Lichtenstein Repair of Inguinal Hernia

Principle

Buttressing of the posterior wall of the inguinal canal by inserting a mesh between the external oblqie aponeurosis and the internal oblique muscle.

Inguinal skin incision

Make the skin incision, measuring about 4 cm, in the line of the inguinal canal 2 fingers medial to it (solid line), or make a transverse incision 2 fingers superior to the pubic bone. Then divide the subcutaneous tissue down to the external oblique aponeurosis.

Division of the external oblique aponeurosis

Now longitudinally divide the fibers of the external oblique, including the superficial inguinal ring. After clamping the aponeurotic flaps and retracting them upward, free the aponeurosis from the internal oblique and cremaster by blunt dissection.

Caution: The iliohypogastric nerve courses immediately below the aponeurosis!

Mobilization and taping of the spermatic cord

Pass a tape around the spermatic cord, gently lift it and free the cord by blunt dissection from the transversalis fascia below and direct hernai sac respectively.

After dividing the cremaster muscle longitudinally, excise its fibers leaving generous stumps, thereby freeing the cord. In this step of the procedure the ilioinguinal nerve and the genital branch of the genitofemoral nerve must be spared.

Important: Postoperative neuralgia can be prevented by proceeding as follows: If you cannot spare the ilioinguinal and/or hypogastric nerves and/or the genital branch of the genitofemoral nerve, you must excise them and infiltrate their stumps with local anesthetic

Preparation and identification of the hernia sac

Sparing the structures of the spermatic cord, free the hernia sac down to the hernia defect in the transversalis fascia. Ligate and excise any preperitoneal lipoma.

In this example, the defect is a direct hernia because the hernia sac has developed medial to the epigastric vessels.

Hernia sac management in direct hernia

Direct hernia

In direct hernia the hernia sac usually does not have to opened. If the hernia sac is too large, it is reduced, suture ligated at its base and submerged below the level of the transversalis fascia; another option is to reduce the sac with a continuous purse string suture.

Hernia sac management in indirect hernia

Indirect hernia

In indirect hernia, free the deep inguinal ring completely and follow the cord into the ring in order to positively identify and spare the spermatic vessels. Splay open the hernia sac and reduce its contents. Close the base of the hernia sac with an outer purse string suture and remove the excess.

Tip: Once you have excised the excess hernia sac, rule out any bleeding along the stump resection line of the sac by slackening the stay sutures first before cutting them off. In case of any bleeding you can easily pull up the stump with the stay sutures and institute the necessary hemostatic measures. If the stump does not retract out of sight spontaneously, reduce and submerge it by suture.

Fitting and tailoring the mesh

If not already available as ready-made Lichtenstein mesh, cut out a 8 x 14 cm mesh with a lateral slit and tapered tails.

Mesh fixation at inguinal ligament

Starting medially at the pubic bone, anchor the mesh along the inferior border of the inguinal ligament. Ensure that medially the mesh covers the pubic bone by at least 2 cm because this is where most recurrences are seen. Anchor the mesh on the inguinal ligament with a continuous suture (polypropylene 2-0) up to the deep inguinal ring. It is important not leave any gaps along the inguinal ligament since this heightens the risk of recurrence.

Creating a new deep inguinal ring

At the deep inguinal ring place the superior tail of mesh over the inferior tail. With a nonabsorbable suture first suture both tails together and then anchor both tails on the inguinal ligament.