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Lichtenstein Tension-Free Open Inguinal Hernia Repair
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glycemic control is optimized. Patients should not shave themselves prior to surgery, as this results in small wounds that may increase risk of infection.
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4 Mesh Choice andPreparation
There exists a large variety of prosthetic mesh options for hernia repair. Evidence
suggests that monolament, macroporous mesh is optimal for hernia repair.
Monolament bers minimize surface area and crevices that may harbor bacterial
contamination, and macroporous mesh allows for wider areas for natural tissue
ingrowth and exibility while minimizing the amount of foreign material implanted
over a given surface area, minimizing infectious risk and postoperative discomfort.
Polypropylene and polyester are both suitable inert mesh materials [4]. Lightweight
mesh is preferred, as this results in a repair of adequate strength and with recurrence
rates equivalent to heavier mesh, but with lower rates of post-operative discomfort
and pain [5]. A mesh of 7.5×15cm is used to achieve complete coverage of the
inguinal oor. The mesh is trimmed to approximate to the inguinal ligament and
rectus sheath in a rounded shape at its medial corner.
5 Operative Technique
5.1 Positioning andPreparation
Patients are positioned supine with preparation of skin from the umbilicus to the
scrotum, which should be included in the eld in the case of large inguinoscrotal
hernias. Perioperative antibiotics are not required for clean, elective cases, but may
be benecial in high-risk environments or in the setting of bilateral inguinal hernia
repairs or recurrent hernias [4].
5.2 Anesthesia andSedation
Our preferred technique for sedation is local anesthesia with monitored sedation for
adults with reducible inguinal hernias. Local anesthesia is safe, effective, low cost,
and allows for quicker return to normal for patients without the side effects of general anesthesia. A 50:50 mixture of 1% lidocaine and 0.5% bupivacaine with
1/200,000 epinephrine is our preferred local anesthetic. In the setting of incarcerated hernias, large inguinoscrotal hernias, or recurrent hernias, general or spinal
anesthesia may be benecial.
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5.3 Operative Steps
After the skin is prepped and draped, an incision is marked from the pubic tubercle
extending 5-6cm laterally following Langer lines to the deep ring. Local anesthesia
is injected both intradermally and in the deep subcutaneous tissue. The skin is
incised sharply and cautery is used to dissect down to the external oblique aponeurosis. Another 10mL of local anesthetic is injected through the external oblique
aponeurosis into the inguinal canal to lift the external oblique bers off the underlying nerves and cord structures, and to provide local anesthetic to the ilioinguinal
nerve, iliohypogastric nerve, and genital branch of the genitofemoral nerve (Fig.1).
The external oblique aponeurosis is incised over the entire canal. The divided
edges of external oblique aponeurosis are then grasped with clamps and retracted to
expose the spermatic cord and inguinal oor (Fig.2). In order to provide adequate
mesh overlap of the inguinal oor, the external oblique aponeurosis should be
opened at least 3cm superior to the inguinal oor. The ilioinguinal and iliohypogastric nerves are next identied and protected. The ilioinguinal nerve is most often
found medial to the anterior superior iliac spine, running over the cord and then
exiting the external ring. The iliohypogastric nerve is typically found emanating
from the internal oblique aponeurosis and running medially through the canal
towards the medial ap of the external oblique aponeurosis. It is important to keep
in mind that there is signicant variation to nerve courses.
Using a gauze Kittner dissector, the spermatic cord is atraumatically separated
from the inguinal oor and pubic tubercle. This is continued approximately 2cm
inferiorly past the tubercle. Care should be taken to avoid trauma to the cremasteric
bers and their contents. Retraction of the cord may be achieved by passage of a
Penrose drain around the cord (Fig.3). After isolation of the cord, the genital branch
of the genitofemoral nerve may be identied where it courses alongside the blue
Fig. 1 Injection of local
anesthetic through the
bers of the external
oblique aponeurosis,
inltrating the inguinal
canal
Lichtenstein Tension-Free Open Inguinal Hernia Repair
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Fig. 2 The external oblique bers are incised and retracted to expose the spermatic cord and
inguinal oor
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Fig. 3 The spermatic cord and ilioinguinal nerve are isolated using a Penrose drain
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Z. N. Weitzner et al.
streak of the external spermatic vein, located lateral and posterior in the cord. Ideal
practice is to identify and protect all three major nerves during dissection. Any nerves
noted to be injured may be managed with “pragmatic neurectomy,” which involves
ligating the nerve ending and burying it in the muscle belly. This practice helps avoid
neuroma formation and minimizes development of post-operative neuropathic pain.
To assess for the presence of an indirect sac, the proximal cremaster bers are
divided longitudinally and the cord contents are explored. Any indirect hernia sac
present is dissected free from cord structures until the sac is completely isolated to
the level of the neck of the sac (Fig.4). The sac is then inverted into the abdomen.
Ligation and excision of the sac is acceptable, but does not improve outcomes.
The oor is then examined for a direct hernia. If a large direct hernia sac is present, this may be inverted into the abdomen and a sutured closure of the transversalis
fascia of the inguinal oor may be performed to improve mesh positioning.
