022|
|Date of Acceptance||05-Sep-2022|
|Date of Web Publication||24-Dec-2022|
Ankara Hernia Center, Department of Surgery, Ankara
Source of Support: None, Conflict of Interest: None
Lichtenstein repair (LR) was described by Irving Lichtenstein in mid-1980s, and was announced to be the gold standard for the treatment of inguinal hernias in 1990s. The technique is a tension-free repair with a prosthetic patch. Today LR is one of the most widely used surgical methods in the world, but it is hard to talk about uniformity in the technique among surgeons. Almost every surgeon has made some modifications to the technique and produced somewhat different repairs independently. In this paper, the original LR and the suggested modifications by the Institute are reviewed, and some critical points are presented with intraoperative photographs. LR is an economic choice, easy to learn, and can be performed with local anesthesia especially when the patient is frail. The technique requires a permanent prosthetic patch. Mesh fixation should be done with separate sutures preferably with monofilament absorbable material. Mesh size should not be kept small, and a 2-cm overlap should be provided beyond the pubic tubercle. A 15 cm × 7 cm commercial mesh can be trimmed and used. Mesh should extend laterally to the internal inguinal ring for 5–6 cm. A proper technique in LR is important for low recurrence and chronic pain rates. Therefore, every surgeon at every level of her/his carrier must know how to perform a decent LR.
Keywords: Chronic pain, ilioinguinal nerve, inguinal hernia, Lichtenstein repair, mesh, recurrence
|How to cite this article:|
Kulacoglu H. Some more time with an old friend: Small details for better outcomes with Lichtenstein repair for inguinal hernias. Int J Abdom Wall Hernia Surg 2022;5:221-8
| Introduction|| |
Lichtenstein repair (LR) was described by Irving Lichtenstein in mid-1980s, and announced to be the gold standard for the treatment of inguinal hernias in 1990s. The technique is a tension-free repair with a prosthetic patch. Today LR is one of the most widely used surgical methods in the world. Despite the minimal invasive hernia repairs that have gained great popularity with thoroughly satisfactory results, LR is still found to be equally effective in some studies., In addition, LR is a less expensive method in comparison with minimally invasive repairs. LR is easy to learn and perform, but it is hard to talk about uniformity in the technique among surgeons. Almost every surgeon has made some modifications to the technique and produced somewhat different repairs independently [Table 1]. Whether personal modifications on the original technique resulted in better or worse surgical outcomes is not clear and there seems to be no reasonable way to measure this.
In this paper, the original LR and the suggested modifications by the Institute in 2004 by Amid are reviewed, and some critical points are presented with intraoperative photographs. Also, some minor recommendations about the nerve-sparing technique and the proper mesh size are presented based on the author’s previous scientific studies on these specific subjects.
| Original Technique and Further Recommendations from the Institute|| |
The original LR is based on the philosophy of tension-free technique. Instead of forcefully bringing the anatomical structures together with sutures, the defective inguinal floor is strengthened by a prosthetic mesh. The prosthesis is placed between the inguinal floor and the external oblique aponeurosis and extends beyond the Hesselbach’s triangle to provide sufficient mesh overlap. Irving Lichtenstein published his first results with prosthetic material in 1987, but did not give any detailed information about the technique including mesh size. However, the initial meshes used by Lichtenstein were probably smaller than the meshes we use today. We can make inferences from that when we read the subsequent papers published by the Institute in 1993 and 2003., These articles described some crucial points as the reasons for the recurrences after LR.
Use a large sheet of mesh that will extend approximately 2 cm medial to the pubic tubercle, 3–4 cm above the Hesselbach’s triangle, and 5–6 cm lateral to the internal ring. We suggest using a 7 cm × 15 cm sheet of mesh for easy handling, then trimming 3–4 cm from its lateral side.
Cross the tails of the mesh behind the spermatic cord to avoid recurrence lateral to the internal ring. Suturing the tails together in a parallel position, without crossing, is a known cause of recurrence in the internal ring area.
Keep the mesh with a slightly relaxed, tented up, or dome-shaped configuration to counteract the forward protrusion of the transversalis fascia when the patient stands up from the intraoperative supine position, and, more importantly, to compensate for the contraction of the mesh.
