BMC Surgery BioMed Central

1BMC
2001,Surgery :3
Research article
Open tension free repair of inguinal hernias; the Lichtenstein
technique
George H Sakorafas*, Ioannis Halikias, Christos Nissotakis,
Nikolaos Kotsifopoulos, Alexios Stavrou, Constantinos Antonopoulos and
George A Kassaras

Address: Department of Surgery, 251 Hellenic Air Force Hospital, Athens, Greece
E-mail: George H Sakorafas* - [email protected]; Ioannis Halikias - [email protected];
Christos Nissotakis - [email protected]; Nikolaos Kotsifopoulos - [email protected];
Alexios Stavrou - [email protected]; Constantinos Antonopoulos - [email protected];
George A Kassaras - [email protected]
*Corresponding author

Published: 15 October 2001 Received: 1 August 2001

Accepted: 15 October 2001
BMC Surgery 2001, 1:3
This article is available from: http://www.biomedcentral.com/1471-2482/1/3
© 2001 Sakorafas et al; licensee BioMed Central Ltd. Verbatim copying and redistribution of this article are permitted in any medium for any non-
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Abstract
Background: Recurrences have been a significant problem following hernia repair. Prosthetic
materials have been increasingly used in hernia repair to prevent recurrences. Their use has been
associated with several advantages, such as less postoperative pain, rapid recovery, low recurrence
rates.
Methods: In this retrospective study, 540 tension-free inguinal hernia repairs were performed
between August 1994 and December 1999 in 510 patients, using a polypropylene mesh
(Lichtenstein technique). The main outcome measure was early and late morbidity and especially
recurrence.
Results: Inguinal hernia was indirect in 55 % of cases (297 patients), direct in 30 % (162 patients)
and of the pantaloon (mixed) type in 15 % (81 patients). Mean patient age was 53.7 years (range,
18 – 85). Follow-up was completed in 407 patients (80 %) by clinical examination or phone call. The
median follow-up period was 3.8 years (range, 1 – 6 years). Seroma and hematoma formation
requiring drainage was observed in 6 and 2 patients, respectively, while transient testicular swelling
occurred in 5 patients. We have not observed acute infection or abscess formation related to the
presence of the foreign body (mesh). In two patients, however, a delayed rejection of the mesh
occurred 10 months and 4 years following surgery. There was one recurrence of the hernia (in one
of these patients with late mesh rejection) (recurrence rate = 0.2 %). Postoperative neuralgia was
observed in 5 patients (1 %).
Conclusion: Lichtenstein tension-free mesh inguinal hernia repair is a simple, safe, comfortable,
effective method, with extremely low early and late morbidity and remarkably low recurrence rate
and therefore it is our preferred method for hernia repair since 1994.

Background There is evidence that a defect in the metabolism of col-

Recurrence following repair of inguinal hernias is a sig- lagen is involved in the pathogenesis of inguinal hernia
nificant problem for both the surgeon and the patient. in adults, leading to a weakening of the transversalis fas-
BMC Surgery 2001, 1:3 http://www.biomedcentral.com/1471-2482/1/3

cia. Obviously, the use of such a weakened tissue is prob- the spermatic cord. The continuous suture extends up
lematic for hernia repair. In an attempt to reduce the just medial to the anterior superior iliac spine. Interrupt-
incidence of recurrences and to reinforce the plastic re- ed Prolene sutures then suture the two cuted edges of the
construction various techniques have been used, includ- mesh together around the spermatic cord. The infero-
ing autologous tissue techniques and a variety of medial corner of the mesh is then attached well overlap-
biomaterials [1,2]. Usher proposed the use of high-den- ping the pubic tubercle. The mesh is then anchored to the
sity polyethylene to repair tissue defects of the chest and conjoined tendon by metal staples (titanium) or by inter-
abdominal wall, about half a century ago [3,4]. Since that rupted sutures (Prolene 3–0). After meticulous hemos-
time, a clear preference for synthetics has been observed tasis, a closed suction drain is placed beneath the
and during the last decade a marked interest in the use of external oblique aponeurosis, especially in large inguinal
prosthetic materials was evident. The reports by Stoppa hernias, where an extensive dissection was performed
et al [5] and by Lichtenstein [6], as well as the innovation during the plastic reconstruction. The aponeurosis of ex-
of laparoscopic hernia repair [7,8], where the use of ternal oblique is then closed sing absorbable sutures
prostheses was associated with many advantages, greatly (Vicryl No 2). Before the closure of the surgical incision,
contributed to this change in our surgical philosophy. In its edges are infiltrated with a long-acting local anesthet-
this paper, we review our experience on tension – free ic, such as Naropein.
surgical repair of a consecutive series of inguinal hernias
using a polypropylene mesh (Lichtenstein technique). Regarding peri-operative care of the patient, prophylac-
tic antibiosis is usually given for 48 – 72 hours postoper-
Methods atively. In high-risk patients (i.e. obese patients), low
From August 1994 through December 1999, 540 tension molecular weight heparin is usually administered to pre-
– free repairs of inguinal hernia were performed in 510 vent deep venous thrombosis the night before surgery
patients, by using a polypropylene mesh (Surgi-Pro in 95 and its administration is continued during the hospitali-
% and Prolene in 5 %). Thirty patients had bilateral her- zation of the patient. Surgery is usually performed under
nias. Inguinal hernia was indirect in 55 % of cases (297 epidural anesthesia. The patient is mobilized about six
patients), direct in 30 % (162 patients) and of the panta- hours after surgery. Postoperative anesthesia consists in
loon (mixed) type in 15 % (81 patients). Mean patient age the administration of paracetamol or NSAIDS or a com-
was 53.7 years (range, 18 – 85). All cases were performed bination of these too analgesics. The usual duration of
under epidural anesthesia. Four surgeons (GHS, NK, AS the hospitalization is 2 days. When a closed suction
and GK) participated in the study. drainage was used, it is removed the day of discharge.

