Lichtenstein hernioplasty

1. NO CONFLICT OF INTEREST
DR. VENKATESH KAMEPALLI (PG)
BHARATI DEEMED UNIVERSITY MEDICAL
COLLEGE & HOSPITAL, SANGLI
DR.CHINMAY GANDHI ASSOCIATE PROFESSOR
OUTCOME OF LICHTENSTEIN
HERNIOPLASTY

2. INTRODUCTION
 Inguinal hernia is the commonest surgical disease.
 Altered ratio of collagen 1 and 3 causes weakness
of fascia.
 Weakness in fascia transversalis causes hernia at
inguinal region, so we strengthen fascia
transversalis with mesh in Lichtenstein
hernioplasty.

3. STUDY DESIGN
This is the retrospective observational study of 150 inguinal
hernia operated by Lichtenstein tension free hernioplasty at
our institute from 2012 to 2014.
Surgeries were done by residents and faculties.
All patients were above 18 years having unilateral non
strangulated inguinal hernia .
Patients were followed for 2 years postoperatively for
recurrence and chronic groin pain.
.

4. SURGICAL
METHOD
Inguinal
incision was
given to expose
external
oblique
aponeurosis
and superficial
ring

5. Types of hernia
sac we encountered
after opening
inguinal canal.
direct sac in
Hasselbachs
triangle was
invaginated most of
times

6. After
Invagination of
direct sac we
can see
ilioinguinal
nerve with
cord.

7. ilihypogastric iliinguinal nerves were seen. Pre
hernia cord lipoma excised to prevent hernia
recurrence.
Indirect sac
dissection from
cord structures up
to retro
peritoneum,
reduction of its
content, inversion
of small indirect
sac ,ligation of the
neck of the large
indirect sac, cutting
across the body and
keeping rest of sac
open.

8. Strengthening of
posterior wall of
inguinal canal
with 6 X 4 inch
polypropylene
mesh was done in
all cases. 2cm
Overlap on medial
side of pubic
tubercle was given
. Lower edge of
mesh was sutured
with
polypropylene 2-0
suture to shelving
part of inguinal
ligament from
pubic tubercle to
internal ring level.

9. Lateral edge of
mesh was cut
approximately
1/3 from lower
edge to make
two tails of mesh
this is done to
accommodate
cord structures
at internal ring.
Anuloplasty
done to make
new internal
ring from mesh.
5 cm overlap of
mesh lateral to
internal ring was
given.

10. Mesh should form a loose dome over the posterior
inguinal wall. Incised external oblique aponeurosis
was sutured with 2-0 polypropylene suture with
creation of new lax external ring.
Medial fixation of
mesh on to anterior
rectus sheath.
Superiorly 3 cm
overlap was given
above Hasselbachs
triangle.
Fixation is also
done at medial and
superior to internal
ring through
internal oblique
muscle.

11. Study follow up
Follow up was done in out patient department and
by telephonic conversation.
All patients received prophylactic cefotaxim 1 gm.
2 hrs prior to surgery

12. Out of 150 operated patients
141 were male and 9 female.
141
9
Male
Female

13. Nyhus distribution of type of hernia
 Nyhus type 1: Indirect hernia with normal internal ring (54
PATIENTS)
 Nyhus type 2: Indirect hernia with dilated internal ring,
posterior wall intact(15 PATIENTS)
 Nyhus type 3 A: posterior wall defect direct inguinal hernia
(66 PATIENTS)
 Nyhus type 3 B: Indirect inguinal hernia ring dilated with
posterior wall defect (11 PATIENTS)
 Nyhus type 3 C: Femoral hernia ( NO PATIENTS)
. Nyhus type 4: Recurrent hernia(4 PATIENTS)

14. Results for recurrence of hernia
 149 patients had no recurrence on 2 years follow-up.
 One patient had recurrence of hernia within 1 year of
surgery.
 We had used polypropylene mesh, with wide overlap
expecting 20 to 40% mesh contracture in future. This had
given only 0.66% recurrence in our study.