Identify and protect the ilioinguinal (IIN), iliohypogastric (IHN), and genital nerves throughout the operation. Inadequate dissection and visualization of the nerves (the so-called minimal dissection) is the most common cause of nerve injuries and chronic postherniorrhaphy neuropathic pain.,
These above precautions tell us that the concerns of the authors are not only related to recurrences but also to the risk of postoperative chronic pain.
| What is the Situation in Practice?|| |
International guidelines for groin hernia management recommends mesh-based repair techniques for inguinal hernias, and do not propose the use of self-adhesive meshes, mesh plugs, or PHS system to replace LR with flat mesh. Nevertheless, these statements are valid for open options, and LR is not considered to be superior to minimally invasive repairs, especially when the patient has bilateral hernias. transabdominal preperitoneal and totally extraperitoneal repairs have gained more popularity by time; however, LR is still has a role in certain situations like elder and frail patients who are not suitable for general anesthesia or patients who previously underwent minimally invasive repairs or radical prostate surgery. Therefore, every surgeon at every level of her/his carrier must know how to perform a decent LR. This is not only a requirement in order to achieve less recurrences, but also is crucial for low chronic inguinal pain rates.
| Basic Principles and Promises of Lichtenstein Repair|| |
LR was created and promoted as a tension-free hernia repair. This is ensured by using a prosthetic patch [Table 2]. However, prosthetic materials do not have any intelligence or magic! They integrate the patient’s native tissues by time to form a resistant layer to prevent any further protrusion. We need to provide a restored anatomy beneath the mesh until that time. It is achieved by repairing transversalis fascia in medial inguinal hernias or narrowing a dilated internal inguinal ring in lateral hernias. The concept of tension-free repair is also important at this stage. Repair of a luxated transversalis fascia or a wide internal ring should be done with a fine absorbable suture material (e.g., 2-0 polydioxanone) with small bites. Care must be taken not to involve internal oblique muscle (conjoint tendon) and inguinal ligament as employed in modified Bassini repair. Internal inguinal ring may need special attention in case of a large indirect hernia if the sac is reduced after dissection without high ligation. Peritoneal sac can come out again despite a prosthetic patch when the internal inguinal ring is left wide.
Mesh selection is not a complex issue in LR. It is the main rule that the prosthesis must be permanent. The Lichtenstein Hernia Institute has used and recommended standard polypropylene meshes. A wide pore or low-weight polypropylene mesh can also be used. On the contrary, absorbable materials and composite meshes have no place in LR. Unfortunately, expensive composite or absorbable meshes have been used as a result of ignorance of the surgeons and unethical marketing efforts of the supply companies.
Proper mesh size for LR of inguinal hernias was given as 7 cm × 15 cm with a trimming 3–4 cm from its lateral side. Nevertheless, only few reports about inguinal hernia repairs with Lichtenstein technique in the current literature specified mesh sizes. A systematic review and meta-analysis on this subject displayed that the most preferred mesh size was 7 cm × 15 cm, but no papers mentioned the exact sizes of meshes after trimming. There are some anthropometric studies in order to determine the proper mesh size for open inguinal hernia repairs.,,, A prospective clinical study that focused on the proper mesh size for LR by intraoperative measurements revealed that the mean dimensions of the mesh were 126.6 mm × 65.2 mm, whereas the largest mesh needed was 140 mm × 88 mm, and the smallest one was 107 mm × 62 mm. In fact, placing a mesh with proper sizes is not a complex issue and surgeons can easily adjust a commercial flat prosthesis by following the recommendations.
