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234 J. Conze
Also the possibility of a combined hernia should always be
considered.
Indirect
An indirect hernial sac lies on the anterosuperior aspect of
the cord structures and is usually easier to fi nd. In the case
of scrotal herniation, with a fi xed hernial sac in the scrotum, a transection of the hernial sac at the midpoint of the
canal leaving the distal part in situ is recommended to minimize the risk of postoperative ischemic orchitis. The anterior wall of the distal sac can be incised to prevent
postoperative hydrocele formation. Further management
depends on the presence and nature of the contents of the
indirect hernial sac.
No Contents
If the sac is empty and does not extend beyond the pubic
tubercle, it is lifted and freed from the adjacent structures by
careful dissection. It is traced back to its junction with the
parietal peritoneum, trans fi xed with an absorbable suture,
which is tied around it securely, and the redundant sac excised
(Fig.
14.7 ). If an indirect hernial sac extends beyond the pubic
tubercle, the sac is transected and the distal sac left in situ
(Fig. 14.8 ).
Fig. 14.7 A simple sac is ligated fl ush to the parietal peritoneum
Small Bowel and/or Omentum, With or Without Adhesions
Unless the hernia is strangulated and the small bowel nonviable, any adhesions are divided and the small bowel is
returned to the abdominal cavity. Strangulated omentum or
small bowel can be resected at this stage. The diagnostic
decision as to what should be done about very adherent and
frequently partially ischemic omentum is dif fi cult. If there is
any doubt about omentum, it is best excised because to return
omentum of doubtful viability to the peritoneal cavity invites
the formation of adhesions.
Sliding Hernia
Such a hernia may contain the cecum and appendix (on the
right side) in its wall, the sigmoid colon (on the left side), or
the bladder (in the medial wall on either side). The following
guidelines apply in these circumstances:
1. No attempt should be made to separate cecum or sig-
moid colon from the sac wall. This may compromise
their blood supply and lead to further unnecessary
problems.
2. The appendix must not be removed, as this could intro-
duce sepsis.
3. Appendices epiploicae must never be removed from the
sigmoid colon—they may harbor small colonic diverticula, excision of which will precipitate sepsis.
4. On the medial side of a sac there should be no attempt to
dissect the bladder clear. If the bladder is inadvertently
Fig. 14.8 If the indirect sac extends beyond the inguinal canal, it must
never be dissected beyond the pubic tubercle; instead, the proximal sac
is identi fi ed across and ligated fl ush with the peritoneum at its neck.
The distal sac is left in situ to preserve the rich anastomosis of vessels
that occurs in the cord and prevent ischemia of the testicle
opened, a two-layer closure with absorbable polymer and
urethral drainage are required for 7 days at a minimum.
Recovery will obviously be delayed.
23514 Anterior Open Repair of Inguinal Hernia in Adults
Fig. 14.9 Closing the sac of a sliding hernia
A sliding hernia is dealt with by excising as much peritoneal hernial sac as possible and then closing it using an
“inside out” purse-string suture. When it is closed it is pushed
back behind the fascia transversalis (Fig. 14.9 ).
Fig. 14.10 The dome -shaped direct bulge; there is no need to open
this sac
Direct
The direct sac may be either a broad-based bulge behind
and through the fascia transversalis or, less commonly, it
may have a narrow neck. In the fi rst type, interference with
the peritoneum is not needed—the sac should be pushed
behind the fascia transversalis, which will subsequently be
repaired (Fig. 14.10 ). In the case of a narrow-necked her-
nia, which is usually at the medial end of the canal, the
extraperitoneal fat is removed, the sac carefully cleared,
the redundant peritoneum excised, and the defect closed
with absorbable trans fi xion suture. Care must be taken to
avoid the bladder, which is often in the wall of such a sac
(Fig. 14.11 ) .
Combined Direct and Indirect
Lastly, a combined direct and indirect “pantaloon” sac
straddling the deep epigastric vessels may be found. In
such cases the sac should be delivered to the lateral side
of the deep epigastric vessels and dealt with as described
for an indirect hernia (Hoguet’s maneuver) [ 28, 29 ]
(Fig. 14.12 ).