Operative technique Results

The patient is placed in the supine position. The groin is Postoperative pain was minimal and easily controlled by
prepared in the usual fashion. Before the incision, a bo- the use of single analgesics (as previously reported). In
lus dose of a second-generation cephalosporin is given the immediate postoperative period we had 13 complica-
intravenously. After incising the skin, subcutaneous tis- tions (morbidity = 2.5 %); hematoma and seroma forma-
sue, and external oblique aponeurosis (as usually), the tion, requiring drainage, were observed in two and six
spermatic cord is elevated from the posterior wall of the patients, respectively. Testicular swelling occurred in 5
inguinal canal. In indirect hernias, the hernial sac is patients (1 %), all of which settled. It should be empha-
identified, dissected to the internal ring and opened to sized that we have not observed abscess formation or
allow examination of its contents. The sac is ligated and acute infection related to the presence of the foreign
its distal portion is usually excised. However, in large in- body (mesh).
direct inguinal hernias, where the sac descents down to
the scrotum, the distal part of the sac may be left open to Follow-up was completed in 407 patients (80 %) by clin-
prevent the formation of a hydrocele, thus allowing ical examination (n = 362) or phone call (n = 45). The
spontaneous obliteration. In direct hernias, we prefer to median follow-up period was 3.8 years (range, 1 – 6
imbricate its contents with non-absorbable sutures (usu- years). In two patients we observed a delayed rejection of
ally silk 2–0). the mesh, 10 months and 4 years after the plastic recon-
struction, respectively. This rare and interesting compli-
A polypropylene mesh (3 × 5 inch) is trimmed to fit the cation was presented by the late formation of a
floor of the inguinal canal, and its apex is first sutured to productive sinus at the site of the surgical incision. In
the public tubercle using a No 3–0 Prolene suture. The both patients, a surgical debridement of this sinus tract
same continuous suture then sutures the lower border of was performed, but the fluid production continued. The
the mesh to the free edge of the inguinal ligament, after mesh was then removed. Surprisingly, the mesh was al-
an opening is made into its lower edge to accommodate most intact in both cases, without having caused the typ-
BMC Surgery 2001, 1:3 http://www.biomedcentral.com/1471-2482/1/3

ical inflammatory response, resulting in mesh vent folding, wrinkling, or curling of the mesh around
incorporation into the host tissues; as is well known, this the cord.
is considered a significant advantage of the mesh repair
over the traditional methods of hernia repair. In one of The method is simple, can be performed by all the sur-
these patients the hernia recurred (0.2 %). Severe post- geons – even those without special interest in hernia sur-
operative neuralgia, persisting over 6 months postopera- gery – and is very effective in the prevention of
tively and requiring analgesics administration, was recurrences. Indeed, an extremely low recurrence rate
observed in 5 patients (1 %). Management was conserva- (range, 0 – 0.7 %) has been reported from many groups
tive in all cases (by using simple, non-narcotic analge- of surgeons [9,12–14]. The method combines many ad-
sics, such as NSAIDS) and progressively settled in all vantages, such as simplicity, effectiveness, safety, com-
cases. fortable postoperative course with easily controlled pain,
rapid return to unrestricted activities, an impressively
Discussion low recurrence rate and high patient satisfaction. We
The description of the Lichtenstein tension-free mesh re- have been encouraged by these good results of this pro-
pair, about 16 years ago, opened a new era in groin hernia cedure in a relatively large number of patients (n = 540).
repair [6]. Postoperative pain is minimal, as a result of For these reasons, it is our preferred method for hernia
the tension-free technique. The method is very simple, repair since 1994.
effective, is associated with a very low recurrence rates
(ranging from 0 to 2 % in the literature) and can be per- Competing interests
formed under local or regional anesthesia [9–11]. For None declared.
these important advantages, it is currently the preferred
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To reduce the chance of recurrence, the mesh should ex-
tent 2 – 4 cm beyond the boundary of Hesselbach's trian-
gle [10]. The position of the mesh beneath the
aponeurosis of the external oblique results in the in-
traabdominal pressure working in favor of the repair,
since the external oblique aponeurosis keeps the mesh
tightly in place by acting as an external support when in-
traabdominal pressure rises. The mesh should be fixated
carefully, by the use of Prolene sutures or staples, to pre-