Open Hernia Repair (Lichtenstein Repair) Technique

Presenter: Dr. T. K. Swamy, Surgical Gastroenterologist

Importance of Open Surgery

• Essential for every general surgeon, especially for large hernias, obstructions, recurrences, and significant scarring.
• Must be performed without complications and with a recurrence rate and post-operative neurology rate of <0.5%.

Overview of Lichtenstein Technique

• Lichtenstein performed 3125 cases from 1984 to 1992 with a low recurrence rate (4 cases).
• Modifications by Lichtenstein are used in this technique.
• Prof. Parviz Ahmed, his assistant, also performed many surgeries.

Case Presentation

• 70-year-old male with a direct inguinal hernia on the left side.
• Patient opted for open surgery over laparoscopic due to family history.

Surgical Procedure

Pre-Operation Setup

• Patient under spinal anesthesia.
• Surgical team positions: Surgeon on the left, assistant on the right, staff nurse to the left.

Incision and Initial Dissection

• Use inguinal incision, preferred over transverse for better access and fewer complications.
• Divide both layers of the superficial fascia (fatty and membranous).
• Preserve the fascia over the external oblique muscle.
• Carefully dissect to avoid damage to the ilio-inguinal nerve.

Dissection Technique

• Use scissors to push and split the muscle rather than cutting to avoid nerve damage.
• Dissect the upper and lower flaps, ensuring visibility of the inguinal ligament.

Handling Cremaster Muscle and Sac

• Separate the cremaster muscle and the sac using delicate dissection.
• Avoid removing the cremaster muscle and handle nerves with care.
• Maintain fascia around nerves and avoid unnecessary handling.

Closing the Defect

• Use non-absorbable polypropylene for suturing the defect.
• Ensure sac is secure and does not protrude.
• Avoid injuring inferior epigastric vessels.
• Excise loose tissues to prevent infection.

Mesh Placement

• Measure and cut polypropylene mesh appropriately.
• Suture mesh starting from the mesh to pubic tubercle, ensuring mesh covers the Hesselbach's triangle.
• Create a prosthetic internal ring by criss-crossing mesh flaps and suturing.
• Ensure mesh lies flat but with some laxity.

Final Steps

• Properly close external oblique muscle using absorbable sutures.
• Avoid using self-retaining retractors to minimize neuropraxia.
• Perform subcuticular suturing, aiming for intradermal stitches to avoid dog-ears.
• Ensure wound is clean and apply minimal ointment and gauze for dressing.

Key Points to Remember

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

Conclusion

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• Thank you for watching.