Lichtenstein open tension-free hernioplasty

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摘要

The description of the Lichtenstein open tension-free hernioplasty covers all aspects of the surgical procedure used for the management of inguinal hernia.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: local anesthesia, opening of inguinal canal, freeing of hernia sac, reduction of hernia sac, the mesh, placing/fixing the mesh, hands-on hints.
Consequently, this operating technique is well standardized for the management of this condition.

媒體類型

刊物

2001-03

普通的

最愛

音訊

數位出版

WeBSurg.com, Mar 2001;1(03).
URL: http://www.websurg.com/doi-ot02en190.htm

Lichtenstein open tension-free hernioplasty

1. Introduction

In 1996, Lichtenstein attracted the attention of surgeons worldwide by justifying the use of a prosthetic mesh to create a tension-free hernia repair, thereby minimizing postoperative discomfort, one of the supplementary criteria for evaluating the efficacy of hernia repair.
Lichtenstein’s team popularized routine use of polypropylene mesh in 1984 and coined the term tension-free hernioplasty.
This technique has become the gold standard in open tension-free hernioplasties.

2. Anatomy

• Inguinal region

For proper performance of this procedure, an excellent understanding of the anatomy of the inguinal region is mandatory. The inguinal region may be divided into superficial and deep planes by defining the layers of the inguinal canal.
1. Superficial plane
2. Deep plane

• Superficial tissues

1. Anterior superior iliac spine
2. External oblique muscle
3. Aponeurosis of the external oblique muscle (AEOM)
4. Femoral vessels
5. Spermatic cord
6. External ring

• Deep tissues

1. Inguinal ligament
2. Internal oblique muscle
3. Transversus muscle
4. Rectus sheath
5. Cremasteric muscle
6. Deep epigastric vessels

• Inguinal canal

1. Transversalis fascia
2. Internal ring (IR)
3. Ductus deferens
4. Spermatic vessels
5. Interfoveolar ligament
6. Inguinal triangle

• Pathophysiology

The role of protease and protease-inhibitor imbalance in the pathogenesis of groin hernias has lead to a new understanding of the etiology of groin hernias and the causes of their surgical failure.
The biochemical evidence that adult male inguinal hernias are associated with impaired hydroxylation of proline has lead to the theory that these changes lead to weakening of the fibroconnective tissue of the groin and subsequent development of inguinal hernias.
The utilization of this already defective tissue, especially under tension, is a violation of basic principles of surgery.

3. Indications

This procedure is suitable for all adult patients regardless of their age, weight, general health or the size of the hernia.

4. Operating room set-up

• Patient

• Installation

Example of a right-sided inguinal hernia:
- supine position;
- legs straight along the axis of the body;
1. both arms maintained at 90° angles in arm holders.
It is important to avoid compression injury of the parts of the patient’s body in contact with the operating table.
The position should be comfortable for the patient as well as for the surgical team.

• Operative field

The sterile preparation and draping of the operative field should be wide, covering the lower limbs, the entire thorax, the upper abdomen, the upper limbs, at the same time leaving the patient’s head free and accessible for conversation with the surgeon.

• Team

1. The surgeon stands on the side of the hernia, which he/she is to operate.
2. The assistant stands opposite him/her.
The presence of a scrub nurse is not required. When present, he/she stands near the instrument table on the side of the operating table opposite the surgeon.
3. The anesthesiologist stands at the patient’s head.

• Equipment

1. Anesthetic equipment
2. Operating table
3. Instrument table
4. Electrocautery device
The anesthetic equipment should enable cardio-vascular as well as oxymetric monitoring.
The surgical instruments are kept to a minimum.

5. Instruments

The procedure is usually performed under local anesthesia.
1. Syringe
2. Bladed surgical knife
3. Atraumatic grasper
4. Scissors
5. Mesh
6. Gauze pads
7. Retractors
8. Auto-static retractor
9. Local anesthetic (lidocaine)

6. Major principles

In tension-free hernioplasty, the entire inguinal floor is reinforced by inserting a sheet of polypropylene mesh. The prosthesis is placed between the transversalis fascia (TF) and the external oblique aponeurosis (EOA). It should extend well beyond the inguinal triangle in order to provide sufficient mesh/tissue interface. Upon increased intra-abdominal pressure, the EOA applies counter-pressure upon the mesh. This allows the increase in intra-abdominal pressure to act as an aide to the repair.
The mesh reinforcement has both therapeutic and prophylactic benefits. It prevents the entire groin region from herniation due to future mechanical stress factors and/or metabolic derangements.

