What modifications can providers make in the Lichtenstein repair for inguinal hernias?

Modifications of the Lichtenstein Repair for Inguinal Hernias

Mesh Fixation Modifications

The most impactful modification to the standard Lichtenstein technique is using tissue adhesive (glue) instead of sutures for mesh fixation, which reduces operative time by approximately 2.6 minutes, decreases postoperative pain, lowers early chronic pain rates by 48%, and shortens return to daily activities by 1.2 days, all while maintaining equivalent recurrence rates. 1

Glue vs. Suture Fixation

• Glue fixation demonstrates superior outcomes in multiple domains: patients experience lower visual analog pain scores (mean difference -0.75 points), reduced early chronic pain occurrence (risk ratio 0.52), and faster recovery without compromising hernia recurrence rates 1
• Self-fixating polypropylene mesh with resorbable polylactic acid microgrips reduces operative time from 53.4 minutes to 44.4 minutes compared to sutured mesh, though it does not significantly reduce early or chronic postoperative pain at 3-month, 1-year, or 2-year follow-up 2
• Autoadhesive meshes with hooks allowing fixation without sutures show no significant advantage over classic sutured polypropylene mesh regarding recovery time, postoperative pain, or long-term complications 3

Technical Modifications for Complex Hernias

For complex groin hernias including huge hernias with massive transversalis fascia destruction or recurrent hernias with destroyed Poupart's ligament, three critical modifications prevent recurrence in all anatomical triangles. 4

Medial Triangle Protection (Direct Hernia Prevention)

• Lateral movement and fixation of the lower corner of the mesh caudally to the pubic tubercle by 20-30 degrees in relation to its lower border fully protects the medial triangle and prevents direct inguinal recurrence 4
• The mesh must overlap at the pubic bone rather than being placed in juxtaposition to the tubercle, as placement adjacent to the tubercle was responsible for three of four recurrences in a large series 5

Femoral Triangle Protection (Femoral Hernia Prevention)

• Fixation of the lower border of the mesh using a running "U" suture to both Poupart's and Cooper's ligaments, from the tubercle to the femoral vein, fully protects the femoral triangle and prevents femoral recurrence 4

Lateral Triangle Protection (Indirect Hernia Prevention)

• The lower mesh border should be fixed by running suture 2-3 cm laterally to the internal inguinal ring 4
• "Locking" of the internal inguinal ring requires two interrupted sutures: one fixing the superior mesh tail to the inferior tail cranial to the spermatic cord 1-1.5 cm medial to Poupart's ligament, and another fixing both mesh tail borders to the inferior part of Poupart's ligament 1 cm cranially and laterally to the preceding suture 4

Mesh Selection in Contaminated Fields

For strangulated hernias requiring bowel resection (CDC wound class III-IV), biological mesh should be used when primary repair is not feasible for defects >3 cm, as biological meshes demonstrate lower recurrence rates, higher resistance to infections, and lower displacement risk compared to synthetic meshes. 6

Contaminated Field Management

• Primary repair is recommended when the defect is small (<3 cm) in patients with strangulated hernia with bowel necrosis and/or gross enteric spillage 6
• When direct suture is not feasible, biological mesh is the preferred option for repair in contaminated-dirty surgical fields 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 resisting mechanical stress better and for longer periods 6
• If biological mesh is unavailable, polyglactin mesh repair or open wound management with delayed repair are viable alternatives 6

Mesh Use in Strangulated Hernias Without Bowel Resection

• Mesh repair appears safe in strangulated inguinal hernias even with bowel resection, showing lower wound infection rates (OR 0.46) and lower recurrence rates (OR 0.2) compared to non-mesh repair 6
• Mesh placement is not a significant predictor of postoperative complications in incarcerated hernia repair after multivariate analysis 6

Critical Technical Pitfalls to Avoid

• Never place the mesh in juxtaposition to the pubic tubercle—this caused 75% of recurrences in one large series; always overlap the mesh at the pubic bone 5
• Avoid using a mesh patch that is too narrow—this creates tension and risks disruption of the lower edge from Poupart's ligament; a wider patch fixed with appropriate laxity is required 5
• Do not use polypropylene mesh in CDC wound class III fields—infection rates reach 21% in emergency repairs with synthetic mesh in contaminated fields 6
• Avoid absorbable prosthetic materials in contaminated fields—complete dissolution of the prosthetic support leads to inevitable hernia recurrence 6