15. Results at 3 month for
chronic groin pain .
Results of chronic groin
pain at 2 years
 Out of 150 patients 16 had
mild pain on 3 month
follow-up.
 10.6% patients had mild
pain at 3 month follow-
up.(four point verbal rating
scale used for measuring
groin pain)
 There was not a single case
of severe or moderate groin
pain requiring emergency or
late surgical intervention.
 Out of 150 patients 3 had
mild pain at 2 years.
 2 % mild pain after 2 year
follow up.
 One patient complained of
heaviness and hyperesthesia
in inguinal region.
(Neuropathic mild pain )
 Two had intermittent mild
groin pain(somatic pain)
relived with mild anti-
inflammatory analgesics.
POST OPERATIVE CHRONIC GROIN PAIN

16. Patients with chronic pain
7
4
3
2
0
1
2
3
4
5
6
7
8
6 months 12 months 18 months 24 months
patientswithpain
Follow-up in months post operative

17. TECHNIQUES WE FOLLOWED TO PREVENT CHRONIC GROIN
PAIN
 Nerves ilioinguinal, ileohypogastric and genital branch of
genitofemoral nerve were identified with meticulous dissection,
preserving investing layer of fascia over it.
 Not lifting ilioinguinal nerve from bed.
 Genital branch of the genitofemoral nerve is located in the cord along
with external spermatic vein, covered and protected from direct contact
with mesh by the deep cremastric fascia. It should be kept with the
cord, while the cord is separated from inguinal floor using blunt peanut
dissection, grasping the cord with thumb and index finger should be
avoided.
 Creating lax external inguinal opening to prevent compression of
ilioinguinal nerve.

18. TECHNIQUES WE FOLLOWED TO PREVENT CHRONIC
GROIN PAIN
 Iliohypogastric is easily visible after superior anatomical
dissection between external and internal oblique muscle. It
has to be safeguarded by splitting mesh and preserving
fascia over it.
 Should wait more than 6 months before surgically treating
chronic groin pain disturbing daily activity.
 Severe pain should be treated immediate postoperative.

19. Take home message
. Meticulous technique can reduce chronic groin pain
up to 0.5% after Lichtenstein hernioplasty
.Use of Light weight mesh( between 35 to 70gm/m2)
recommended in Lichtenstein hernioplasty.
.Lichtenstein hernioplasty can bring recurrence below
1%.
Lichtenstein hernioplasty has short learning curve for
residents, results can be reproduced.
Lichtenstein hernioplasty gives satisfactory long term
results to community

