What is the step-by-step surgical procedure and surgical consent for Lichtenstein repair in an adult male patient with a diagnosed inguinal hernia and no significant past medical history or allergies?

Lichtenstein Repair: Surgical Procedure and Consent

Surgical Consent Elements

For Lichtenstein inguinal hernia repair, informed consent must explicitly cover mesh placement, potential for chronic groin pain (12-15% incidence), recurrence risk (0-3% with mesh vs 7-19% with tissue repair), and testicular complications in males. 1, 2, 3

Key Consent Discussion Points:

• Benefits: Significantly lower recurrence rates (0-3%) compared to tissue repair (7-19%), faster return to work (median 8 days), and can be performed under local anesthesia 2, 3, 4
• Risks to discuss: Chronic groin pain (12-15%), wound infection, seroma/hematoma formation, testicular complications (orchitis, testicular atrophy), nerve injury causing paresthesia/neuropraxia, and mesh-related complications 1, 3
• Recurrence discussion: Emphasize that mesh repair has 0-3% recurrence versus 7-19% with tissue-only repair, making it the standard of care 1, 2, 4
• Alternative approaches: Laparoscopic repair (TEP/TAPP) offers comparable outcomes with lower wound infection rates and ability to identify contralateral hernias (present in 11-50% of cases) 1, 5

Step-by-Step Surgical Procedure

Preoperative Setup

• Anesthesia: Local anesthesia is preferred and recommended for uncomplicated inguinal hernias, avoiding general anesthesia risks 1, 5
• Patient positioning: Supine position with appropriate sterile field preparation 6
• Antibiotic prophylaxis: Single dose for clean cases; 48-hour prophylaxis if intestinal manipulation occurs 1

Operative Steps

Step 1: Incision and Exposure

• Make an oblique incision approximately 2-3 cm above and parallel to the inguinal ligament, centered over the internal ring 6
• Incise external oblique aponeurosis in the direction of its fibers to expose the inguinal canal 6
• Identify and protect the ilioinguinal nerve throughout the procedure to prevent chronic neuropathic pain 1, 6

Step 2: Hernia Sac Management

• Identify the spermatic cord and carefully dissect the hernia sac (indirect) or reduce direct hernia bulge 6
• For indirect hernias: Dissect the sac from cord structures, ligate at the internal ring level if large, or simply reduce if small 6
• Preserve the cremasteric muscle fibers when possible to reduce postoperative pain 6

Step 3: Mesh Preparation and Placement

• Use polypropylene mesh measuring at least 8 x 15 cm to ensure adequate overlap of 1.5-2.5 cm beyond the defect edges 1, 6
• Create a slit in the mesh from the lateral edge toward the center to accommodate the spermatic cord 6
• Position the mesh to overlap the pubic tubercle by at least 2 cm medially—critical technical point as three of four recurrences in the original series occurred from inadequate pubic tubercle coverage 6

Step 4: Mesh Fixation

• Mesh fixation is optional: Non-fixation technique shows significantly lower operative time and pain scores without increased recurrence rates 7
• If fixating: Suture the inferior edge to the shelving edge of the inguinal ligament with interrupted non-absorbable sutures, ensuring the mesh lies flat without tension 6
• Secure the superior edge to the internal oblique and transversus abdominis muscles 6
• Ensure adequate mesh width and laxity—one recurrence in the original series resulted from using too narrow a patch under tension 6
• Overlap the mesh tails around the cord, creating a new internal ring that admits the tip of a small clamp alongside the cord 6

Step 5: Closure

• Close the external oblique aponeurosis over the cord with running absorbable suture 6
• Close Scarpa's fascia and skin in standard fashion 6

Critical Technical Pitfalls to Avoid

• Inadequate pubic tubercle coverage: Mesh must overlap the pubic bone by at least 2 cm to prevent medial recurrence 6
• Mesh under tension: Use adequately sized mesh (minimum 8 x 15 cm) placed with appropriate laxity to prevent disruption from the inguinal ligament 6
• Nerve injury: Identify and preserve the ilioinguinal nerve to prevent chronic neuropathic pain (occurs in 12-15% of cases) 1, 3
• Inadequate lateral coverage: Mesh must extend beyond the internal ring laterally to prevent indirect recurrence 1, 6

Postoperative Management

• Pain control: Prioritize acetaminophen and NSAIDs; limit opioids to 15 tablets of hydrocodone/acetaminophen 5/325mg or 10 tablets of oxycodone 5mg for laparoscopic repair, 15 tablets for open repair 1
• Return to activity: Median return to normal workload is 8 days (range 4-14 days) 3
• Follow-up schedule: Examine at 7 days for wound complications, seroma, scrotal edema; at 6 months for chronic pain, paresthesia, and recurrence 7
• Monitor for complications: Wound infection, chronic pain (12-15%), testicular complications, and recurrence (0-3% with proper technique) 1, 2, 3