Lichtenstein Hernioplasty

Lichtenstein Hernioplasty Overview

The Lichtenstein hernioplasty, also known as the Lichtenstein tension-free hernia repair, is a widely accepted surgical technique for repairing inguinal hernias. Here’s an overview of the key principles, procedure, advantages, and evolution of this method:

Key Principles of Lichtenstein Hernioplasty

Tension-Free Closure: The Lichtenstein repair is based on the principle of tension-free closure. It involves using a synthetic mesh to reinforce the weakened area of the abdominal wall where the hernia has occurred.
Mesh as a Scaffold: The synthetic mesh acts as a scaffold that allows new tissue to grow into it, eventually incorporating the mesh into the muscle layer, creating a strong and permanent repair.

Procedure Overview

The Lichtenstein hernioplasty procedure typically includes the following steps:

An incision is made in the groin area to access the hernia.
The hernia sac is identified, and if necessary, its contents are pushed back into the abdomen.
A synthetic mesh is cut to the appropriate size and shape and placed over the hernia defect.
The mesh is sutured in place, usually to the inguinal ligament and the conjoint tendon, to cover the hernia opening without tension.
The layers of the abdominal wall are closed over the mesh.

Advantages

The Lichtenstein hernioplasty offers several advantages:

Tension-Free Repair: Unlike traditional methods that sew the hernia defect edges together under tension, this technique bridges the defect with a mesh, reducing the risk of recurrence due to tension.
Low Recurrence Rate: Studies have shown a recurrence rate of less than 1% when the key principles of the procedure are followed.
Outpatient Procedure: It is typically performed under local anesthesia and on an outpatient basis, allowing for a quicker return to normal activities.
Suitability: Suitable for all adult patients, regardless of age, weight, general health, or the presence of other medical conditions.
Widespread Use: The technique is well-suited for various hospital settings and has been adopted worldwide due to its simplicity and effectiveness.

Evolution and Refinements

Over time, the Lichtenstein technique has evolved with minor changes to improve its efficacy. These refinements are based on the experiences and outcomes of the procedure, resulting in the establishment of key principles that guide surgeons in achieving the best results.

Conclusion

The Lichtenstein tension-free hernioplasty is considered a gold standard procedure for inguinal hernia repair. It is recognized for its simplicity, safety, and effectiveness. Endorsed by the American College of Surgeons, it is characterized by a low rate of complications and recurrences, making it a preferred choice for hernia repair surgeries.

Skin Incision: Make a 4 cm incision in the inguinal canal area, approximately 2 fingers medial to it.
Division of External Oblique Aponeurosis: Longitudinally divide the fibers of the external oblique, including the superficial inguinal ring.
Mobilization of Spermatic Cord: Tape and lift the spermatic cord, free it from the transversalis fascia and direct hernia sac by blunt dissection, and divide the cremaster muscle longitudinally.
Handling Hernia Sac: Splay open the hernia sac, reduce its contents, close the base of the hernia sac with an outer purse string suture, and remove excess sac tissue.
Fitting and Tailoring Mesh: Cut a synthetic mesh to the appropriate size and shape to cover the abdominal wall defect.
Mesh Fixation: Anchor the mesh to the inguinal ligament and secure it onto the internal oblique muscle.
Closure of External Oblique Aponeurosis: Close the external oblique aponeurosis over the mesh to complete the repair.

Division of External Oblique Aponeurosis: Longitudinally divide the fibers of the external oblique, including the superficial inguinal ring.

Mobilization of Spermatic Cord: Tape and lift the spermatic cord, free it from the transversalis fascia and direct hernia sac by blunt dissection, and divide the cremaster muscle longitudinally.

Fitting and Tailoring Mesh: Cut a synthetic mesh to the appropriate size and shape to cover the abdominal wall defect.

Mesh Fixation: Anchor the mesh to the inguinal ligament and secure it onto the internal oblique muscle.

Hernia Mesh Types:

Synthetic Meshes:
- Non-absorbable: Permanent reinforcement for hernia repair.
- Absorbable: Degrade over time, providing temporary support while promoting tissue growth.
- Common materials: Polypropylene and polyester.
- Lightweight with large pores for comfort and reduced infection risk.
Biological Meshes:
- Derived from animal tissues (e.g., pig or cow).
- Treated to be safe for human use.
- Absorbable but not as strong as synthetics.
- Higher risk of hernia recurrence.
Hybrid Meshes:
- Combine layers of polymer and biological materials.
- Offer the strength of synthetics and advantages of animal-derived materials.

Mesh Forms:

Mesh can come in various forms, including sheets, plugs, and patches.
Newer mesh types feature tentacle straps for broader coverage and suture-free hernia repairs.

Types of synthetic mesh

Polypropylene Mesh:
- Known for durability.
- Suitable for most hernia repairs.
- Less prone to shrinkage when fixed with sutures.
Polyester Mesh:
- Used in various hernia repairs.
- Associated with a higher recurrence rate in some studies.
ePTFE (Expanded Polytetrafluoroethylene) Mesh:
- Known for small pore size and hydrophobic properties.
- May be more prone to interface failure.
Composite Meshes:
- Designed to address specific issues, such as adhesion formation.
- Combine different materials for their respective benefits.
Lightweight Meshes:
- Have large pores and minimal surface area.
- Offer comfort to patients and reduce infection risk.
Knitted Mesh or Non-Knitted Sheet Forms:
- Provide flexibility in how they are used during surgery.