The indirect sac is completely freed from the vas, spermatic vessels, and the adjacent fascia transversalis at the
deep ring. It is best then to mobilize the fascia transversalis
Fig. 14.11 The narrow neck medial direct hernia. The sac is isolated,
closed, and excised
medially so that the whole of the sac can be drawn laterally.
Whether or not the direct sac should be opened at this stage
is a question of judgment. The hazard of wounding the
bladder must be acknowledged. Any opening into a direct
236 J. Conze
Fig. 14.12 Hoguet maneuver. The combined direct/indirect sac (pantaloon hernia) is delivered lateral to the deep epigastric vessels. Any redundant peritoneum is excised and the sac closed
sac must be commenced laterally; care must be taken to
identify the bladder margin medially and any peritoneal incision must stop short of this. Alternatively the direct sac can
be opened—a fi nger inserted into the peritoneal cavity
through the indirect sac will identify the dimensions of the
direct sac and facilitate dissection and mobilization.
Once the indirect and direct sacs are mobilized, the
redundant peritoneum is excised and the peritoneal defect
closed.
Step II: The Reconstruction
After the preparation an assessment of the hernial ori fi ce is
possible. This is also the moment to look for the femoral
ori fi ce to rule out a concomitant femoral hernia.
The repair of the defect can be achieved by an impressive
variety of different procedures. The main differentiation is a
repair by suture or by augmentation with nonabsorbable
mesh prosthesis, in an anterior or posterior position:
Suture repair –
Marcy/Zimmermann •
Shouldice •
McVay •
Anterior fl at mesh repair –
Lichtenstein •
Anterior plug and patch –
Open Suture Technique
In Table 14.3 the most common suture techniques are
enlisted. A description of each technique would certainly go
beyond the scope of this chapter. Therefore only techniques
in common usage will be described.
Marcy/Zimmermann Suture Repair
The fi rst description of a narrowing of the deeper inguinal
hernia ring by suture was by Marcy in 1887 [ 24 ] and later by
Zimmermann [ 30 ] . Indications for his simple repair are
small, indirect inguinal hernias (EHS classi fi cation L1) with
a stable fascia transversalis. In these cases a further incision
of the posterior wall is neglected and a reduction of the hernial ori fi ce by suture is performed.
A prerequisite for this repair is a suf fi cient preparation of the
internal inguinal ring, with identi fi cation of the fascia transversalis, complete dissection of the spermatic cord from the internal inguinal ring, and removal of preperitoneal fatty tissue. The
suture repair starts medial to lateral. The narrowing of the internal hernia ring should accomplish a remaining ori fi ce of
5–8 mm, admitting just the tip of a fi nger, to guarantee a
suf fi cient blood supply for the testis. To standardize the size of
the ring, the use of an 11.5 Hegar dilator has proved to be helpful. The closing sutures are placed medial to the spermatic cord.
To achieve a secure placement of the sutures, the fascia transversalis, the aponeurosis of the m. transversus, and the caudal
fi bers of the iliopubic tract are included into the suture.
23714 Anterior Open Repair of Inguinal Hernia in Adults
After suf fi cient narrowing of the internal hernia ring, the
posterior wall of the inguinal canal is augmented by a single
continuous suture fi xation of the internal oblique and transverse muscles to the inguinal ligament.
Results and Evaluation
Due to the lack of classi fi cation and differentiation of
the different non-mesh techniques for inguinal hernia repair
in adults, an evaluation of this technique is limited.
Valenti et al. performed a modi fi ed Marcy repair, sparing
the cremaster muscle, in over 200 patients with indirect
hernias. After a median follow-up of 4.7 years, they did not
have a recurrence [ 31 ] .
Hübner et al. have compared the results of a Marcy repair
versus tension-free Lichtenstein repair in small lateral hernias. After a median follow-up period of 56 months, there
was no difference concerning recurrence or chronic pain but
a clear trend to less neuropathic symptoms in favor of the
suture repair [ 32 ] .
The Marcy/Zimmermann repair is a fast and minimal procedure with reduction of surgical trauma in comparison to
other open techniques. The long-term results correlate with
careful patient selection. Only small indirect hernias in young
patients without risk factors should be considered for this
procedure.
One of the advantages of an open approach is the option
to switch the procedure according to the intraoperative
fi ndings. In case of a weak fascia transversalis or in larger
hernias (EHS classi fi cation >L1), other open techniques
such a complete reduplication of the posterior wall
(Shouldice repair) or mesh augmentation (Lichtenstein) can
be performed.