7. Anesthesia

Principles
The procedure may be performed under local anesthesia, our preferred choice for all reducible adult inguinal hernias (Amid et al., 1994).
Epidural anesthesia may be utilized alternatively.
We also recommend the use of sedatives during the procedure.

Local anesthesia
Local anesthesia is safe, simple, effective, economical, and without any side effects such as nausea, vomiting, and urinary retention. Furthermore, local anesthesia administered prior to making the incision produces a prolonged analgesic effect via inhibition of the build-up of local nociceptive molecules (Amid et al., 1994).

Epidural anesthesia
Epidural anesthesia is preferable for repair of non-reducible inguinal hernias.

Use of sedative drugs
Sedative drugs given by the surgeon or by an anesthesiologist during conscious sedation will reduce the patient's anxiety. Infusion of fast-acting, amnesic and anxiolytic agents such as propofol also reduces the amount of local anesthetic agents required, especially with cases such as bilateral inguinal hernia repair in obese patients.

8. Local anesthesia

• Anesthetics

Injection of local anesthesia is performed by the surgeon as part of the surgical technique. It is placed in dermal and subcutaneous layers prior to the skin incision and deeper planes as the dissection progresses.
Several safe and effective anesthetic agents are currently available on the market.
Our preference is a 50:50 mixture of 1% lidocaine and 0.5% bupivacaine, with 1/200,000 epinephrine. An average of 45 mL of this mixture is usually sufficient for a unilateral hernia repair and is administered in the following fashion:
1. Pubic tubercle
2. Anesthetics: 50:50 mixture of 1% lidocaine, 0.5% bupivacaine, and 1/200,000 epinephrine

• Types of injection

• Subdermal injection

A 25 mL syringe is used.
About 5 ml of the mixture is infiltrated along the line of the incision with a 5 cm long needle inserted into the subdermal tissue parallel with the surface of the skin.
Infiltration continues as the needle is advanced.
1. Line of skin incision
2. 5 mL subcutaneous injection

• Intradermal injection

The needle in the subdermal plane is withdrawn slowly until the tip of the needle reaches the intradermic level. Without extracting the needle completely, the dermis is infiltrated by slow injection of about 3 mL of the mixture along the line of the incision.
1. Slow 3 mL intradermic injection
2. Making of the skin wheal

• Deep subcutaneous

A total of 10 mL of the mixture is injected deep into the subcutaneous adipose tissue through vertical insertions of the needle (perpendicular to the skin surface) 2 cm apart.
Once more, the mixture is injected as the needle is kept moving to reduce the risk of intravascular infusion.
1. 10 mL injection

• Sub-aponeurotic injection

After incising the skin and subcutaneous fatty tissue, about 10 mL of the anesthetic mixture is injected immediately underneath the aponeurosis of the external oblique muscle through a window created in the subcutaneous fat at the lateral corner of the incision.
This injection floods the enclosed inguinal canal and anesthetizes all three major nerves in the region while the remaining subcutaneous fat is incised. It also lifts the external oblique aponeurosis (EOA) away from the underlying ilioinguinal nerve, reducing the likelihood of injuring the nerve when the EOA is incised.
1. Skin incision
2. 10 mL subaponeurotic injection
3. Incision of the subcutaneous fat

• Tips

Occasionally, it is necessary to infiltrate a few milliliters of the mixture at the level of the pubic tubercle, around the neck and inside the indirect hernia sac, to achieve complete local anesthesia.
The local anesthesia can be further prolonged by the pooling of 10 ml of the mixture in the inguinal canal before closure of the EOA and in the subcutaneous space before skin closure (Amid et al., 1994).
1. Infiltration at the level of the pubic tubercle
2. Infiltration around the neck
3. Infiltration inside the indirect hernia sac

