Lichtenstein Repair Surgical Technique
Overview and Indications
The Lichtenstein tension-free mesh repair is the gold standard open technique for inguinal hernia repair, utilizing a polypropylene mesh to reinforce the inguinal floor without tissue tension, and is recommended for all non-complicated inguinal hernias in clean surgical fields. 1, 2
This technique can be performed under local or spinal anesthesia and is particularly advantageous for patients who cannot tolerate general anesthesia required for laparoscopic approaches. 3, 2
Surgical Steps
1. Anesthesia and Patient Positioning
- Perform the procedure under spinal or local anesthesia (local anesthesia is particularly useful in emergency settings without bowel gangrene). 3, 2
- Position the patient supine with slight Trendelenburg positioning.
2. Incision and Exposure
- Make a 4-6 cm oblique incision approximately 2 cm above and parallel to the inguinal ligament, centered over the internal ring. 4, 5
- Incise through skin, subcutaneous tissue, and Scarpa's fascia.
- Open the external oblique aponeurosis in the direction of its fibers to expose the inguinal canal.
- Identify and protect the ilioinguinal nerve running on the spermatic cord.
3. Hernia Sac Management
- For indirect hernias (55% of cases): Dissect the hernia sac from the cord structures, reduce contents, and either ligate at the internal ring or invert the sac. 4, 5
- For direct hernias (30% of cases): Reduce the hernia sac by inverting it back through the defect in the transversalis fascia. 4, 5
- For pantaloon/mixed hernias (15% of cases): Address both indirect and direct components. 4, 5
- Preserve the spermatic cord structures, including the vas deferens and testicular vessels, to avoid testicular complications. 1, 2
4. Mesh Placement (Critical Step)
- Use a polypropylene mesh measuring approximately 8 x 15 cm (must be wide enough to overlap the pubic tubercle and extend laterally beyond the internal ring). 6
- Create a slit in the lateral aspect of the mesh to accommodate the spermatic cord, forming two tails that will wrap around the cord at the internal ring. 4, 6
- Position the mesh to cover the entire myopectineal orifice with adequate overlap:
- Medially: Overlap the pubic tubercle by at least 2 cm (critical to prevent recurrence at this common failure point). 6
- Inferiorly: Extend to the shelving edge of the inguinal ligament.
- Superiorly: Cover the internal ring and conjoint tendon.
- Laterally: Extend beyond the internal ring.
5. Mesh Fixation
Two acceptable approaches exist:
Standard Fixation Technique:
- Suture the mesh to the inguinal ligament inferiorly using interrupted or continuous non-absorbable sutures (polypropylene). 4, 5
- Secure the mesh medially to the rectus sheath and conjoint tendon.
- Cross the two tails of the mesh around the cord at the internal ring and suture them to the inguinal ligament, creating a new internal ring. 6
- Ensure the mesh is placed with appropriate laxity (not under tension) to prevent recurrence. 6
Non-Fixation Technique:
- The mesh can be safely placed without suture fixation, which significantly reduces operative time and postoperative pain without increasing recurrence rates. 7
- The mesh is held in place by tissue ingrowth and intra-abdominal pressure. 7
6. Closure
- Close the external oblique aponeurosis over the cord using absorbable sutures.
- Close Scarpa's fascia and skin in layers.
Critical Technical Points to Prevent Recurrence
All four documented recurrences in the landmark series occurred due to specific technical errors: 6
- Three recurrences at the pubic tubercle: Caused by placing mesh in juxtaposition rather than overlapping the tubercle by at least 2 cm. 6
- One recurrence at the lower edge: Caused by using a mesh that was too narrow, creating tension when secured to the inguinal ligament. 6
To avoid these failures:
- Always overlap the mesh at the pubic bone by at least 2 cm medially. 6
- Use a sufficiently wide mesh (minimum 8 cm width) to allow tension-free placement. 6
- Secure the mesh with appropriate laxity, never under tension. 6
Expected Outcomes
- Recurrence rate: 0.2-0.4% with proper technique. 4, 5
- Operative time: Significantly shorter with non-fixation technique (approximately 30-40 minutes). 7
- Postoperative pain: Lower with non-fixation technique without compromising outcomes. 7
- Chronic neuralgia: 1-2% of cases. 4, 5
- Seroma formation: Occurs in approximately 0.5-2% of cases. 4, 5
- Mesh infection/rejection: Rare (0.4%), typically occurring months to years postoperatively. 4
Special Considerations for Emergency/Complicated Hernias
- For incarcerated hernias without strangulation (clean field): Proceed with standard Lichtenstein repair using synthetic mesh. 3, 2
- For strangulated hernias with bowel resection but no gross spillage (clean-contaminated field): Synthetic mesh can still be safely used without increased infection risk. 3
- For contaminated/dirty fields with bowel necrosis or peritonitis: Consider primary repair for small defects (<3 cm) or biological mesh if direct suture is not feasible. 3, 2
Common Pitfalls to Avoid
- Inadequate medial overlap at the pubic tubercle is the most common cause of recurrence. 6
- Using a mesh that is too narrow creates tension and increases recurrence risk. 6
- Injury to the ilioinguinal nerve during dissection causes chronic postoperative neuralgia. 4, 5
- Failure to examine the contralateral side may miss occult hernias present in 11-50% of cases (consider laparoscopic approach if bilateral repair is anticipated). 1, 2
- Excessive dissection of the spermatic cord increases risk of testicular complications including ischemia and atrophy. 1, 2