Shouldice Repair
In 1945 it was Earl E. Shouldice who described this novel
method of inguinal hernia repair. It is an open, transinguinal
suture technique to repair defects in the posterior wall of the
inguinal canal. In the same year he founded the Shouldice
Hospital, but it took until 1952 and the support of his assistants E. A. Ryan and N. Obney that after several modi fi cations
of the initial technique led to the development of today’s
classical “Shouldice repair” also known as the “Canadian
repair” [ 33 ] .
Dissection of Fascia Transversalis
The most essential part of the Shouldice operation is the
repair of the fascia transversalis. This structure should
Fig. 14.13 Dissection of the fascia transversalis
already have been identi fi ed at its condensation around the
cord forming the deep inguinal ring. The condensed medial
margin of the deep inguinal ring is freed from the emerging
cord by sharp dissection. When this is completed, the medial
margin of the ring is grasped in a dissecting forceps or a
hemostat and lifted up off the underlying extraperitoneal fat.
Dissecting scissors are now passed through the ring between
the fascia and the underlying fat. By this maneuver the fascia is separated from the underlying structures, particularly
the deep epigastric vessels. If there is no direct herniation
and no gross distortion of the deep ring, only the margin of
the deep ring, the “sling” of the deep ring, needs dividing; if
there is a direct hernia and attenuation of the fascia transversalis, the fascia transversalis is now divided along the length
of the canal, beginning at the deep inguinal ring and continuing down to the pubic tubercle. The upper medial fl ap is
lifted up away from the underlying fat. Attention is now
turned to the lower fl ap. If it is penetrated by cremasteric
vessels arising from the deep epigastric vessels, these should
now be divided and ligated close to their origin. If care is not
taken with the cremasteric vessels, they may be torn off the
deep epigastric vessels and troublesome hemorrhage will
follow. If a direct hernia is present, it will bulge forward at
this time and must be pushed back in order to free the lower
lateral fl ap of the fascia transversalis. This fl ap must be freed
down to its continuation as the anterior femoral sheath deep
to the inguinal ligament. The lower, condensed fascia transversalis as it merges to the anterior femoral sheath is the
iliopubic band. Any grossly attenuated fascia transversalis
about a direct sac is excised. With the fascia transversalis
238 J. Conze
Fig. 14.14 After the neck of the sac has been divided at the deep
inguinal ring, the fascia transversalis of the deep opening is identi fi ed
and assessed. If ring is normal sized the stump of the sac is reduced and
no more need be done. If the ring is marginally dilated ( stretched ) it
should be carefully dissected and possibly divided slightly ( inset ) and
then sutured tightly around the medial side of the cord with polypropylene to reconstitute a competent deep inguinal ring
opened and developed, the femoral canal should be checked
again (Fig. 14.13 ).
Repair of Fascia Transversalis
If the previous dissection has been carried out carefully, and
if hemostasis is now complete, the repair with the reconstruction of the inguinal fl oor commences. First, the fascia
transversalis is reapproximated and the deep ring is carefully reconstituted using a “double breasting” technique.
The posterior wall of the canal must be reconstituted so that
all of the peritoneum and the stump of a hernial sac are
retained behind it. To do this, the lower lateral fl ap of the
fascia transversalis is sutured to the deep surface of the upper
medial fl ap. The repair is begun toward the medial end of the
canal. Where the medial margin of the deep ring only has
been divided and the more medial aspect of the posterior
wall of the canal shown to be sound, no direct herniation,
only the divided fascia transversalis at the medial margin of
the deep ring, the “sling,” will need careful two-layered
reconstruction with a nonabsorbable suture (Fig. 14.14 ). If
there is a direct hernia, the whole of the posterior wall of the
canal will have been divided and will need repair, the fi rst
suture being placed in fascia transversalis where that structure becomes condensed into the aponeurosis and perios-
Fig. 14.15 Suturing the lower lateral fl ap of fascia transversalis to the
undersurface of the upper medial fl ap along the “ white line ” or “ arch ”
teum on the pubic tubercle. The lower lateral fl ap of the
fascia transversalis is then sutured to the undersurface of the
upper fl ap at the point where the upper fl ap is just deep to the
tendon of the transversus abdominus (conjoint tendon). At
this point there is a thickening or condensation of the fascia
transversalis (the “white line” or “arch”), which holds
sutures easily (Fig. 14.15 ).
