Overview
Definition:
The Lichtenstein open tension-free inguinal hernia repair is a surgical procedure that uses a prosthetic mesh to reinforce the posterior wall of the inguinal canal
It is a widely adopted and highly effective method for treating inguinal hernias, aiming to reduce recurrence rates by avoiding tension on the sutured tissues.
Epidemiology:
Inguinal hernias are common, affecting approximately 25% of men and 2-5% of women at some point in their lives
Indirect inguinal hernias are the most frequent type
The incidence increases with age and is associated with factors like heavy lifting, chronic cough, and obesity.
Clinical Significance:
Inguinal hernias can lead to significant morbidity, including pain, discomfort, bowel obstruction, and strangulation, a surgical emergency
Effective surgical repair, such as the Lichtenstein procedure, is crucial for symptom relief, prevention of complications, and restoring quality of life for patients
This procedure is a cornerstone of general surgery practice and a vital topic for surgical trainees.
Indications
Absolute Indications:
Symptomatic inguinal hernia (pain, discomfort, bulge)
Incarcerated or strangulated inguinal hernia.
Relative Indications:
Asymptomatic hernias in young, active individuals
Large hernias posing risk of complications
Hernias in patients undergoing other abdominal surgery.
Contraindications:
Unfit for general anesthesia
Active infection at the surgical site
Uncorrected coagulopathy
Severe comorbidities limiting surgical risk tolerance.
Preoperative Preparation
History And Examination:
Detailed history of symptoms, duration, precipitating factors
Physical examination to confirm bulge, assess reducibility, and rule out incarceration/strangulation
Assess for comorbidities.
Investigations:
Generally, no specific investigations are required for uncomplicated inguinal hernias
Blood tests (CBC, electrolytes, coagulation profile) and ECG may be done in elderly or comorbid patients
Imaging (ultrasound, CT) may be used if diagnosis is uncertain or for complex cases.
Informed Consent:
Thorough discussion of the procedure, alternatives (e.g., laparoscopic repair), risks (infection, bleeding, recurrence, chronic pain, mesh-related issues), benefits, and expected outcomes
Ensure patient understanding.
Anesthesia Considerations:
Can be performed under general anesthesia, spinal anesthesia, or local anesthesia with sedation
Choice depends on patient factors, surgeon preference, and institutional protocols.
Procedure Steps Lichtenstein
Incision And Dissection:
A curvilinear incision is made 2-3 cm medial to the anterior superior iliac spine, extending down towards the pubic tubercle
The external oblique aponeurosis is incised longitudinally along its fibers
The cord structures are identified and dissected free
The hernia sac is identified and reduced into the abdomen.
Mesh Placement:
A piece of polypropylene mesh is cut to size and shaped to cover the entire myopectineal orifice
The mesh is then secured in place: superiorly to the internal oblique and transversus abdominis muscles (conjoined tendon), inferiorly to the inguinal ligament (Cooper's ligament), and medially to the pubic tubercle and rectus sheath
Key is to create a tension-free repair.
Cord Reapproximation:
The external oblique aponeurosis is closed over the mesh and cord structures using absorbable or non-absorbable sutures, reapproximating the internal and external leaf of the aponeurosis
Care is taken not to constrict the cord structures.
Closure:
The subcutaneous tissue is closed with absorbable sutures, and the skin is closed using sutures or staples
A sterile dressing is applied.
Postoperative Care
Pain Management:
Analgesics, typically NSAIDs and paracetamol, are prescribed
Opioids may be used for severe pain
Early mobilization is encouraged to prevent deep vein thrombosis and pneumonia.
Wound Care:
Keep the wound clean and dry
Advise patients to avoid strenuous activity and heavy lifting for 4-6 weeks
Follow-up appointments are scheduled to monitor wound healing and assess for complications.
Activity Restrictions:
Patients are advised to avoid lifting more than 5-10 kg for 4-6 weeks postoperatively
Gradual return to normal activities is permitted based on pain levels and comfort
Strenuous exercises should be avoided initially.
Discharge Criteria:
Patient should be hemodynamically stable, adequately pain-controlled with oral analgesics, able to ambulate with assistance, and tolerating a diet
Wound should be clean and dry.
Complications
Early Complications:
Hematoma formation
Seroma formation
Wound infection
Urinary retention
Testicular pain or swelling
Damage to cord structures or nerves.
Late Complications:
Recurrence of hernia
Chronic groin pain (persistent inguinalalgia)
Mesh-related complications (migration, infection, extrusion, foreign body reaction).
Prevention Strategies:
Meticulous surgical technique, proper mesh fixation, sterile operative field, appropriate antibiotic prophylaxis, careful dissection to avoid nerve injury, and patient education on activity restrictions are key to preventing complications.
Prognosis
Recurrence Rates:
Recurrence rates for the Lichtenstein repair are low, typically ranging from 1-3% in experienced hands, significantly lower than historical non-mesh repairs.
Pain Resolution:
Most patients experience significant relief from preoperative pain
However, a small percentage may develop chronic groin pain, which can be challenging to manage.
Long Term Outcomes:
The Lichtenstein repair offers excellent long-term outcomes with a high success rate in preventing hernia recurrence and restoring functional capacity for most patients
Quality of life is significantly improved.
Key Points
Exam Focus:
Understand the principles of tension-free repair
Know the layers involved and how the mesh is anchored
Be aware of indications, contraindications, and common complications
Differentiate from laparoscopic approaches.
Clinical Pearls:
Adequate exposure is key
Ensure the mesh adequately covers the myopectineal orifice
Meticulous hemostasis is crucial
Consider local anesthesia for higher-risk patients
Postoperative pain management is important for patient recovery and mobility.
Common Mistakes:
Inadequate mesh coverage
Placing the mesh under tension
Undersizing the mesh
Failing to adequately reapproximate the external oblique aponeurosis
Poor hemostasis leading to hematoma
Aggressive mobilization too early, increasing risk of strain.