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G. Campanelli et al.
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Lichtenstein Onlay Mesh
Hernioplasty: Original Technique
andPersonal Modications
EzioGianetta andCesareStabilini
26
Several years have passed from the last time we
read Irving Lichtenstein’s Hernia Repair Without
Disability published in 1986 [1], and, despite
changes and “corruptions” introduced by different authors during the years, the technique
described by Lichtenstein still shows its value
standing still and valid in the present days. The
concept of tension-free repair for inguinal hernia
represents one of the turning points of abdominal
wall surgery: it was a paradigm shift from traditional tissue repair to modern mesh repair from
the technical, physiopathological, and organizational standpoint.
This innovative technique however was not
perfect at its very beginning [2] but went through
several renements before getting to its nal
form [3]. Major and minor changes with time
allowed Lichtenstein hernioplasty to become a
“one-size-ts-all” procedure for the cure of primary and recurrent inguinal hernia and the current recommended technique by international
guidelines [4].
Accordingly, in our daily practice, this procedure represents the rst approach to inguinal
defects except for those cases of bilateral and
recurrent inguinal hernia suitable for a laparoscopic repair.
E. Gianetta (*) · C. Stabilini
University of Genova, Genova, Italy
e-mail: gianetta@unige.it
26.1 Indications
In 2009 and 2014, the European Hernia Society
published guidelines [4, 5] on the treatment of
inguinal hernia in adult patients. Several recommendations were done, and accordingly in our
practice patients of both sexes complaining of
symptomatic primary unilateral inguinal hernia
are operated with an anterior approach under
local anesthesia. In the past, recurrent and bilateral inguinal hernias were approached through
the anterior route [6], and starting from 2010 we
moved to TAPP by laparoscopy. All those patients
not suitable for a general anesthesia or unable to
tolerate pneumoperitoneum are offered a
Lichtenstein procedure under local anesthesia.
Patients complaining of inguinal pain with or
without radiological signs of hernia but no clinically detectable defects are referred for watchful
waiting.
26.2 Patient Preparation
Before hospitalization, the patient is given information concerning surgery, type of anesthesia,
and recovery in dedicated visit. At our hospital,
according to current guidelines, the patient is
accepted the morning of the procedure, fasting
from midnight. A dose of subcutaneous low
molecular weight heparin is given in patient
judged at high risk of thrombosis the night before
the procedure. The inguinal region is shaved the
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_26
251
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E. Gianetta and C. Stabilini
day of admission with clipper. The antibiotic prophylaxis is adopted only in cases with predisposing comorbidities [4].
The patient lies in the supine position, leg
adducted, and the surgeon stands on the site of the
hernia with the rst assistant on the opposite site. In
our division, if not rst operator, the rst assistant
is always a resident, and a second assistant, if available, is a rst-year resident who uses retractors.
26.3 Original Technique
26.3.1 Anesthesia
We consider local anesthesia as the “gold standard” technique for the repair of unilateral primary inguinal hernia: it’s simple, easily
administered and mastered, well accepted by the
patients, and with virtually no side effects.
For its characteristics of high tolerability, it is
a formidable tool for the increasing number of
elderly patients with concomitant morbidities: it
represents a good solution to the problem of an
aging population with high life expectancy, asking for an effective and low-risk treatment to
their disability [7].
In our division, since the introduction of tension-free hernioplasty, local anesthesia has been
used also in the setting of recurrent hernia, and
we acknowledged that the technique becomes
more challenging with this approach because of
the suboptimal diffusion of the anesthetic solution in the tissues and more challenging in the
presence of a previous mesh repair. However, we
clearly showed its feasibility in the setting of a
teaching hospital [6] with low morbidity and low
recurrence. Some form of additive light sedation
is asked from the anesthesiologist in cases in
which patient’s pain or anxiety becomes an
obstacle for the surgeon.
We do not adopt regional anesthesia on a regular basis for its well-known risks and side effects
(urinary retention, nausea and vomiting, headache) that can end in prolonged hospital stay. The
indication to this procedure is represented mainly
by difcult cases such as scrotal hernias regardless whether primary or recurrent.
On the opposite hand, when general anesthesia is needed, it is indicated mainly for a posterior
laparoscopic approach. Its use in the setting of
open anterior approach, in our practice, is considered as a “rescue procedure” for those patients
not tolerating a local anesthesia or asking for a
complete unconsciousness.
26.3.2 Local Anesthesia
26.3.2.1 Mixture
Even if very old, mepivacaine, a local anesthetic of
the amide type, is the agent of choice in our practice. Its pharmacokinetic prole ts well our needs
because the fair rapid onset helps us save time
where no other drug is given outside of the operatory room; on the other hand, its medium duration
of action allows us the completion of the procedure
and analgesia during the minutes after the end of
the procedure. We utilize a solution of mepivacaine
2% (20mL) neutralized with sodium bicarbonate
8.4% (10mL) and diluted with saline (30mL).