Care must be taken with the closure of the fascia transversalis as it approaches the lateral rectus sheath, which
must be adequately repaired to the fascia transversalis and
the pubic tubercle. The anatomy here is variable, and the
falx inguinalis should be included in the repair. The fascia is
sutured laterally until the stump of an indirect hernia lies
behind it and it has been snugly fi tted around the spermatic
cord (Fig. 14.16 ). The direction of suturing is then reversed.
The free margin of the upper medial fl ap is brought down
over the lower lateral fl ap and sutured to the fascia transversalis at its condensation (the iliopubic tract), just above the
upturned deep edge of the inguinal ligament in the fl oor of
the canal. Suturing is continued back to the pubic tubercle,
where the suture is tied. By this maneuver the fascia transversalis is “double breasted” on itself, the “direct area” of
the canal is reinforced, and the internal ring carefully reconstituted and tightened. It is important not to split the fascial
fi bers. Sutures should be placed about 2–4 mm apart and
bites of different depth taken with each so that an irregular
“broken saw tooth” effect is produced. The repair of the fascia transversalis is the crucial part of the operation. The fas-
23914 Anterior Open Repair of Inguinal Hernia in Adults
Fig. 14.17 If the subjacent extraperitoneal fat and peritoneum is
bulging, a “trick of the trade” is to pack it down with a gauze swab. This
must be removed before the sutures are snugged tight
Fig. 14.16 Completing the overlap of the fascia transversalis repair.
The margin of the upper medial fl ap is sutured to the anterior surface of
the lower lateral fl ap ( a ). A neat closure up to the cord makes a new
deep ring ( b )
cia must be dissected and handled with care if its structure is
to be maintained.
A “trick of the trade” sometimes facilitates this suturing
of the fascia transversalis: After the upper medial and lower
lateral lea fl ets of fascia transversalis have been developed to
clearly show the “white line” of the transversus tendon
through the fascia above and the iliopubic tract below, a loose
swab (sponge) is pushed into the dissection to keep the extraperitoneal fat out of the way when the fi rst sutures are introduced (Fig. 14.17 ).
When these sutures are loosely in place, the swab is
removed and the suture tension adjusted to give tissue
closure.
Fig. 14.18 The aponeurotic, white part of the internal oblique tendon
and the conjoint tendon are used to reinforce the repair
Reinforcement with the Conjoint Tendon
The conjoint tendon is now used to reinforce the repair of the
240 J. Conze
Fig. 14.19 The anterior aponeurotic surface of the internal oblique
aponeurosis is loosely sutured to the aponeurosis of the external oblique
medially
fascia transversalis medially. A suture is started laterally
through the upturned deep edge of the inguinal ligament
medial to the margin of the reconstituted deep inguinal ring
and continued to the deep tendinous surface of the conjoint
tendon, which is directly to the medial side of the deep ring.
Sometimes, particularly if the cord is bulky, it is easier to
proceed in reverse by passing the needle fi rst through the
undersurface of the conjoint tendon and then under the cord
and through the upturned edge of the inguinal ligament. At
the point where this suture is inserted, the deep surface of the
conjoint tendon is just beginning to become aponeurotic (the
tendon of the transversus muscle), and it should hold sutures
easily. The suture is continued in a medial direction, picking
up the upturned edge of the inguinal ligament and the undersurface—the aponeurotic part—of the conjoint tendon down
to the pubic tubercle (Fig. 14.18 ). The direction is then
reversed, suturing the aponeurotic part of the conjoint
tendon, the internal oblique tendon now, loosely to the
external oblique aponeurosis about 0.5 cm above the inguinal ligament. The “broken saw tooth” technique previously
mentioned is again used, and as it is done the suture is gently
pulled snug, not tight, so that the conjoint tendon and rectus
sheath are rolled down onto the deep surface of the external
oblique aponeurosis. Suturing is continued laterally until the
conjoint tendon ceases to be aponeurotic at the medial edge
of the emergent spermatic cord. The suture is then tied. The
reconstruction of the posterior wall and the fl oor of the ingui-
Fig. 14.20 The external oblique aponeurosis is closed, double breasted,
anterior to the cord. Thus the inguinal canal is reconstituted with the
cord obliquely traversing it
Fig. 14.21 Closure of the subcutaneous tissue
nal canal is now complete. The cord is now placed back in
the canal (Fig. 14.19 ) .