9. Inguinal canal/opening

• Incision of EOA

The external oblique aponeurosis (EOA) is incised for 5–6 cm starting from the pubic tubercle and extending laterally parallel to the Langer's skin lines, giving excellent exposure of the pubic tubercle and the internal ring.
1. Incision of the EOA
2. Pubic tubercle
3. Opening of the inguinal canal

• Dissection of the EOA

The lower leaf of the EOA is freed from the spermatic cord.
The upper leaf is then freed from the underlying internal oblique muscle and aponeurosis for a distance of 3 cm above the inguinal floor. The plane between these two layers is avascular and the dissection can be done rapidly and in atraumatically.
Wide separation of these layers has a dual benefit, as it allows visualization of the iliohypogastric nerve, and creates sufficient space for insertion of a wide sheet of mesh. The mesh should overlap the internal oblique by at least 3 cm above the upper margin of the inguinal floor.
1. Freeing of the lower leaf
2. Freeing of the upper leaf
3. Wide separation of the layers
4. Iliohypogastric nerve

• Freeing of spermatic cord

The cord, with its covering of cremaster muscle fibers, is lifted and separated from the floor of the inguinal canal and the pubic bone for a distance of about 2 cm beyond the pubic tubercle. The anatomic plane between the cremasteric sheath and the aponeurotic tissue attached to the pubic bone is avascular, so there is little risk of damaging the spermatic vessels.

• Preserving the nerves

When lifting the cord, care should be taken to include the ilioinguinal nerve, external spermatic vessels and the genital nerve with the cord. This assures that the genital nerve, which is always in juxtaposition to the external spermatic vessels, is preserved.
The present author found this method of preserving the genital nerve safer and easier (Amid et al., 1993) than the originally described lesser cord method (a method in which the genital nerve and external spermatic vessels are separated from the cord in form of a bundle, referred to as lesser cord, and passed through a gap along the mesh-inguinal ligament suture line).
The iliohypogastric nerves should also be preserved.
1. Genital nerve
2. Ilioinguinal nerve
3. External spermatic vessels

10. Hernia sac/freeing

• Identification of sac

Once the inguinal canal is opened, the hernia sac must be identified and isolated. The difficulty of this part of the procedure depends on the type and chronicity of the hernia.
At this time, the region is examined thoroughly in order to identify a combined hernia, taking care to preserve the anatomy of the region.
Regardless of the type of hernia, the principle is the same. The peritoneal sac can be easily identified by having the patient cough. It is then freed either by opening the cremasteric fibers (indirect hernias), or by retracting the spermatic cord (direct hernias).
It is necessary to search for an associated hernia.
1. Indirect hernia
2. The patient coughs.
3. Incision of the cremasteric fibers
4. Freeing of the sac
5. Peritoneal lining of the hernia sac
6. Spermatic cord

• Indirect hernia

The indirect hernia sac is isolated from the spermatic cord structures after the fibers of the cremasteric sheath have been longitudinally opened. The sac is then freed beyond its neck.
Complete stripping and excision of the cremasteric fibers is unnecessary, and can result in injury to the nerves, small blood vessels, and the ductus deferens.
1. Freeing of the sac
2. Peritoneal lining
3. Spermatic cord
4. Ductus deferens

• Direct hernia

Direct hernias are revealed once the spermatic cord has been lifted and retracted. They are caused by weakness or perforation of the transversalis fascia, which should be strongest part of the posterior wall of the inguinal canal. The direct hernia sac is easily isolated.
In addition, the internal ring must be explored in search of a combined indirect hernia. To do so, the cremasteric sheath is incised either transversely (if extremely thick) or longitudinally at the level of the internal ring.
A transverse incision may cause cremasteric muscle dysfunction and/or cause the testicle to drop lower, hindering or preventing ejaculation.
1. The patient coughs.
2. Hernia sac
3. Search for a combined indirect hernia
4. Incision

• Associated hernias

Search for associated hernias:
In cases of voluminous direct hernias, a thorough exploration of the groin is necessary to rule out any coexisting intraparietal (interstitial), low lying Spigelian or femoral hernias. The femoral ring is routinely evaluated via the retroinguinal space through a small opening in the canal floor.
1. Pectineal ligament
2. Opening in the transversalis fascia
3. Search for a femoral or Spigelian hernia

