Mesh Fixation on the Lateral Side During Inguinal Hernioplasty
During inguinal hernioplasty, the mesh should be fixed to Poupart's ligament (inguinal ligament) on the lateral side, not the conjoint tendon.
Anatomical Rationale and Technical Approach
The standard tension-free mesh repair technique requires the mesh to be secured inferiorly to the inguinal ligament (Poupart's ligament) along its entire length, extending from the pubic tubercle laterally toward the internal ring 1, 2. The conjoint tendon (also called the inguinal falx) is located superiorly and medially, and the mesh is typically fixed to this structure along the superior/medial border, not the lateral border.
Key Technical Points:
Mesh positioning follows this pattern:
- Inferior border: Fixed to Poupart's ligament (inguinal ligament) from the pubic tubercle extending laterally
- Superior/medial border: Fixed to the conjoint tendon or internal oblique muscle
- Lateral extent: The mesh should extend beyond the internal ring laterally, with adequate overlap
Critical Technical Details to Prevent Recurrence
The pubic tubercle area requires special attention - one of the most common technical errors leading to recurrence is inadequate fixation at the pubic tubercle. The mesh must overlap the pubic bone by at least 1-2 cm, not simply be placed in juxtaposition to it 2. Three of four recurrences in a large series of 3,125 repairs occurred specifically because the mesh was placed adjacent to rather than overlapping the pubic tubercle 2.
Mesh width is crucial - using a mesh patch that is too narrow creates tension on the inferior fixation line to Poupart's ligament, which can lead to disruption and recurrence. The mesh should be wide enough (typically 6-8 cm in height) to allow fixation with appropriate laxity rather than tension 2.
Fixation Technique
The mesh-reinforced repair involves:
- Medially: Overlapping the pubic tubercle by 1-2 cm
- Inferiorly: Continuous or interrupted sutures fixing mesh to Poupart's ligament
- Superiorly: Fixation to conjoint tendon or internal oblique aponeurosis
- Laterally: Mesh extends beyond the internal ring with a slit created for the spermatic cord
The original Lichtenstein technique specifically describes using continuous polypropylene sutures to fix the mesh to Poupart's ligament along the inferior border 1, 2.
Common Pitfall to Avoid
Do not confuse the lateral fixation point with the superior fixation point. The conjoint tendon is a superior/medial structure. On the lateral aspect of the repair, the mesh wraps around the spermatic cord and the two tails of the mesh are sutured together and to the inguinal ligament, creating the new internal ring 3.
The femoral canal should also be assessed during the procedure to ensure adequate coverage and prevent femoral hernia development 3.