Mesh Placement in Lichtenstein Technique
Mesh Type Selection
Lightweight polypropylene mesh (≤50 g/m²) with large pore size (>1.0 × 1.0 mm) should be used for Lichtenstein inguinal hernia repair, as it reduces chronic pain and foreign body sensation without increasing recurrence rates. 1
Evidence for Lightweight vs Heavyweight Mesh
Lightweight mesh significantly reduces any chronic pain (risk ratio 0.78,95% CI 0.64-0.96) and the sensation of a foreign body (risk ratio 0.64,95% CI 0.51-0.80) compared to heavyweight mesh (>70 g/m²), with no difference in recurrence rates between groups 1
At 3-year follow-up, patients with lightweight mesh experienced less pain on examination, less pain when rising from lying to sitting, and fewer miscellaneous groin problems compared to standard mesh, with equivalent recurrence rates (3.6% vs 3.7%) 2
The lightweight large porous mesh concept optimizes foreign body reaction through reduced mesh material and decreased surface area contact with host tissues, while maintaining adequate mechanical strength 3
Pore Size Considerations
Large-pored meshes (>1.0 × 1.0 mm) are associated with lower risk of pain at rest and pain on exertion at 1-year follow-up compared to small-pored meshes (≤1.0 × 1.0 mm) 4
No association exists between mesh pore size and intraoperative complications, general complications, postoperative complications, or recurrence rates 4
Large pore size reduces foreign body reaction, inflammation, and scar bridging while improving mesh integration 4
Mesh Fixation Technique
Mesh fixation can be safely omitted in Lichtenstein repair, as non-fixation reduces operative time and postoperative pain without increasing recurrence rates. 5
The non-fixation technique demonstrates significantly lower operative times and pain scores compared to standard fixation, with no increase in recurrence rates 5
Non-fixation avoids potential nerve injury and reduces the risk of chronic pain from suture-related nerve entrapment 5
Special Circumstances: Contaminated Fields
Clean and Clean-Contaminated Fields (CDC Class I-II)
Synthetic polypropylene mesh should be used for all defect sizes in clean and clean-contaminated surgical fields, including cases with intestinal incarceration without strangulation or bowel resection 6
Synthetic mesh can be safely used even with intestinal strangulation and/or concurrent bowel resection when there is no gross enteric spillage, with significantly lower recurrence risk (OR = 0.2) and similar surgical site infection rates 7, 6
Contaminated and Dirty Fields (CDC Class III-IV)
For defects <3 cm with bowel necrosis and/or gross enteric spillage, perform primary repair without mesh 8, 7
For defects ≥3 cm in contaminated fields, biological mesh is the preferred option when available 8, 6
If biological mesh is unavailable, polyglactin mesh repair or open wound management with delayed repair are viable alternatives 8, 6
The choice between cross-linked and non-cross-linked biological mesh should be evaluated based on defect size and degree of contamination, with cross-linked meshes providing better resistance to mechanical stress 8
Critical Pitfalls to Avoid
Do not use polypropylene mesh in grossly contaminated fields (CDC Class III-IV), as infection rates can reach 21% in emergency hernia repairs and 19% in contaminated ventral hernia repairs 8, 7
Avoid absorbable prosthetic materials for permanent repair, as complete dissolution leads to inevitable hernia recurrence through loss of prosthetic support 8, 7
Do not automatically exclude mesh use based solely on the presence of non-viable intestine, as studies show no significant difference in infection rates between viable and non-viable bowel cases when gross spillage is absent 7
Recognize that bowel resection increases overall postoperative complications (P < 0.0001) and major complications (P = 0.003), but not necessarily surgical site infection (P = 0.42) 7