11. Hernia sac/reduction

• Reduction

Any and all abdominal contents that may be in the hernia sac must be reduced into the abdomen. The hernia sac, itself, should be completely reduced into the pre-peritoneal space to avoid postoperative pain.
There are several ways of managing the hernia sac: inversion, division, resection or ligation.
1. Indirect hernia
2. Reducing the sac

• Simple inversion of sac

In small and middle-sized indirect hernias, the freed sac is simply inverted into the pre-peritoneal space without suture ligation. The freed sac may drop back down into the abdomen spontaneously.
In voluminous direct hernias, the sac is inverted and maintained in position by a purse-string suture.
1. Direct hernia
2. Indirect hernia

• Division/voluminous sacs

Division of voluminous sacs:
Voluminous scrotal hernia sacs can be transected at their midpoint along the inguinal canal, leaving the distal part of the sac open and in place to minimize the risk of postoperative ischemic orchitis. The distal portion is transected on its anterior border to prevent postoperative hydrocele formation. The proximal part of the sac is suture ligated.
1. Inguinoscrotal sac
2. Ligation
3. Division
4. Incision on the anterior border

• Resection and ligation

• Resection

Resection of the sac, once it has been completely freed, is not necessary. It requires ligation at the origin of the sac, which may lead to postoperative pain.
1. Resection of the sac

• Ligation of the sac

Ligation of the peritoneal sac should not be performed unnecessarily.
It has been shown that the risk of recurrence is not increased when small or medium sized indirect hernia sacs are not ligated. Additionally, this prevents postoperative pain secondary to denervation caused by mechanical pressure and/or ischemia.

12. The mesh

• The mesh

To reduce the risk of recurrence, the mesh should be wide enough to overlap tissues 3-4 cm beyond the boundary of the inguinal triangle. After tissue incorporation is complete, this overlap results in uniform distribution of intra-abdominal pressure over the much wider surface area, rather than just the line where the mesh is joined to the tissue.
This overlap of the mesh has also been shown to compensate for future shrinkage of the mesh (Amid, 1997).
Proper fixation of the margins of the mesh to the groin tissue is another important step in the prevention of recurrence.
1. Inguinal triangle
2. Mesh in place

• Size of the mesh

A 8 X 16 cm sheet of mesh is used.

• Structure of the mesh

We prefer monofilament polypropylene mesh because the surface texture promotes fibroplasia and their monofilament structure does not tend to perpetuate nor harbor infection (Amid, 1997).
The mesh should not be placed completely flat (without a ripple) in a patient under conscious sedation in a supine position. It will be placed under tension postoperatively, when the patient strains, or resumes a standing position.

• Shape of the mesh

1. The medial end of the mesh is rounded to the shape of the medial corner of the inguinal canal by the surgeon.
2. A slit is made intra-operatively at the lateral end of the mesh creating two tails, a wide one (two-thirds) above and a narrower one (one-third) below.
3. Medial corner

13. Placing/fixing the mesh

• Standards

Operative time for placement and fixation of the mesh has been well standardized.
The mesh is placed:
1. over the pubic bone;
2. then around the cord in order to create a prosthetic internal ring;
3. cephalad, on the internal oblique aponeurosis;
4. laterally below the external oblique aponeurosis (EOA).

• Over the pubic bone

• Technique

Positioning the mesh over the pubic bone is an essential step in the procedure. The mesh must cover the pubic bone to avoid recurrences.
1. The mesh covers the pubic bone.

• From within

The cord is retracted upwards. The mesh is placed on the posterior wall of the inguinal canal and its rounded corner is sutured to the aponeurotic tissue over the pubic bone with a non-absorbable monofilament suture, overlapping the bone by 1 to 1.5 cm.
1. Posterior wall
2. Mesh placement
3. Suture to the aponeurotic tissue

• Inferiorly

The lower edge of the mesh is attached to the inguinal ligament up to a point just lateral to the internal ring, using a continuous suture with up to four passages.
1. Internal ring (IR)

• Around the cord

• Goal

The goal is to create a prosthetic internal ring.
The mesh is incised to create two tails. The crossing of the two tails produces a configuration similar to that of the normal transversalis fascia sling.
In addition, it results in buckling of the mesh in this area ensuring a tension-free repair of the internal ring area.