Assessment for a coexisting femoral hernia may be performed by opening the
hernia sac or inguinal oor. If present, a femoral hernia may be repaired by modifying the mesh to extend to Cooper’s ligament.
The 7.5×15cm piece of mesh is cut to the appropriate shape as described above.
This is then sutured to the pubic tubercle using permanent monolament suture. The
suture should not extend into the periosteum, as this can increase pain. Medially, the
mesh should overlap the pubic tubercle by 2 cm. This overlap protects against
medial recurrence as the mesh contracts over time. The same permanent suture is
then used in running fashion to x the mesh to the inguinal ligament (Fig.5). This
suture line runs from tubercle to just lateral to the deep inguinal ring.
Fig. 4 An indirect hernia sac is dissected free to the level of the neck of the sac
Lichtenstein Tension-Free Open Inguinal Hernia Repair
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Fig. 5 The lateral edge of the mesh is sutured to the inguinal ligament using running permanent
monolament suture
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Two tails are created in the lateral portion of the mesh by cutting a slit along the
long dimension of the mesh. The inferior tail should be approximately half the
width of the superior tail. The superior tail is passed under the spermatic cord, positioning the spermatic cord between the two mesh tails.
The medial and superior borders of the mesh are then sutured to the anterior
rectus sheath and aponeurotic portion the internal oblique (Fig.6). The iliohypogastric nerve should be identied and avoided during this process. The use of interrupted absorbable sutures minimizes risk to this nerve and its branches. Leaving
these interrupted stitches loose may also reduce the chance of nerve injury. These
medial interrupted sutures proceed superiorly to the level of the deep inguinal ring.
The nal step of mesh placement is to recreate the internal ring by overlapping
the superior tail of the mesh over the inferior tail just lateral to the spermatic cord.
These tails are then sutured to the inguinal ligament using permanent monolament
suture (Fig.7). A new mesh internal ring of appropriate size will allow for unconstructed passage of the spermatic cord, but will not be so loose as to accommodate
the passage of a nger.
The lateral mesh tails may be trimmed, but should extend a minimum of 5cm
beyond the mesh deep inguinal ring. Next, the tails are positioned at underneath
the external oblique aponeurosis (Fig.8). The external oblique is closed over the
cord and mesh with running absorbable suture, ultimately creating a new external
inguinal ring.
Absorbable suture is used to reapproximate the subcutaneous tissues and the skin.
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Fig. 6 The medial border of the mesh is sutured to the anterior rectus sheath and conjoint tendon
using interrupted absorbable sutures
Z. N. Weitzner et al.
Fig. 7 The lateral mesh tails are overlapped to surround the spermatic cord, forming a new deep
inguinal ring
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Fig. 8 In its nal orientation, the mesh covers the entire inguinal oor and extends at least 5cm
lateral to the inguinal ring
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6 Post-operative Management
Lichtenstein hernia repair is typically an outpatient procedure. Oral analgesic medications are appropriate. Immediate post-operative resumption of normal cardiovascular activities is encouraged. It is not our practice to place restrictions on vigorous
exercise and heavy lifting post-operatively for recurrence prevention, but these may
be advised for reasons of comfort.
7 Discussion andConclusion
Success in hernia surgery requires detailed knowledge of the relevant anatomy and
the ability to perform the repair technique most appropriate for clinical circumstances. It is crucial to understand the advantages and disadvantages of each technique. In 2018, the HerniaSurge Group published updated consensus guidelines on
the treatment of inguinal hernia in adults [4]. Based on data from the latest randomized controlled trials (RCTs), the use of the Lichtenstein tension-free hernioplasty
for repair of primary, unilateral, symptomatic inguinal hernias is strongly
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recommended by the HerniaSurge guidelines. This technique is considered superior
to the Bassini and Shouldice methods of tissue repair [6–9].
The Lichtenstein tension-free hernia repair has the benets of being effective,
low cost and possible to perform under local anesthesia. The outcomes of recurrence, post-operative pain, chronic pain, and other complications compare equivalently or favorably to other repair techniques. For repair of initial, unilateral inguinal
hernias and in patients wishing to avoid the risks of general anesthesia, the
Lichtenstein hernia repair remains an excellent option.
References
1. Hori T, Yasukawa D.Fascinating history of groin hernias: comprehensive recognition of anat-
omy, classic considerations for herniorrhaphy, and current controversies in hernioplasty. World
J Methodol. 2021;11(4):160–86. https://doi.org/10.5662/wjm.v11.i4.160.
2. Lichtenstein IL, Shulman AG.Ambulatory outpatient hernia surgery. Including a new concept,
introducing tension-free repair. Int Surg. 1986;71(1):1–4.
3. Amid PK. Lichtenstein tension-free hernioplasty: its inception, evolution, and principles.
Hernia. 2004;8(1):1–7. https://doi.org/10.1007/s10029- 003- 0160- y.
4. HerniaSurge Group. International guidelines for groin hernia management. Hernia.
2018;22(1):1–165. https://doi.org/10.1007/s10029- 017- 1668- x.