Choice of anesthesia
The classical LR promises early ambulation. This is mainly a result of tension-free repair; however, the use of local anesthesia is also an important factor to achieve this goal. In fact, LR is entirely suitable for all anesthesia modalities. This choice can be made by discussing the pros and cons of the different anesthesia techniques with the patient. Nevertheless, international guidelines do not recommend regional anesthesia techniques for open inguinal hernia repairs because of complications like headache and urinary retention. It is also obvious that spinal anesthesia, but not epidural anesthesia, prevents early mobilization which is one of the main advantages of LR. Surgeons should keep a point in their mind that local anesthesia can be the only option for frail patients with systemic medical problems. Therefore, they should learn and adapt themselves to the tips and tricks of a good local anesthesia. The technical details of local anesthesia for LR were described by the Lichtenstein Hernia Institute. Unfortunately, surgeons have seemed to be reluctant to use local anesthesia in inguinal hernia repair., The rate of local anesthesia has even decreased in some centers within the last two decades.
Original LR promises nerve-sparing surgery without disturbing regional nerves; IHN, IIN, and genital branch of genitofemoral nerve (GBGFN). Parviz Amid from the Lichtenstein Hernia Institute underlined the importance of nerve preservation during hernia repair like inferior laryngeal nerve protection in thyroid surgery. He recommended the ligation of the cut edge of the nerve with absorbable material and embedding it into the internal oblique muscle if there is no other chance to preserve the nerve. An experimental study investigated this issue. In this rat study, IIN was completely preserved in the first group, cut by scissors without a further process in the second group, and proximal cut end was ligated with polyglactin in the third. Protection of the nerve resulted in virtually zero neuroma formation. Surgical trauma to the nerve was observed to have an obvious potential for neuroma formation. On the contrary, some of recent randomized studies displayed that transection of the IIN nerve during hernia repair may be resulted in a decrease in the rate of chronic postoperative pain., Nevertheless, some others reported that there is no difference between the groups of transection and preservation., The results regarding sensory loss or numbness are also conflicting. Mui et al. reported no difference for postoperative sensory loss or changes at the groin, and quality of life measurement at 6 months after the resection of IIN. Malekpour et al. also confirmed no difference in the incidence of hypoesthesia after 6 months. Contrarily, two other studies revealed higher rates for loss of sensation in the groups where IIN was divided., International Guidelines for Groin Hernias does not recommend a prophylactic IIN or IHN nerve resection in order to achieve low chronic pain incidences; however, it is in favor of pragmatic nerve resection if an iatrogenic injury has happened or if there is an interference between the mesh and the regional nerves.
The first regional nerve we meet during the opening of the external oblique aponeurosis is the IIN. The nerve is just beneath the aponeurosis and it can be damaged inadvertently if caution is not served [Figure 1]. The thin sheet beneath the aponeurosis should be left intact to protect both IIN and IHN [Figure 2]. Apart from these two main nerves, small nerve branches should also be handled with care. This is especially the case when the surgeon sutures the cranial edge of the mesh in the internal oblique muscle or its aponeurosis [Figure 3]. Also, some small branches can be encountered during mesh fixation on the inguinal ligament lateral to the internal inguinal ring [Figure 4]. Therefore, mesh fixation should be performed by separate sutures instead of a continuous manner. Amid already mentioned the importance of this delicate technical detail in his paper published in 2004 “Secure the mesh with two interrupted sutures on the upper edge and one continuous suture with no more than three to four passes on the lower edge of the mesh to prevent folding and movement of the mesh in the mobile area of the groin.” It is better to choose a monofilament absorbable material like polydioxanone, and place somewhat loose-tying (air knot) to avoid inadvertent nerve entrapments [Figure 5]. İlioinguinal nerve can also be damaged when it is stretched during traction, for this reason retractors should be used gently with caution [Figure 6].
|Figure 1: Administration of a bolus local anesthetic solution beneath the external oblique aponeurosis (A). The ilioinguinal nerve is exposed just after opening the aponeurosis (B)|
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|Figure 2: Appearance of the thin covering sheet beneath the aponeurosis. This thin layer should be left intact in order to protect both the ilioinguinal and the iliohypogastric nerves|
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|Figure 3: Small nerve branches that lie over the internal oblique aponeurosis. Surgeon should be careful not to entrap these structures during fixation of the cranial edge of the mesh in the internal oblique muscle or its aponeurosis|
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|Figure 4: Small branches on the inguinal ligament lateral to the internal inguinal ring. Care must be given during mesh fixation at this area and separate sutures should be used instead of continuous manner|
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|Figure 5: Loose-tying (air knot) of the fixation suture with monofilament absorbable material over the internal oblique aponeurosis|
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|Figure 6: İlioinguinal nerve can be stretched and damaged during traction of spermatic cord|
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The third sensory nerve of the inguinal region is GBGFN. It normally lies within the spermatic fascia and cremasteric muscle. This nerve, which is thinner than other two, can be identified just below the spermatic vein (blue line) and it is protected when the spermatic cord is lifted from the inguinal floor en bloc. However, GBGFN can course outside the spermatic cord and can be as thick as IIN in some patients [Figure 7]. The nerve should be identified and not stretched in those cases.
