Evidence - Inguinal hernia repair, Lichtenstein

  1. Summary of the literature

    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].

  2. Currently ongoing studies on this topic

  3. Literature on this topic

    1. Amato B, Moja L, Panico S, Persico G, Rispoli C, Rocco N, Moschetti I. Shouldice technique versus other open techniques for inguinal hernia repair. Cochrane Database Syst Rev. 2012 Apr 18;(4):CD001543.

    2. Amid PK. Classification of biomaterials and their related complications in abdominal wall hernia surgery. Hernia 1997 1:12–19

    3. Amid PK, Shulman AG, Lichtenstein IL. Critical scrutiny of the open "tension-free" hernioplasty. Am J Surg. 1993 Mar;165(3):369-71.

    4. Amid PK, Shulman AG, Lichtenstein IL. [Lichtenstein herniotomy]. Chirurg. 1994 Jan;65(1):54-8. German.

    5. Amid PK. Lichtenstein tension-free hernioplasty: its inception, evolution, and principles. Hernia. 2004 Feb;8(1):1-7.

    6. Bittner R, Arregui ME, Bisgaard T, Dudai M, Ferzli GS, Fitzgibbons RJ, Fortelny RH, Klinge U, Kockerling F, Kuhry E, Kukleta J, Lomanto D, Misra MC, Montgomery A, Morales-Conde S, Reinpold W, Rosenberg J, Sauerland S, Schug-Pass C, Singh K, Timoney M, Weyhe D, et al. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]. Surg Endosc. 2011 Sep;25(9):2773-843.

    7. Bittner R, Montgomery MA, Arregui E, Bansal V, Bingener J, Bisgaard T, Buhck H, Dudai M, Ferzli GS, Fitzgibbons RJ, Fortelny RH, Grimes KL, Klinge U, Köckerling F, Kumar S, Kukleta J, Lomanto D, Misra MC, Morales-Conde S, Reinpold W, Rosenberg J, Singh K, et al. Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society). Surg Endosc. 2015 Feb;29(2):289-321.

    8. Bobo Z, Nan W, Qin Q, Tao W, Jianguo L, Xianli H. Meta-analysis of randomized controlled trials comparing Lichtenstein and totally extraperitoneal laparoscopic hernioplasty in treatment of inguinal hernias. J Surg Res. 2014 Dec;192(2):409-20.

    9. Campanelli G, Pascual MH, Hoeferlin A, Rosenberg J, Champault G, Kingsnorth A, Miserez M. Randomized, controlled, blinded trial of Tisseel/Tissucol for mesh fixation in patients undergoing Lichtenstein technique for primary inguinal hernia repair: results of the TIMELI trial. Ann Surg. 2012 Apr;255(4):650-7.

    10. Eker HH, Langeveld HR, Klitsie PJ, van't Riet M, Stassen LP, Weidema WF, Steyerberg EW, Lange JF, Bonjer HJ, Jeekel J. Randomized clinical trial of total extraperitoneal inguinal hernioplasty vs Lichtenstein repair: a long-term follow-up study. Arch Surg. 2012 Mar;147(3):256-60.

    11. Klinge U, Weyhe D. [Hernia surgery: minimization of complications by selection of the "correct mesh"]. Chirurg. 2014 Feb;85(2):105-11.

    12. Köckerling F, Stechemesser B, Hukauf M, Kuthe A, Schug-Pass C. TEP versus Lichtenstein: Which technique is better for the repair of primary unilateral inguinal hernias in men? Surg Endosc. 2016 Aug;30(8):3304-13.

    13. Köckerling F, Bittner R, Kofler M, Mayer F, Adolf D, Kuthe A, Weyhe D. Lichtenstein Versus Total Extraperitoneal Patch Plasty Versus Transabdominal Patch Plasty Technique for Primary Unilateral Inguinal Hernia Repair: A Registry-based, Propensity Score-matched Comparison of 57,906 Patients. Ann Surg. 2019 Feb;269(2):351-357

    14. Koning GG, Wetterslev J, van Laarhoven CJ, Keus F. The totally extraperitoneal method versus Lichtenstein's technique for inguinal hernia repair: a systematic review with meta-analyses and trial sequential analyses of randomized clinical trials. PLoS One. 2013;8(1):e52599.

    15. Lichtenstein IL, Shulman AG. Ambulatory outpatient hernia surgery. Including a new concept, introducing tension-free repair. Int Surg. 1986 Jan-Mar;71(1):1-4.

    16. Matikainen M, Kössi J, Silvasti S, Hulmi T, Paajanen H. Randomized Clinical Trial Comparing Cyanoacrylate Glue Versus Suture Fixation in Lichtenstein Hernia Repair: 7-Year Outcome Analysis. World J Surg. 2017 Jan;41(1):108-113.

    17. Miserez M, Peeters E, Aufenacker T, Bouillot JL, Campanelli G, Conze J, Fortelny R, Heikkinen T, Jorgensen LN, Kukleta J, Morales-Conde S, Nordin P, Schumpelick V, Smedberg S, Smietanski M, Weber G, Simons MP. Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2014 Apr;18(2):151-63.

    18. O'Dwyer PJ, Kingsnorth AN, Molloy RG, Small PK, Lammers B, Horeyseck G. Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair. Br J Surg. 2005 Feb;92(2):166-70.

    19. O'Reilly EA, Burke JP, O'Connell PR. A meta-analysis of surgical morbidity and recurrence after laparoscopic and open repair of primary unilateral inguinal hernia. Ann Surg. 2012 May;255(5):846-53.

