What structures are involved in securing the mesh in a Lichtenstein hernia repair?

Structures Involved in Securing the Mesh in Lichtenstein Hernia Repair

In Lichtenstein inguinal hernia repair, the mesh is secured to the inguinal ligament (Poupart's ligament) inferiorly, the conjoint tendon/internal oblique muscle superiorly, the pubic tubercle/Cooper's ligament medially, and the transversalis fascia laterally around the internal ring, creating a tension-free reinforcement of the inguinal floor. 1, 2

Key Anatomical Fixation Points

Inferior Border Fixation

• The mesh is sutured to the inguinal ligament (Poupart's ligament) using a continuous suture technique from the pubic tubercle laterally to beyond the internal ring 1, 2
• For complex or recurrent hernias, the inferior border should also be fixed to Cooper's ligament from the pubic tubercle to the femoral vein to fully protect the femoral triangle and prevent femoral recurrence 1
• The mesh must overlap the pubic bone rather than being placed in juxtaposition to the tubercle, as failure to do so is a documented cause of recurrence 2

Superior Border Fixation

• The upper edge of the mesh is secured to the conjoint tendon (combined internal oblique and transversus abdominis aponeurosis) using interrupted or continuous sutures 1, 3
• This fixation distributes tension and reinforces the posterior inguinal wall 3

Medial Fixation

• The mesh must extend at least 2 cm medial to the pubic tubercle and be secured to prevent medial recurrence 1, 2
• Inadequate medial overlap at the pubic tubercle is a primary cause of recurrence 2

Lateral Fixation Around Internal Ring

• The mesh is fashioned with a slit to accommodate the spermatic cord, creating superior and inferior tails 1
• The internal ring is "locked" with two key sutures:
  • One suture fixes the superior mesh tail to the inferior tail cranial to the spermatic cord, 1-1.5 cm medial to the inguinal ligament 1
  • A second suture fixes both tail borders to the inferior part of Poupart's ligament, 1 cm cranially and laterally to the first suture 1
• The lower mesh border is fixed with running suture 2-3 cm lateral to the internal ring to fully protect against indirect recurrence 1

Transversalis Fascia Integration

• The mesh is placed directly on the transversalis fascia, providing total reinforcement of the inguinal floor 2, 4
• In laparoscopic approaches, the mesh is sutured to the transversalis fascia and transversus abdominis aponeurosis superior-medially, and to the iliopubic tract or Cooper's ligament inferiorly 5

Critical Technical Principles

Tension-Free Repair

• The mesh must be placed with appropriate laxity, never under tension, as this is fundamental to preventing recurrence 2, 4
• A mesh that is too narrow or placed under tension can disrupt from the inguinal ligament, causing recurrence 2

Adequate Mesh Size and Overlap

• The mesh should be approximately 2.5 x 4.5 inches (or larger for complex hernias) to ensure adequate coverage 5
• Inadequate overlap beyond the hernia defect increases recurrence risk, particularly at the pubic tubercle and internal ring 6, 2

Modified Technique for Complex Hernias

• For recurrent hernias or those with destroyed Poupart's ligament, the lower corner of the mesh should be moved laterally and fixed caudally to the tubercle by 20-30 degrees relative to its lower border 1
• This modification fully protects the medial triangle and prevents direct inguinal recurrence 1

Common Pitfalls to Avoid

• Placing mesh in juxtaposition to (rather than overlapping) the pubic tubercle causes medial recurrence 2
• Using a mesh patch that is too narrow creates tension and risks disruption from the inguinal ligament 2
• Inadequate lateral fixation around the internal ring leaves the lateral triangle unprotected 1
• Improper mesh fixation can lead to migration or displacement 6