Open Hernia Repair for Inguinal Hernia - Lichtenstein Repair

Key Points

• Importance of being well-versed in open surgery for general surgeons.
• Open surgery necessary for large hernias, obstructions, strangulations, recurrences, or numerous lower abdomen scars.
• Emphasis on reducing complications and recurrence rates (<0.5%).

About Lichtenstein Repair

• Dr. Lichtenstein performed 3125 cases from 1984-1992 with follow-up in 87% of cases.
• Only 4 recurrences: 3 in front of the pubic tubercle, 1 under the inguinal ligament.
• Lichtenstein's techniques and modifications are standard for this surgery.

Case Study

• Patient: 70-year-old male with direct inguinal hernia on left side.
• Preference for open surgery due to previous family issues with laparoscopic surgery.

Surgical Procedure

Preparation

• Patient under spinal anesthesia.
• Surgical team positioning: Surgeon on the left, assistant on the right, staff nurse to the left.
• Inguinal incision preferred over transverse incision due to better access and less neuropraxia.

Initial Incision and Dissection

• Divide both layers of the superficial fascia.
• Careful handling of the superficial inferior epigastric vein.
• Maintain thin layer over external oblique muscle to stabilize muscle fibers.

Handling Nerves

• Ilio-inguinal nerve: make small incision, push tissues down, avoid shearing movements with scissors.
• Dissect until internal ring, handle nerves with care to avoid neuropraxia.

Sac and Cord Structures

• Dissect cremaster fascia and muscle from the sac and cord structures.
• Preserve fascia around nerves, avoid unnecessary handling or stripping of nerves.
• Proper cleavage identification for effective dissection.

Mesh Placement

• Measure mesh accurately, ensure coverage of Hesselbach's triangle and beyond.
• Use lightweight polypropylene mesh.
• Fold and secure mesh properly, ensuring adequate tension and placement.
• Avoid too tight or too loose placement.

Suturing and Finishing

• Use non-absorbable sutures for defect closure (polypropylene preferred).
• Continuous sutures recommended for stability.
• Careful handling of inferior epigastric vessels to avoid injury.
• Properly suture external oblique muscle to support mesh placement.
• Subcuticular (intradermal) stitches for optimal healing and cosmetic results.

Key Takeaways

• Use a larger, lax mesh.
• Cover the pubic tubercle adequately.
• Preserve the cremaster muscle.
• Avoid finger dissection.
• Invaginate the sac properly.
• Create a proper prosthetic internal ring.
• Be mindful of nerves throughout the procedure.

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