External Oblique Aponeurosis
Now that the cord has been replaced, the external oblique
aponeurosis can be closed over it. This can be performed as
a single continuous suture or a “double breasting” technique.
Remembering that aponeurotic wounds are slow to regain
strength, nonabsorbable sutures are used for this layer. A
new super fi cial inguinal ring is constructed at the medial end
of the canal. Care should be taken during the suturing to
spare the ilioinguinal nerve from the suture line. The repair
Fig. 14.22 The skin is closed
with a subcuticular continuous
absorbable polymer suture
24114 Anterior Open Repair of Inguinal Hernia in Adults
is now complete, and if all the layers have been sutured
exactly as described, the loads on the suture lines should be
well distributed; there should be no undue tension and no
splitting of fi ber bundles. Indeed, the structures should have
just “rolled together” (Fig. 14.20 ).
Subcutaneous Tissue and Skin Closure
The subcutaneous tissue is carefully closed with interrupted
absorbable sutures. No “dead spaces” should be left and the fat
should be closed so that the skin is closely approximated. If
there is much tissue trauma or dead space, a closed drain is
useful in this layer but seldom necessary (Fig. 14.21 ). The skin
is closed with a subcuticular absorbable suture (Fig. 14.22 ).
Results and Evaluation
In the 1980s the Shouldice repair has become the standard
suture procedure for inguinal hernia repair in Europe.
Compared to the customary Bassini repair, it has proved
superior. The long-term results with follow-up of 5–10
years showed recurrence rates between 1.3 and 6.7%
[ 16, 34– 36 ] . High recurrence rates of up to 22% occurred in
patients with large medial hernias and in recurrent hernias
16, 34 ] emphasizing the need of meticulous patient selec-
[
tion, tailoring the surgical therapy to each patient’s individual condition.
The Shouldice repair however requires a good detailed
anatomical knowledge and surgical experience. It is a more
demanding surgical procedure than for example a Lichtenstein
repair. The learning curve takes longer, and a higher number
of procedures are required to gain competence. Muschaweck
reported on 158 reoperations for recurrence after previous
Shouldice repair [
37 ] . In less than 20% of the patients could
evidence of an actual previously performed Shouldice repair
be found, accentuating the urgent need of standardization of
our surgical technique. This might also help to understand
the wide range of recurrence rates.
In a recent Cochrane review from 2009, the Shouldice
technique was compared to other open techniques for
inguinal hernia repair. The authors found 16 trials with a
total of 2,566 hernias in the Shouldice group and 1,608
other non-mesh techniques. The authors’ conclusion
found the Shouldice herniorrhaphy the best non-mesh
technique in terms of recurrence, though it is more time
consuming [ 38 ] .
McVay: Repair
The initial indication for the McVay/Cooper’s ligament repair
was for patients with a large direct hernia and an absent cau-
242 J. Conze
Fig. 14.23 The McVay/Cooper’s ligament operation: clearing the
anterior femoral sheath
dal margin of the fascia transversalis. It is also useful in the
management of concomitant femoral and inguinal hernias.
Today the McVay repair has lost most of its initial relevance.
The advantages of the different mesh techniques have reduced
the indication and propagation of this technique.
The McVay repair is therefore described only in summary.
The incision, exposure, and dissection of the canal and cord
are identical to the above mentioned. The transversalis fascia
is incised, preserving the inferior epigastric vessels, and the
preperitoneal space opened. The dissection is then taken
deeper to expose and free the iliopectineal (Cooper’s) ligament. Great care must be taken here to preserve the anastomosis between the obturator and epigastric arteries (“the corona
mortis”). The hernial sac can be dissected bluntly away from
the superior pubic ligament. The main principle of this procedure is a triple layer repair, attaching the fascia transversalis,
the m. transversus abdominis, and the m. oblique internus to
Cooper’s ligament. To reduce possible tension on the suture
line, a relaxing incision is made as medial as possible in the
internal oblique aponeurosis—anterior rectus sheath—deep to
the external oblique aponeurosis before the two aponeuroses
fuse (Fig.14 .23 ). The repair is now initiated by bringing the
transverse abdominis arch down to the inguinal ligament.