5. Amid PK. Classication of biomaterials and their related complications in abdominal wall
hernia surgery. Hernia. 1997;1(1):15–21. https://doi.org/10.1007/BF02426382.
6. Prospective randomized comparison of the Shouldice and Lichtenstein hernia repair proce-
dures—PubMed. https://pubmed.ncbi.nlm.nih.gov/9749850/. Accessed 17 July 2023.
7. Nordin P, Bartelmess P, Jansson C, Svensson C, Edlund G.Randomized trial of Lichtenstein
versus Shouldice hernia repair in general surgical practice. Br J Surg. 2002;89(1):45–9. https://
doi.org/10.1046/j.0007- 1323.2001.01960.x.
8. Danielsson P, Isacson S, Hansen MV. Randomised study of Lichtenstein compared with
Shouldice inguinal hernia repair by surgeons in training. Eur J Surg. 1999;165(1):49–53.
https://doi.org/10.1080/110241599750007504.
9. Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on
the treatment of inguinal hernia in adult patients. Hernia. 2009;13(4):343–403. https://doi.
org/10.1007/s10029- 009- 0529- 7.
Minimally Invasive Inguinal Hernia
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Repair: TAPP, TEP, andeTEP Approaches
AdamT.Lucy andMargauxN.Mustian
1 Introduction
Inguinal hernias are one of the most common problems seen in surgical clinics and are
among the most common general surgical operations performed worldwide [1, 2].
Minimally invasive inguinal hernia repair has become an increasingly utilized
approach to inguinal hernias in recent decades, and is an excellent option for bilateral
hernias or for women with hernias [3]. There are several minimally invasive inguinal
hernia repair options available for surgeons, including transabdominal preperitoneal
(TAPP), totally extraperitoneal (TEP) and extended totally extrapertioneal (eTEP).
With the TAPP approach, mesh is placed between the abdominal wall and the peritoneum in the preperitoneal space via access to the abdominal cavity via laparoscopic or
robotic approach. This introduces the risk of any intraperitoneal surgery, including
iatrogenic injury to abdominal viscera and future adhesive disease. In contrast, the
TEP and eTEP techniques create a preperitoneal space without entering the abdominal
cavity. However, viscera adherent to the peritoneum remain at potential risk of injury.
2 Preoperative Setup
Preoperative setup remains the same for minimally invasive inguinal hernia repair
regardless of approach: TAPP, TEP, or eTEP.The patient is instructed to void on call
to the operating room and if successful, intraoperative bladder decompression is not
A. T. Lucy · M. N. Mustian (*)
Department of Surgery, University of Alabama at Birmingham Heersink School of Medicine,
Birmingham, AL, USA
e-mail: alucy@uabmc.edu; mmustian@uabmc.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_35
409© The Author(s), under exclusive license to Springer Nature
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routinely performed. However, for large defects containing bladder or large bilateral
hernias, foley catheter placement may be considered. The patient is positioned
supine with the arms tucked to the side. Preoperative prophylactic antibiotics are
administered within 30min of incision and lower extremity pneumatic compression
stockings are utilized for deep vein thrombosis prophylaxis. The abdomen and groin
areas are prepped and draped in the usual sterile fashion.
A. T. Lucy and M. N. Mustian
2.1 Minimally Invasive Transabdominal Preperitoneal
Approach (TAPP)
2.1.1 Abdominal Entry andPort Placement
Abdominal entry may be achieved through a variety of techniques according to
surgeon preference. We will describe our typical approaches below.
For robotic assisted laparoscopic cases: Veress needle insufation is achieved
at Palmer’s point and pneumoperitoneum is established to 15mmHg. Local anesthesia is injected along each port placement site prior to incision. Abdominal entry
is performed rst via Optiview technique superior to the umbilicus approximately
15cm above the pubis. Two additional 8mm trochars are placed along the upper
abdomen on either side under direct visualization. The patient is placed in
Trendelenburg position and the robot is docked to the cannulas after the pelvis is
inspected.
For laparoscopic cases: The surgeon and assistant should position themselves
optimally for operating in the inferior abdomen and pelvis. The room and equipment should be organized to allow clear line of sight to a single monitor which is
placed at the patients feet. Abdominal entry can again be performed via veress,
optiview, or Hasson technique with a 12mm port placed near the umbilicus. Two
additional 5mm ports are then placed at the right and left midclavicular lines at the
level of the umbilicus. The patient is then placed in trendelenburg position and both
groins are inspected.
2.1.2 Hernia Evaluation
Looking in the inferior abdomen and anteriorly, the hernias are identied by the sac
extending through the defect(s) in the abdominal wall in the indirect or direct space
as well the epigastric vessels behind their covering of parietal peritoneum (Fig.1).
It should be noted, however, that the absence of a visualized hernia defect on peritoneoscopic view does not fully exclude a hernia containing extraperitoneal fat. The
peritoneum is then incised from the median umbilical fold laterally. The incision
should be created cephalad to the groin defect and care should be taken not to injure
the epigastric vessels which lie just anterior to the peritoneum at this location. At the
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