Lichtenstein Repair (aka tension-free repair or plug-and-patch repair)
Indications
Indirect inguinal hernia – this type of hernia occurs because of the weakness of the tissue in and around the inguinal canal. The tissue in this hernia projects through the internal inguinal ring that the spermatic cord and vessels traverse. By definition this hernia lies lateral to the inferior epigastric vessles. Contents of indirect inguinal hernias can include fat, bowel, peritoneum, and bladder. These hernias are extremely common and occur in 5% of men – they are the hernia that is most common in young men.
Direct inguinal hernia – these hernias are more common in older men. They are caused by a weakness in the anterior abdominal wall muscles and by definition protrude medial to the inferior epigastric vessels.
Incision
Parallel to inguinal ligament – this is the most common incision and is made approximately two finger breadths above the imaginary line running from the anterior iliac spine to the tubercle of the pubic bone. If there is a palpable bulge the over the external ring the incision is carried down to this area. The trend in hernia surgery is to make smaller incisions and most hernias can be repaired in non-obese patients through a 6-7 cm incision.
Surgical Details of Procedure
1. The incision is made through the skin with a No. 10 scalpel.
2. Dissection is carried through the subcutaneous tissue and through Scarpa’s fascia with Bovie cautery.
3. The fascia of the external oblique is appreciated and dissected free of the surrounding tissue.
4. A self-retaining retractor (e.g., Weitlander retractor) is placed to allow good visualization of the external oblique fascia.
5. A small incision is made in the center of the external oblique fascia along the lines of tissue.
6. The closed tips of a Metzenbaum scissors are placed through this small incision and pushed under the external oblique fascia both caudally (toward the feet) and cephalad (toward the head) to dissect away the ilioinguinal nerve that may be on the anterior surface of the cord.
7. The Metzenbaum scissors is then used to incise the external oblique fascia both cephalad and caudally.
8. The free edges of the fascia are grasped with hemostats and used to retract the fascia up into the wound to expose the cord.
9. Blunt dissection is then used (usually a gauze sponge over the surgeons forefinger or thumb) to dissect the cord and internal oblique muscle away from the underside of the external oblique fascia.
10. Most surgeons then make a diligent search for the ilioinguinal nerve which usually lies on the anterior part of the cord.
11. If located this is carefully dissected free from the cord with care taken to not directly grasp the nerve.
12. When the external oblique fascia is sufficiently dissected away from the cord the hemostat on the upper edge of the external oblique fascia is released and the nerve is put of the outside of the external oblique fascia and the hemostat is reapplied.
13. The self-retaining retractor is then moved to the inside of the cut edges of the fascia.
14. Using the tip of the forefinger that is placed on the pubic tubercle the cord is then bluntly dissected free of the floor of the inguinal canal. When mastering this maneuver surgical trainees are taught to “scrape your fingernail against the bone.”
15. A soft Penrose drain is then passed underneath the cord and any hernia contents.
16. An inspection is then made of the floor of the inguinal canal to ascertain if a direct hernia is present.
17. Regardless of whether a direct hernia is present, a diligent search must be made for an indirect hernia.
18. To locate an indirect hernia, the tissue layers of the cord must be carefully and meticulously dissected away from the spermatic vessels and spermatic cord.
19. This is done by blunt dissection of the cremasteric muscle fibers using a “stripping” technique that pulls the muscle fibers toward the internal ring.
20. Care must be taken not to injure the “cord structures” – the spermatic vessels and the vas deferens
21. When the hernia sac (a portion of the normally intraabominal peritoneum) is located in the cord tissues (it is a thin white filmy line) the edge is grasped with two fine-tipped hemostats.
22. A diligent search must be made for an accompanying cord lipoma (mass of intraperitoneal fat that has travelled with hernia through the internal ring).
23. If present the cord lipoma must be dissected free of the hernia sac down to the level of the internal ring.
24. The cord lipoma is usually transected with a bovie cautery after a stay suture of usually 2-0 Vicryl is placed at the base of the lipoma close to the internal ring.
25. After it is transected the lipoma remnant usually retracts into the abdomen.
26. The hernia sac is then opened so it can be inspected internally for presence of bowel or bladder wall.
27. This is done by retracting the hemostats placed on the edge of the sac and retracting up into the wound and making a small incision at the top edge with a Metzenbaum scissors.
28. The inside of the sac is then inspected for bowel or the side wall of the bladder.
29. If bowel is present it is manually reduced back into the abdominal cavity (i.e., pushed back into the abdomen with the surgeon’s finger)
30. If bladder is present it is more difficult to manually reduce. The level of intrusion is noted and care is taken to ligate the sac above the edge of the bladder.
31. The ligation of the hernia sac is performed by either twisting the cord and placing an absorbably suture at the cinch area or by placing a pursestring suture under direct visualization and then cinching this down onto the walls of the hernia sac.
32. The sac above the ligation is then resected (cut-off) and the hernia sac is allowed to retract into the abdomen.
33. If a direct hernia is present in the floor of the canal the surgeon may choose to close this with a mesh plug that resembles a badminton birdie.
34. The plug is moistened and then the edges are approximated with a hemostat and it is fitted gently into the defect so that the mouth of the plug springs open at the level of the fascial ring.
35. It is then secured in place using interrupted sutures (e.g., 2-0 or 3-0 Prolene sutures).
36. If there is an indirect hernia the surgeon will select the appropriately sized mesh patch.
37. The toe of the mesh is usually sutured in place first with a 2-0 or 3-0 Prolene suture placed into the fascia of the pubic tubercle and then through the edge of the mesh.
38. Interrupted sutures as above are then used to fasten the mesh (which is roughly fish-shaped with two tails fashioned from the one end due to the slit in the patch) circumferentially to the inguinal ligament and the conjoined tendon.
39. The tails of the mesh patch are wrapped around the cord with additional length given to the slit to ensure that the cord is not strangulated.
40. If a previously placed plug had been positioned in a direct hernia the mesh patch should completely cover the edges of the plug.
41. After the mesh patch has been secured circumferentially, the tip of the little finger is placed between the cord and the edge of the mesh to insure that the repair is not overly tight.
42. Many surgeons at this juncture ask the anesthesia team to valvsalva the patient (similar to pushing down when having a bowel movement) to insure that the plug and patch do not unduly move too much.
43. The wound is then irrigated with saline solution (many surgeons add an antibiotic such as kanamycing to the irrigation).
44. The hemostats are released and the nerve if it has been identified is gently restored to the anterior of the cord.
45. The edges of the external oblique are reapproximated using a running 3-0 Vicryl stitch.
46. The wound is then irrigated again and the subcutaneous tissue and Scarpa’s fascia is reapproximated using interrupted 3-0 Vicryl stitches.
47. The skin is closed using staples or a running subcuticular 4-0 absorbable suture such as Monocryl.
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