    20. Reinpold W, Schroeder AD, Schroeder M, Berger C, Rohr M, Wehrenberg U. Retroperitoneal anatomy of the iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve: consequences for prevention and treatment of chronic inguinodynia. Hernia. 2015 Aug;19(4):539-48.

    21. Reinpold WM, Nehls J, Eggert A. Nerve management and chronic pain after open inguinal hernia repair: a prospective two phase study. Ann Surg. 2011 Jul;254(1):163-8.

    22. Rönkä K, Vironen J, Kössi J, Hulmi T, Silvasti S, Hakala T, Ilves I, Song I, Hertsi M, Juvonen P, Paajanen H. Randomized Multicenter Trial Comparing Glue Fixation, Self-gripping Mesh, and Suture Fixation of Mesh in Lichtenstein Hernia Repair (FinnMesh Study). Ann Surg. 2015 Nov;262(5):714-9; discussion 719-20.

    23. Sanders DL, Waydia S. A systematic review of randomised control trials assessing mesh fixation in open inguinal hernia repair. Hernia. 2014 Apr;18(2):165-76.

    24. Schmedt CG, Sauerland S, Bittner R. Comparison of endoscopic procedures vs Lichtenstein and other open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Surg Endosc. 2005 Feb;19(2):188-99.

    25. Scott NW, McCormack K, Graham P, Go PM, Ross SJ, Grant AM. Open mesh versus non-mesh for repair of femoral and inguinal hernia. Cochrane Database Syst Rev. 2002;(4):CD002197. Review.

    26. Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, de Lange D, Fortelny R, Heikkinen T, Kingsnorth A, Kukleta J, Morales-Conde S, Nordin P, Schumpelick V, Smedberg S, Smietanski M, Weber G, Miserez M. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009 Aug;13(4):343-403.

    27. Simons MP, Aufenacker TJ, Berrevoet F et al World Guidelines for Groin Hernia Management 2016.www.herniasurge.com. Accessed: 15.03.2017

    28. Wijsmuller AR, Lange JF, Kleinrensink GJ, van Geldere D, Simons MP, Huygen FJ, Jeekel J, Lange JF. Nerve-identifying inguinal hernia repair: a surgical anatomical study. World J Surg. 2007 Feb;31(2):414-20; discussion 421-2.

  4. Reviews

    Aiolfi A, Cavalli M, Ferraro SD, Manfredini L, Bonitta G, Bruni PG, Bona D, Campanelli G. Treatment of Inguinal Hernia: Systematic Review and Updated Network Meta-analysis of Randomized Controlled Trials. Ann Surg. 2021 Dec 1;274(6):954-961.

    Aiolfi A, Cavalli M, Micheletto G, Lombardo F, Bonitta G, Morlacchi A, Bruni PG, Campanelli G, Bona D. Primary inguinal hernia: systematic review and Bayesian network meta-analysis comparing open, laparoscopic transabdominal preperitoneal, totally extraperitoneal, and robotic preperitoneal repair. Hernia. 2019 Jun;23(3):473-484.

    Bakker WJ, Aufenacker TJ, Boschman JS, Burgmans JPJ. Lightweight mesh is recommended in open inguinal (Lichtenstein) hernia repair: A systematic review and meta-analysis. Surgery. 2020 Mar;167(3):581-589.

    Cirocchi R, Sutera M, Fedeli P, Anania G, Covarelli P, Suadoni F, Boselli C, Carlini L, Trastulli S, D'Andrea V, Bruzzone P. Ilioinguinal Nerve Neurectomy is better than Preservation in Lichtenstein Hernia Repair: A Systematic Literature Review and Meta-analysis. World J Surg. 2021 Jun;45(6):1750-1760.

    Cunningham HB, Weis JJ, Taveras LR, Huerta S. Mesh migration following abdominal hernia repair: a comprehensive review. Hernia. 2019 Apr;23(2):235-243.

    Gavriilidis P, Davies RJ, Wheeler J, de'Angelis N, Di Saverio S. Total extraperitoneal endoscopic hernioplasty (TEP) versus Lichtenstein hernioplasty: a systematic review by updated traditional and cumulative meta-analysis of randomised-controlled trials. Hernia. 2019 Dec;23(6):1093-1103.

    Lyu Y, Cheng Y, Wang B, Du W, Xu Y. Comparison of endoscopic surgery and Lichtenstein repair for treatment of inguinal hernias: A network meta-analysis. Medicine (Baltimore). 2020 Feb;99(6):e19134.

    Pereira C, Varghese B. Desarda Non-mesh Technique Versus Lichtenstein Technique for the Treatment of Primary Inguinal Hernias: A Systematic Review and Meta-Analysis. Cureus. 2022 Nov 18;14(11):e31630.

    Phoa S, Chan KS, Lim SH, Oo AM, Shelat VG. Comparison of glue versus suture mesh fixation for primary open inguinal hernia mesh repair by Lichtenstein technique: a systematic review and meta-analysis. Hernia. 2022 Aug;26(4):1105-1120.

    Sun L, Shen YM, Chen J. Laparoscopic versus Lichtenstein hernioplasty for inguinal hernias: a systematic review and Meta-analysis of randomized controlled trials. Minim Invasive Ther Allied Technol. 2020 Feb;29(1):20-27.

  5. Guidelines

  6. literature search

    Literature search on the pages of pubmed.