We do not use adrenalin because the anesthetic mixture is adequate in the vast majority of
cases; the protraction of the procedure beyond
2h is very rare and in our opinion not advantageous for the patients. We consider this type of
event precognizable, and usually we approach it
with a general or spinal anesthesia.
26.3.3 Technique
We adopt a step-by-step approach in which the
mixture is given in subsequent injections of local
anesthetic during the procedure.
Before starting the intervention, a single injection with an insulin needle (25G) is performed in
order to obtain an intradermal wheal (Fig.26.1).
Afterward, using this wheal as an entry mark, we
shift to a 22G spinal needle; the supercial subcutaneous tissue is injected moving forward and
backward the needle to obtain an area with
3–4 cm width around the site of the future
incision. From the supercial layer, we then
move to anesthetize the deep subcutaneous tissue
to obtain a preliminary nerve block (Fig.26.2).
26 Lichtenstein Onlay Mesh Hernioplasty: Original Technique andPersonal Modications
253
Fig. 26.1 Derma inltration with a 25G insulin needle
Fig. 26.2 Supercial subcutaneous layer inltration with
a 22G spinal needle
Authors’ Comment
1. The continuous movement of the tip off
the needle prevents from inadvertent
injection of anesthetic in a vessel.
2. The spinal needle is sufciently long to
avoid the complete withdrawal of the
needle and reduce the number of punctures and possibly the risk of infection.
3. We are not in favor of truncal anesthesia
since the search of the site for a correct
entry is subject to failure due to the frequent anatomical variations of the nerve
emergences; moreover, this maneuver
can be complicated by hematomas or
inadvertent lesion to visceral structures.
Fig. 26.3 Deep subcutaneous layer (below Scarpa’s fas-
cia) inltration with a 21G needle
26.4 Surgical Dissection
After the onset of anesthesia, an oblique 6–7 centimeters skin incision is made on the cutaneous
projection of Poupart’s ligament, in the inguinal
fold, using the pubic tubercle (PT) and superior
iliac spine (SIS) as landmarks. The line of section
falls between the middle and medial third of the
aforementioned line.
The dissection of the supercial subcutaneous
tissue is carried with monopolar energy, and the
epigastric supercial vessels when encountered
are ligated and transected.
Scarpa’s fascia represents the boundary between
supercial and deep subcutaneous tissue. Before
division of this thickened connectival structure, we
usually perform injection of 2mL of anesthetic in
the deep subcutaneous layer (Fig.26.3).
Authors’ Comment
We adopt this type of strategy to block
aberrant branches of the ilioinguinal nerve
that several times can be encountered
immediately coming out from the external
inguinal ring [8].
Another 2mL of local anesthesia is delivered
under the external oblique aponeurosis (EOA) as
soon as it is visualized in order to anesthetize the
ilioinguinal and iliohypogastric nerves (Fig.26.4).
254
Fig. 26.4 Anesthesia of iliohypogastric and ilioinguinal
nerves
E. Gianetta and C. Stabilini
The internal oblique, conjoined tendon, and
inguinal ligament or Poupart’s ligament are gently dissected with scissors or ngertips from the
EOA.During this step, it easily can be visualized
the ilioinguinal nerve entering the inguinal canal
and the iliohypogastric nerve that pierces the
EOA.The spermatic cord is freed from the deep
oor of the inguinal canal, underpassed at the
level of the pubic tubercle, and suspended with a
silastic tube.
Firstly 2–3mL of anesthetic is injected in the
space between the cremasteric muscle, the external spermatic fascia, and spermatic cord at the
level of the genital branch of the genitofemoral
nerve using the “blue line” as anatomical landmark and then some 2mL on the upper part of the
cremasteric fascia to obtain anesthesia of the
entire cord (Fig.26.6).
The suspended cord is retracted and completely freed from its posterior attachments to the
inguinal oor.
The ilioinguinal nerve is identied at this level
and gently isolated from the underlying muscle
bers. The cremasteric muscle is then divided
longitudinally (Fig.26.7) from the deep inguinal
ring toward the pubic tubercle for 3–4 cm and
dissected from the spermatic structure. The
resulting medial leaf of the cremaster, usually
very thin, is resected with monopolar cautery
(Fig.26.8). In the classic Lichtenstein’s description, the lateral leaf which carries also vascular
structures is preserved.
Fig. 26.5 External oblique aponeurosis opened and
retracted with clamps
The EOA is dissected free to expose its lower
part from which the inguinal ligament reection
and the supercial inguinal ring take origin. The
aponeurosis is opened following its longitudinal
bers downward to the pubic tubercle and upward
for 5cm in direction of the SIS.The free edges of
the aponeurosis are retracted with clamps
(Fig.26.5).