Alternative fixation techniques
Atraumatic mesh fixation techniques may be good alternatives. Some comparative studies found shorter operative time, and more comfortable early postoperative period with self-gripping mesh in comparison with standard polypropylene mesh with suture fixation, there were no advantages regarding postherniorrhaphy chronic pain rates.,,, The case with fibrin sealant or cyanoacrylate is also similar.,,
Pubic tubercle overlap
Medial extension of the mesh beyond the pubic tubercle for a 2-cm overlap was advised by Amid in 2004 to prevent recurrences from this area. This precaution is based on an experimental study by Klinge et al., which reported approximately 20% mesh shrinkage in both directions after implantation. Although more recent studies using imaging modalities have not supported a shrinkage to that extent a 2-cm overlap still may be of benefit in reducing recurrence rates. This overlap is easily available with a simple subcutaneous dissection by electrocautery at the pubic tubercle [Figure 8]. In addition, a small incision on the inferior border of the rectus sheet provides more room for mesh just above the pubic tubercle when a large medial hernia is the case [Figure 9].
|Figure 8: Dissection with electrocautery at the pubic tubercle in order to provide sufficient overlap for mesh. Before dissection (A); after dissection (B)|
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|Figure 9: A small incision is made on the inferior border of the rectus sheet in order to provide more room for mesh superior-medial to the pubic tubercle. Before making an incision (A); after making the incision (B)|
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| Superior and Lateral Mesh Coverage|| |
Other recommendations for mesh placement are a 3–4 cm coverage above the Hesselbach’s triangle, and a 5–6 cm overlap lateral to the internal ring [Figure 10]. Superior margin of the mesh is easily secured over the internal oblique muscle and its aponeurosis with an absorbable suture material. However, lateral coverage is trickier. Amid recommended crossing the tails of the mesh lateral to the spermatic cord in order to avoid recurrence lateral to the internal ring, and claimed that this maneuver could prevent recurrence at the internal ring. Two tails of the mesh are crossed and secured in the inguinal ligament with a suture.
|Figure 10: A schematic drawing of mesh used for Lichtenstein repair. Please not medial and lateral overlaps|
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The risk of recurrence in the internal inguinal ring is especially a concern when the primary hernia is a lateral (indirect hernia). Theoretically, this risk is smaller for medial or direct hernias. A recent randomized controlled study displayed that leaving the mesh tails in a parallel position without crossing did not increase recurrence and even might decrease the frequency of postoperative chronic inguinal pain 5 years after primary repair of medial inguinal hernias [Figure 11]. Nevertheless, there is no information yet about this approach for lateral inguinal hernias.
|Figure 11: Management of the tails of the mesh lateral to the internal inguinal ring. Crossing the mesh tails vs. no-crossing|
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| Conclusions|| |
LR is still a good choice for the treatment of inguinal hernias. It provides low recurrence and chronic pain rates when applied properly. The technique is easy to teach, learn and perform. Minimally invasive inguinal hernia repairs have been gaining larger shares in most areas; however, LR seems to keep always its place and value. Therefore, the proper technique should be taught, and every surgeon should try to get excellence in LR.
Financial support and sponsorship
Conflicts of interest
Dr. Hakan Kulacoglu is an Editorial Board member of International Journal of Abdominal Wall and Hernia Surgery. The article was subject to the journal’s standard procedures, with peer review handled independently of this Editorial Board member and their research groups.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
[Table 1], [Table 2]