Following its publication by Irving L. Lichtenstein in 1986, the concept of tension-free open inguinal hernia mesh repair with was quickly adopted worldwide.[15] The Lichtenstein technique is currently the most commonly practiced open mesh procedure worldwide in the treatment of inguinal hernia.[17,26,27]
If necessary, Lichtenstein hernioplasty can be performed under local anesthesia and is less demanding in terms of technique and instruments than laparoscopic procedures. The Lichtenstein procedure is also well suited in the repair of large scrotal hernia. Bilateral hernias, femoral hernia and recurrent hernia after open repair should be managed laparoscopically.[6,7,17,26,27]
In recent years, mesh material, mesh size and fixation have undergone various modifications aimed at reducing postoperative pain.[2-5,9,15,16,18,22,23].
Nerve management
The prevention of postoperative pain requires profound knowledge of nerve anatomy.[21,20,28]. During the procedure, the nerves in the inguinal region must be spared as much as possible.[21,26,27]. If a nerve is injured during dissection or the course of the nerve obstructs mesh placement, neurectomy should be performed. The nerves in the inguinal region should be exposed, but left in their natural setting, which is possible in > 95% of cases for the iliohypogastric nerve and genital branch of the genitofemoral nerve.
As demonstrated in a prospective long-term follow-up clinical study of 781 patients with primary inguinal hernia, nerve sparing mobilization of the ilioinguinal nerve is a significant risk factor for chronic pain following Lichtenstein repair.[21] Nerves damaged by dissection, scar tissue or a hernia and those that have been detached from their natural setting should be excised by neurectomy. After infiltration with a long-acting local anesthetic, the nerve stump should be buried in the abdominal wall to prevent it from scarring and fusing with the synthetic mesh. There is no evidence as to whether the nerve stump should simply be transected, ligated or coagulated.[27]
Mesh
Current international guidelines recommend large-pore meshes made of monofilament non-absorbable synthetic material (polypropylene, polyvinylidene fluoride or polyester). Pore size appears to be more important than weight for tissue ingrowth and prevention of acute and chronic pain.[11,17,18,26,27].
Atraumatic mesh fixation
In recent years, various techniques of sutureless mesh fixation have been developed to reduce postoperative pain and bleeding complications. These include the use of self-adhesive meshes and mesh fixation with cyanoacrylates and fibrin sealants.
A systematic review of 12 RCTs in 1992 examined various fixation modalities in primary inguinal hernia repair.[23] No differences in recurrence rates were noted, and in 9 trials there was no significant difference in chronic pain between the different types of mesh fixation.[17,22,23]
A prospective randomized multicenter study (TIMELI) compared fibrin sealant with conventional suture fixation in small and medium-sized primary inguinal hernia. The fibrin sealant group experienced significantly less pain, discomfort and foreign body sensation after one month, 6 months and one year, with the same recurrence rate.[9] In a prospective randomized multicenter study from Finland published in 2015, cyanoacrylate glueing, self-adhesive meshes and suture fixation did not differ in terms of recurrence and postoperative pain.[22] The outcomes of cyanoacrylate glueing and suture fixation were confirmed by an RCT with a 7-year follow-up.
In summary, it was determined that in terms of chronic pain atraumatic mesh fixation does not offer any benefit compared to suture fixation. Atraumatic fixation does not appear to be associated with higher recurrence rates.[22,23,27].
Complications
The most common complication following Lichtenstein repair is chronic pain, seen in 5-30% of cases, depending on the definition.[6,7,8,10,12-14,17,19,24-27]. One possible cause is nerve damage due to injury, scarring or contact with alloplastic material. Postoperative bleeding requiring reoperation is seen in 0.5-3% of cases. In most studies, the rates reported for recurrence and infection are less than 1% [6,7,8,10,12-14,17,19,24-27]. Testicular atrophy, visceral and vascular injuries are rather rare complications. Mortality after elective Lichtenstein repair is no higher than in the general population, but rises to more than 5% in emergent procedures with bowel resection.[17,
Summary
The European Hernia Society guidelines of 2009 and 2014 and the first world guidelines of 2016 for the management of adult inguinal hernia currently recommend Lichtenstein repair as the best open procedure in the management of primary unilateral adult inguinal hernia.[17,26,27] The recurrence rates following Lichtenstein repair are significantly lower than with sutured techniques (Bassini and Shouldice) and comparable to those reported for laparoscopic procedures.
While Lichtenstein hernioplasty is associated with more early postoperative and chronic pain than TAPP and TEP procedures, the latter are linked to more severe intestinal injuries.[1,6-8,10,12-14,17,19,24-27]. In a Herniamed registry analysis of around 58,000 patients with primary unilateral inguinal hernia, a one-year follow-up after Lichtenstein repair revealed significantly more chronic pain on exertion and rest than after laparoscopic procedures.[13] Long-term follow-up studies, however, have failed to demonstrate significant differences in chronic pain.[17,27].