• Incision of the mesh

A slit is made at the lateral end of the mesh to create two tails: a wide one (two-thirds) above and a narrower one (one-third) below. The mesh incision should reach the internal ring.

• New internal ring

Creation of a new internal ring:
The upper wide tail is grasped with a hemostat and passed cephalad from underneath the spermatic cord; this positions the cord between the two tails of the mesh.
The wider upper tail is crossed and placed over the narrower one and held with a hemostat.
Using a single non-absorbable monofilament suture, the lower edges of each of the two tails are fixed to the inguinal ligament.
1. Fixation to the inguinal ligament

• Fixations

• To aponeurosis 1

Fixation to the internal oblique aponeurosis, cephalad:
With the cord retracted downwards and the upper leaf of the EOA retracted upwards, the upper edge of the patch is sutured in place with two interrupted absorbable sutures at the level of the rectus sheath up to the internal edge of the deep inguinal ring.
1. Fixation to the internal oblique aponeurosis

• To aponeurosis 2

Constant upward retraction of the upper leaf of the external oblique during this phase of the repair is important because it achieves the appropriate amount of laxity for the mesh prosthesis. When the retraction is released, the mesh buckles slightly, and, once again, this laxity assures a true tension-free repair. This laxity resolves when the patient strains on command during the operation or postoperatively, upon resumption of an upright position. Equally importantly, it compensates for the future contraction of the mesh (Amid, 1997).

• Underneath the EOA

Underneath the EOA, laterally:
External to the cord, the tails of the mesh are tucked laterally underneath the EOA.
The excess patch on the lateral side is trimmed, leaving at least 5 cm of mesh beyond the internal ring.

• Danger

• 1

Injury to the femoral nerve:
Suturing the mesh beyond this point, just lateral to the internal ring, is unnecessary and could injure the femoral nerve.
1. Femoral nerve
2. IR

• 2

Abnormal course of the iliohypogastric nerve:
Occasionally, the iliohypogastric nerve has an abnormal course and comes up against the upper edge of the mesh.
1. Iliohypogastric nerve

• 3

Incision of the mesh:
The solution is to make a slit in the mesh to accommodate the nerve.
1. Iliohypogastric nerve
2. Slit

• 4

Entrapment of the ilioinguinal nerve:
The ilioinguinal nerve may become entrapped if the tails of the mesh are fixed to the internal oblique muscle, lateral to the internal ring. This fixation is not necessary to hold the mesh into position.

• Variation

If there is a concurrent femoral hernia, the mesh is also sutured to the pectineal ligament, 1-2 cm below its suture line with the inguinal ligament, to close the femoral ring.
The same technique is used for the repair of isolated femoral hernias.
1. Femoral hernia

14. Hands-on hints

• Goal

The main goal is to prevent recurrence. It is essential to use a large mesh, which is properly fixed in place and also allows for the atraumatic passage of the cord in the new internal ring.

• Size of the mesh

Using a wide piece of mesh to overlap tissues beyond the boundary of the inguinal triangle for 3-4 cm is important in order to reduce the risk of recurrence.
After incorporation is complete, this overlap results in uniform distribution of intra-abdominal pressure over the much wider surface area, rather than just the line where the mesh is joined to the tissue. More importantly, it compensates for future shrinkage of the mesh (Amid, 1997).
1. Inguinal triangle

• Fixation of the mesh

Proper fixation of the margins of the mesh to the groin tissue is another important step in the prevention of recurrence. In mobile areas such as the groin, there is a tendency for the prosthesis to fold, wrinkle, or curl around the cord. More importantly, according to our laboratory and clinical studies, in vivo, mesh prostheses lose approximately 20% of their size due to shrinkage. Movement of the mesh from the pubic tubercle, the inguinal ligament, and the area of the internal ring is a leading cause of failure of mesh repair of inguinal hernias.

• New internal ring

Creation of a new internal ring by crossing the tails of the mesh is another important part of the mesh hernioplasty. Making a new internal ring by end-to-end suturing of the two tails of the mesh, laterally to the ring results in recurrences of indirect hernias behind the cord.