20. REFERENCES
 1) Jack Abrahamson, Hernia. Seymour Schwartz’s and Harold Ellis. Edited Maingot’s abdominal operations. 9th edition Connecticut, Appleton & Lange, 1990. P.215-296
 2) Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. The tension free hernioplasty. Am J. Surg.1989 Feb; 157(2):188-93)
 3) Chen DC. And Amid PK. Technique: Lichtenstein, Bruce Ramshow, Edited. The SAGES Manual of hernia repair. New York, Springer, 2013.p.41-5
 4) Inguinodynia A SAGES Wiki Article
 5) Callesen T, Bech K, Kehlet H, Prospective study of chronic pain after groin hernia repair. Br. J. Surg. 1007 Dec; 86(12):1528-31
 6) Hakeem A. and Shanmugam V. Current trends in the diagnosis and management of postherniorraphy pain. World J Gastrointestinal Surg. June 27 2011; 3(6): 73-81
 7) O’ Dwyer PJ, Alani A, McConnachie A. Groin hernia repair: postherniorraphy pain. World J Surg.2005; 29:1062-1065
 8) Robert E, Condon MD, Groin pain after hernia repair. Ann Surg. Jan 2001; 233(1):8
 9) Smed’s, Lofstrom L, Ericsson O. Influence of nerve identification and resection of nerve at risk on postoperative pain in open inguinal hernia repair. Hernia, 2010; 14:265-270
 10) H.S.Sajid, C Leaver, M.K.Baig, P.Sains. Systemic review and meta- analysis of the use of lightweight versus heavyweight mesh in open inguinal hernia repair. bjs.volume
99.Issue 1. 31st oct.2011
 11)Bringman S, Wollert S, Osterberg J, Smedberg S, Granlund H, Heikkinen T J. Three year results of a randomized clinical trial of lightweight or standard polypropylene mesh in
Lichtenstein repair of primary inguinal hernia. Br.J.Surg.2006.Sep; 93(9):1506-9
 12)Nikkolo C, Lepner U, Murruste M, Vaasna T, Seepter M, Tikk T. Randomized clinical trial comparing lightweight mesh with heavyweight mesh for inguinal hernioplasty. Hernia.
2010 Jun; 14(3):253-258
 13) Weyhe D, Belyaev O, Muller C, Meurer K, Baner K H. Improving outcome in hernia repair by the use of light meshes, a comparison of different implant constructions based on a
critical appraisal of the literature. World J Surg Jan.2007; 31:234-244
 14)O’Dwyer P.T, Kingsnorth A.N, Molloy RG, Small PK, Lammers B, Horeyseck G. Randomized clinical trial accessing impact of a lightweight or heavyweight mesh on chronic pain
after inguinal hernia repair.Br.J. Surg Feb 2005; 92(2):166-170
15) Heise CP, Starling JR. Mesh inguinodynia: a new clinical syndrome after inguinal herniorrhyphy. J Am Coll Surg Nov1998; 187(5):514-518
 16) Al. dabbagl.AK. Anatomical variations of the inguinal nerves and risks of injury in 110 hernia repairs. Surg. Radiol Anat. 2002 May; 24(2):102-7
 17) Aasvang EK, Mohl B, Kehlet H. Ejaculatory pain: a specific post-herniotomy pain syndrome. Anesthesiology 2007; 107(2):298-304
 18) Aasvang EK, Mohl B, Kehlet H. Pain related sexual dysfunction after inguinal herniorrhyphy. Pain, 2006; 122:258-263
 19)Lange JF, Wijsmuller AR, Van Geldere D, Simons MP,Swart R, Oomen J, Kleinrensink GJ, Jeekel J, Lange JF. Feasibility study of three nerve recognizing Lichtenstein
procedure for inguinal hernia.Br. J. Surg 2009 Oct; 96(10)1210-1214
 20) Alfieri S, Rotondi F, Di Giorgio A. Influence of preservation versus division of ileoinguinal nerve and genital nerves during open mesh herniorraphy. Ann Surg, 2006Apr;
243(4)553-558.
 21) Hakeem A. and Shanmugam V. Inguinodynia following Lichtenstein tension free hernia repair: A review. World Journal of Gastroenterol.2011 Apr.14; 17(14)1791-1796
22)Wijsmuller AR, Van Veen RN, Bosch JL, Lange JF, Jeekel J. Nerve management during open hernia repair.Br.J.Surg.2007Jan;94(1):17-22.
 23) Amid PK. Causes, prevention, and surgical treatment of postherniorraphy neuropathy inguinodynia: triple Neurectomy with proximal end implantation.
Hernia 2004; 8(4):343-349.
 24)Deysin and Sterling JR, Harms BA, Schroder ME, Eichman PL. Diagnosis and treatment of genitofemoral and ileoinguinal entrapment neuralgia.
Surgery.1987; 102:581-586
 25) Loos MJ, Scheltinga MR, Roumen RM. Tailored Neurectomy for treatment of postherniorraphy inguinal neuralgia. Surgery: 2010; 147:275-281
 26)Johner A, Faulds J, Wiseman SM. Planned ileoinguinal nerve excision for prevention of chronic pain after inguinal hernia repair, a meta-analysis. Surgery,
2011 Sep. 150(3) 534-45.