Fig. 26.6 Anesthesia of the spermatic cord and genital
branch
26 Lichtenstein Onlay Mesh Hernioplasty: Original Technique andPersonal Modications
255
Fig. 26.7 Longitudinal incision of the cremaster muscle Fig. 26.8 Resection of the medial leaf of the cremaster
Authors’ Comment
On principle, we prefer not to immediately
underpass the spermatic cord, because mainly
in the setting of local anesthesia, this maneu-
ver can elicit some form of reaction from the
muscle with electric scalpel
during the reconstruction of the deep inguinal
ring.
The cord structures are then easily under-
passed and suspended with a silastic tube.
Possible advantages:
patient due to discomfort or actual pain.
After anesthesia, the cremaster is divided
along its longitudinal bers from the deep
inguinal ring downward for 3–4cm. The two
leaves of muscle (lateral and medial) are dissected from the cord and the sac and immediately interrupted between sutures (Fig. 26.9)
or coagulated with monopolar energy.
Usually, the remnant of the lateral leaf of
the cremaster is kept redundant and used
1. This maneuver eases underpassing the
spermatic structures alone without undue
traction on the nerves, which is a possible
cause of pain.
2. Cutting off the muscle helps identifying
small indirect defects and helps in the dissection of the sac.
3. Without cremaster, the spermatic cord can
be surrounded effectively with the mesh,
Fig. 26.9 The lateral leaf of the cremaster muscle is interrupted and ligated
256
E. Gianetta and C. Stabilini
and a lateral recurrence becomes less
likely.
Possible disadvantages:
1. The function of the muscle is lost, and few
patients complain of descending testis.
26.4.1 Hernia Sac Treatment
This step of the procedure can cause several
problems to the operating surgeon depending on
the grade of inammation, the length of the sac,
and the nature of the hernia (congenital vs.
acquired). All these features determine tight
adhesions of the cord structures to the peritoneal
sac; thus, the dissection maneuvers can produce
lesions to the vas deferens, nerve branches, and
vascular structures which can turn in serious
complications, namely, reproductive dysfunction, pain syndromes, and ischemic orchitis followed by testicle atrophy.
26.4.1.1 Medial Hernia Sac
For non-scrotal hernia, the so-called direct sac
does not represent a surgical challenge, and it’s
easily visualized medially to the cord covered by
the medial leaf of the cremaster muscle. It’s dissected and inverted, and care must be taken when
reducing the part near to the internal inguinal ring
since several times the epigastric vessels can be
dislocated and inadvertently injured during dissection or reconstruction of the inguinal oor.
26.4.1.2 Lateral Hernia Sac
To truly access the plane containing this type of
hernia, it is very important to open the external
spermatic fascia, a thin layer of unorganized connective tissue arising from the innominate fascia
at the cord emergence from the internal ring.
We usually look rst for the distal end of the
sac and dissect it proximally to the neck. In case
2. The direct contact of the mesh with spermatic structure could lead to undesired
inammatory reactions.
3. The ilioinguinal or genitofemoral nerves
can be damaged while dividing the muscle
in case of misidentication during dissection of the cord.
of a long sac or a particular type of sac, namely,
those entering in the middle of the spermatic
cord, we adopt the technique of dissecting circularly the sac halfway in the spermatic cord, in the
place where it is most accessible, and subsequently the distal end is retrieved and the proximal dissection is nalized.
Authors’ Comment
We adopt several tricks to treat a difcult
hernia sac:
1. The injection of anesthetic in the contact surface between the sac and the
structures to be preserved allows tissue
divarication and a safer dissection
(hydrodissection).
2. In case of big hernia sac, the peritoneal
layer can be opened, entered with a nger, and retracted more efciently.
3. The sac can be transected and the distal
portion left opened (drained or everted
to avoid a secondary hydrocele) in the
case of encasement of important structures in the hernia sac, such as for the
congenital hernia, to avoid lesion mainly
to the vas and vessels.
During this step, the patient can feel pain originating from excessive traction on the peritoneal
sac or inadvertent stimulation of the genital
26 Lichtenstein Onlay Mesh Hernioplasty: Original Technique andPersonal Modications
Fig. 26.10 Reconstruction of the internal ring with absorbable sutures
branch of the genitofemoral nerve with monopolar energy. We advise inltration of the neck of
the sac with 1–2mL of anesthetic mixture when
approaching the deep inguinal ring to reduce this
occurrence particularly in presence of an inamed
eld.
Except for some scrotal hernia and emergent
cases to check the bowel for vitality, the sac, once
dissected completely, is never opened or excised
since it’s well known that this maneuvers can
cause postoperative pain.