This is best achieved with a layer of interrupted sutures,
beginning at the pubic tubercle and continued laterally to the
medial edge of the femoral vein. Each is placed carefully
under direct vision and held before serial knotting (Fig.
14.24 )
Fig. 14.24 Sutures are placed between the transversalis abdominis
arch and Cooper’s ligament as far as the femoral vein
Fig. 14.25 The femoral canal is closed with two or three transition
sutures between Cooper’s ligament and the anterior femoral fascia
24314 Anterior Open Repair of Inguinal Hernia in Adults
and placed between the transversus arch, the “white line,” and
the iliopectineal (Cooper’s) ligament. The femoral vein is
retracted and protected by a retractor. The femoral canal is
then narrowed by placement of two or three transition sutures
of nonabsorbable sutures between Cooper’s ligament and the
anterior femoral fascia (sheath). The lateral suture is placed
just lateral to the last suture in Cooper’s ligament; the medial
two or three are medial to this and go between the Cooper’s
ligament sutures (Fig.
erally between the transversus abdominis arch and the anterior femoral fascia with the line of sutures just displacing the
internal ring laterally, but not placing any sutures lateral to the
cord. These sutures are of mono fi lament, nonabsorbable
material. The sutures are now tied beginning medially and a
new internal ring created such that a hemostat can be inserted
between the last tied suture and the cord.
14.25 ). The repair is now continued lat-
Results and Evaluation
In McVay’s experience of the Cooper’s ligament repair, a
recurrence rate of under 1% in 1,000 cases over 16 years is
recorded. In part these excellent results are due to the
securing of an adequate viable posterior wall for the inguinal canal (the intact rectus sheath with its blood supply) to
the fi rm anchorage of Cooper’s ligament. Rutledge records
906 consecutive primary Cooper’s ligament repairs with a
recurrence rate of 1.9% overall: 3.5% for direct and 1.1%
for indirect inguinal hernia. The patient follow-up was 97%,
80% of patients being examined, and average follow-up was
9 years. The operative technique, however, is extensive,
requiring deep retraction. In 13% of patients the repair was
combined with a Marlex mesh overlay. With a 5% testicular
atrophy rate in skilled hands, this operation might have
medicolegal consequences. Rutledge comments that the
recurrence rate rises to 5.5% if the cord is brought out
straight through the external oblique and transplanted subcutaneously. Testicular atrophy occurred in 7.9% of recurrent hernia repairs [ 39 ]
The recurrence rates in the literature seem quite inconsistent, ranging between 0.5 and 20.9%, depending on followup time and centers [ 40– 45 ] .
The Open Anterior Mesh Repair
The Lichtenstein Technique
The true tension-free hernioplasty using mesh and no suture
closure of the hernial defect was introduced in 1984 by Irving
Lichtenstein and colleagues [ 46 ] .
Fig. 14.26 Wide dissection of the posterior wall of the canal
The Lichtenstein Tension-Free Hernioplasty
The incision, exposure, dissection of the canal and cord, and
the method of dealing with indirect hernial sacs are identical
to that described for the open suture techniques.
The upper leaf of the external oblique aponeurosis needs
to be lifted up and dissected from the underlying internal
oblique muscle and aponeurosis high enough to accommodate a 6–8-cm-wide patch. Between these two layers the anatomical cleavage is avascular and the dissection can be
performed nontraumatic by blunt preparation. In most cases
the n. iliohypogastricus and the n. inguinalis can be displayed
and if possible preserved. A suf fi cient overlap is required for
Hesselbach’s triangle, the pubic tubercle, and laterally
beyond the internal ring. Medially this dissection should be
taken beyond the pubic tubercle to the midline (Fig. 14.26 ).
The cremaster muscle is preserved to cover the cord as a
natural barrier for the mesh contact.
In the case of large direct sacs, in order to fl atten the posterior inguinal wall to facilitate placement of the mesh, a
running, inverting, absorbable suture is applied to the transversalis fascia.
A nonabsorbable mesh prosthesis precut to 16 × 8 cm is
now tailored to the individual patient’s requirements. This
will involve trimming 1–2 cm of the patch’s width and
the upper medial corner so that it will tuck itself between
the external oblique and internal oblique muscles without
wrinkles.