15. End of procedure

• Reapproximation

The superficial planes are re-approximated without tension after ensuring that there is no strangulation of the cord or compression on the nerves.
1. Ensure there is no strangulation of the cord

• Closure of the EOA

The slit in the external oblique aponeurosis (EOA) is closed anterior to the cord using slow absorbable sutures. The subcutaneous plane is then re-approximated using a few interrupted sutures.
1. Slow absorbable sutures
2. EOA

• Closure of the skin

The skin is sutured using intradermal sutures.
1. Intradermal sutures

16. Postop period

Regardless of the approach of the tension-free mesh hernioplasty, whether by open or laparoscopic approach, postoperative pain is minimal, requiring only moderate oral analgesics for a 1-4 day period (Amid and Lichtenstein, 1998). Several prospective randomized studies including those by Horeyseck (Horeyseck et al., 1996) and by Filipi (Filipi et al., 1996) show no statistical difference in postoperative pain following open tension-free hernia repair compared with the laparoscopic tension-free technique.
The recurrence rate for this type of repair is very low (less than 1%). Complications such as infection, hematoma and seroma occur in approximately 1% of cases. The most serious complications associated with the technique are chronic neuralgia and testicular atrophy, which represent 1% of all complications.
Returning to work after a hernia operation has been shown to depend largely on patient motivation and on socioeconomic factors. In general, return to work after tension-free hernioplasty (regardless of the approach) is between 2-14 days depending on the patient's occupation (Amid and Lichtenstein, 1998).

17. Conclusion

Lichtenstein’s tension-free mesh hernia repair has been thoroughly evaluated in large series and has been gaining increasing acceptance with surgeons around the world. Currently at least 70% of British surgeons are now using the Lichtenstein tension-free method of hernia repair.

The procedure is safely performed under local anesthesia. This allows immediate mobilization of the patient. Also, the learning curve for this technique is very short, as opposed to the laparoscopic approach.

Using Lichtenstein’s method, the same surgical technique can safely be applied to all inguinal hernias, indirect and direct as well as recurrent and femoral hernias.

The Lichtenstein repair has been shown to have excellent results, which also appear to be unrelated to the surgeon’s experience (Amid and Lichtenstein, 1998).

18. Reference

Amid PK, Shulman AG, Lichtenstein IL. Critical scrutiny of the open ''tension-free'' hernioplasty. Am J Surg 1993;165:369-71.

Amid PK, Shulman AG, Lichtenstein IL. Local anesthesia for inguinal hernia repair step-by-step procedure. Ann Surg 1994;220:735-7.

Amid PK, Shulman AG, Lichtenstein IL. Simultaneous repair of bilateral inguinal hernias under local anesthesia. Ann Surg 1996;223:249-52.

Amid PK. Classification of biomaterials and their related complications in abdominal wall hernia surgery. Hernia 1997;1:15-21

Amid PK, Lichtenstein IL. Long-term result and current status of the Lichtenstein open tension-free hernioplasty. Hernia 1998;2:89-94.

Chung RS, Rowland DY. Meta-analyses of randomized controlled trials of laparoscopic vs conventional inguinal hernia repairs. Surg Endosc 1999;13:689-94.

Filipi CJ, Gaston-Johansson F, McBride PJ, Murayama K, Gerhardt J, Cornet DA et al. An assessment of pain and return to normal activity. Laparoscopic herniorrhaphy vs open tension-free Lichtenstein repair. Surg Endosc 1996;10:983-6.

Horeyseck G, Roland F, Rolfes N. Die ''spannungsfreie'' Reparation der Leistenhernie: laparoskopisch (TAPP) versus offen (Lichtenstein). Chirurg 1996;67;1036-40.

Kark AE, Kurzer MN, Belsham PA. Three thousand one hundred seventy-five primary inguinal hernia repairs: advantages of ambulatory open mesh repair using local anesthesia. J Am Coll Surg 1998;186:447-55; discussion 456.

Kawji R, Feichter A, Fuchsjager, Kux M. Postoperative pain and return to activity after five different types of inguinal herniorrhaphy. Hernia 1999;3:31-5.

Lichtenstein IL. Immediate ambulation and return to work following herniorrhaphy. Ind Med Surg 1966;35:754-9.

Wantz GE. Experience with the tension-free hernioplasty for primary inguinal hernias in men. J Am Coll Surg 1996;183:351-6.

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