The concept of "tension-free repair" in the open treatment of inguinal hernias with mesh implantation was quickly adopted worldwide after it was published by Irving L. Lichtenstein in 1986 [15]. The Lichtenstein operation is currently the most commonly used open mesh procedure for the treatment of inguinal hernias worldwide [17, 26, 27].
The Lichtenstein operation can be performed under local anesthesia if necessary and is technically and instrumentally less demanding than laparoscopic procedures. The Lichtenstein procedure is also well-suited for the treatment of large scrotal hernias. Bilateral hernias, femoral hernias, and recurrent hernias after open repair should be treated laparoscopically [6, 7, 17, 26, 27].
Regarding the mesh material, size, and fixation, there have been various modifications in recent years aimed at reducing postoperative pain [2 - 5, 9, 15, 16, 18, 22, 23].
Nerve Management
Postoperative pain avoidance requires a thorough understanding of nerve anatomy [21, 20, 28]. During the procedure, the inguinal nerves must be monitored and preserved as much as possible [21, 26, 27]. If nerve injury occurs during preparation or if the nerve course hinders mesh placement, a neurectomy should be performed. The inguinal nerves should be exposed but left in their natural embedding, which is possible in > 95% of cases for the iliohypogastric nerve and the genital branch of the genitofemoral nerve.
A significant risk factor for chronic pain in the Lichtenstein operation is the mobilization of the ilioinguinal nerve with nerve preservation, as shown in a prospective long-term follow-up study of 781 patients with primary inguinal hernias [21]. Nerves damaged by preparation, scar tissue, or a hernia mass, or nerves removed from their natural embedding, should be removed by neurectomy. After infiltration with a long-acting local anesthetic, the nerve stump should be buried in the abdominal wall to prevent scar adhesion to the synthetic mesh. There is no evidence whether the nerve stump should simply be transected, ligated, or coagulated [27].
Mesh Management
According to international guidelines, large-pore meshes made of monofilament non-resorbable plastic (polypropylene, polyvinylidene fluoride, or polyester) are recommended today. The pore size seems to be more important for tissue integration and the avoidance of acute and chronic pain than the weight [11, 17, 18, 26, 27].
Atraumatic Mesh Fixation
In recent years, various techniques of mesh fixation without sutures have been developed to reduce postoperative pain and bleeding complications. These include the use of self-adhesive meshes as well as mesh fixation using cyanoacrylates and fibrin glue.
The various fixation modalities were examined in a systematic review of 12 RCTs with primary inguinal hernia operations in 1992 [23]. No differences in recurrence rates were found, and in 9 studies, no significant difference in chronic pain was found with the different mesh fixations [17, 22, 23].
In primary small and medium-sized inguinal hernias, a prospective randomized multicenter study (TIMELI) compared fibrin glue with conventional suture fixation. In the fibrin glue group, significantly less pain, discomfort, and foreign body sensations were found at one month, six months, and one year with the same recurrence rate [9]. Cyanoacrylate gluing, self-adhesive meshes, and suture fixation showed no difference in recurrence and postoperative pain in a prospective randomized multicenter study from Finland published in 2015 [22]. The results of cyanoacrylate gluing and suture fixation were confirmed by an RCT with a 7-year follow-up.
In summary, it was found that atraumatic mesh fixation does not offer an advantage over suture fixation in terms of chronic pain. Atraumatic fixation does not appear to be associated with higher recurrence rates [22, 23, 27].
Complications
After the Lichtenstein operation, chronic pain is the most common complication, occurring in 5–30% of cases depending on the definition [6, 7, 8, 10, 12, 13, 14, 17, 19, 24 - 27]. Nerve damage due to injuries, scarring, and contact with alloplastic material are possible causes. In 0.5–3% of cases, postoperative bleeding occurs, requiring revision. In most studies, recurrence and infection rates are below 1% [6, 7, 8, 10, 12, 13, 14, 17, 19, 24 - 27]. Very rare complications include testicular atrophy, bowel, and vascular injuries. The mortality rate after elective Lichtenstein operation is not higher than in the general population but rises to more than 5% in emergency procedures with bowel resection [17,
Conclusion
The Lichtenstein operation is recommended in the guidelines of the European Hernia Society from 2009 and 2014 and the first world guidelines for the treatment of adult inguinal hernias from 2016 as the best current open procedure for the treatment of primary unilateral inguinal hernias in adults [17, 26, 27]. After the Lichtenstein operation, recurrence rates are significantly lower than after suture procedures (Bassini and Shouldice) and comparable to those in laparoscopic procedures.
The Lichtenstein hernioplasty is associated with more early postoperative and chronic pain than the TAPP and TEP procedures but with fewer serious bowel injuries [1, 6, 7, 8, 10, 12, 13, 14, 17, 19, 24, 25 - 27]. In an analysis of the Herniamed registry with around 58,000 patients with primary unilateral inguinal hernias, significantly more chronic rest and exertion pain was found after a one-year follow-up after the Lichtenstein operation than after laparoscopic procedures [13]. In long-term follow-up studies, however, a significant difference in chronic pain is no longer detectable [17, 27].