According to Lichtenstein [1], we routinely
reduce the hernia content in the abdominal cavity:
in case of lateral hernias, few resorbable stitches
are required to narrow the patent deep inguinal
Fig. 26.11 The transversalis fascia is inverted with
running absorbable suture
ring (Fig. 26.10), and for medial sac, we use
inverting continuous resorbable suture
(Fig.26.11). These maneuvers of reconstruction
of the anatomy have the only purpose of keeping
in place the hernia content during placement of
mended by current guidelines [4]. The material
originally adopted was polypropylene, but also
polyester and PVDF meshes have shown their
efcacy in the treatment of this disease.
the mesh and do not represent a support for the
repair.
Authors’ Comment
The choice of mesh material for
26.4.2 The Mesh: Material
Lichtenstein’s technique is crucial and is
inuenced by the clinical scenario, patient’s
Today, after several years have passed and study
performed, the mainstay of every inguinal hernia
characteristics, costs, surgeon preferences,
and hospital choices.
repair is represented by the mesh [9] as recom-
257
258
E. Gianetta and C. Stabilini
From standard polypropylene mesh,
several innovations in materials have
occurred, and the focus has changed from
simply preventing recurrence to reducing
postoperative pain and discomfort by
improving biocompatibility and reducing
foreign body reaction to the mesh. Clinical
research has developed several types of
meshes suitable for Lichtenstein’s technique to meet these needs, in recent years:
Lightweight meshes were introduced at
the beginning of 2000s and have less
polypropylene volume; it is postulated that
they encourage collagen production which
integrates the mesh into the abdominal wall
with less inammation compared with
heavier-weight meshes and that may reduce
the complications after surgery [10]. They
range from weight-reduced implants to
partially absorbable to material-reduced
and titanium-coated meshes [11]. Several
trials and metanalises [11, 12] were performed on the use of this type of material in
open Lichtenstein hernia repair, and their
results, in comparison to traditional heavyweight meshes, showed that lightweight
meshes offer less chronic pain and foreign
body sensation without difference in
recurrence.
Accordingly, their use is currently recommended from European Hernia Society
guidelines [4] as a measure to prevent the
occurrence of chronic postoperative pain. It
is our preferred type of mesh, and its use in
our practice is limited only to younger and
active patients due to the costs of the
device.
Biologic meshes derived from human or
animal sources are degraded gradually,
inducing neovascularization and colonization by host cells that progressively cause a
site-specic remodelling process until
reconstruction of a new and mature autologous fascia is completed.
The ability to be remodelled makes the
new materials theoretically attractive to
surgeons as a means to reduce post inguinal
herniorrhaphy complications [10].
However, a recent Chinese meta-analysis
showed that biologic mesh has no superiority to synthetic mesh in open inguinal hernia
repair with similar recurrence rates and incidence of chronic groin pain but higher rate
of seroma and longer operating time.
To date we reserve the use of this type of
material as an alternative to synthetic mesh
when the use of the latter becomes a risk
for the growing patient or in contaminated
and emergent scenarios to lower the risk of
postoperative infection.
The mesh is tailored on table, not preshaped
but trimmed according to the patient’s inguinal
oor, and the dimensions are 7×13cm.
The mesh is tailored to look like the outline of
a foot with the toe covering medially the angle
between the inguinal ligament and the anterior
rectus sheath. The mesh has a slit, along its major
axis, at the level of the internal ring to allow the
passage of the spermatic cord forming two tails
of different dimension: the lateral thinner and the
medial wider. These tails are crossed and solidarized with nonresorbable sutures 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 [3].
26 Lichtenstein Onlay Mesh Hernioplasty: Original Technique andPersonal Modications
259
How I Do It
We are used to shape the mesh in a different
way from original Lichtenstein’s description
(Fig.26.12). This type of tailoring helps us, in
our intention, to follow more precisely the
shape of the inguinal oor, to really protect it,
and to make possible a safe suture to the surrounding structures. We usually cut a vertical
slit (perpendicular to the main axis of the mesh)
(Fig.26.13) starting from the medial border of
the mesh to the emergence of the spermatic
cord. The reason for this choice lies in the anal-
ysis of the direction of the inferior edge of the
internal oblique muscle: it forms an acute angle
with the inguinal ligament cranially and laterally to the deep inguinal ring. In the original
description, the slit lies just above this weak
zone and could be challenged in case of a lateral hernia sac, leaving possibility to a lateral
recurrence. In our modication, the slit is completely protected by the underlying muscle.
The most lateral part of the mesh lies at in
the space between EOA and oblique muscle
without the need for further xation.
Fig. 26.12 The mesh reproduces the shape of patient’s inguinal canal
Fig. 26.13 The slit of the mesh