Lichtenstein Tension-Free Mesh Hernioplasty — Operative Steps

Anaesthesia & Patient Positioning

• Local anaesthesia with sedation (preferred), spinal, or general anaesthesia
• Patient supine; operative field prepared and draped

Step 1 — Skin Incision

• Oblique incision in the groin crease, approximately 4–6 cm, from 2 cm above and medial to the pubic tubercle toward the anterior superior iliac spine (ASIS)
• Subcutaneous fat and Scarpa's fascia divided

Step 2 — Opening the External Oblique Aponeurosis (EOA)

• EOA incised in the direction of its fibres, beginning just lateral to the external (superficial) inguinal ring and extending laterally through the ring
• Upper and lower flaps of the EOA are elevated off the underlying cord structures
• The shelving edge of the inguinal ligament is exposed inferiorly

Step 3 — Nerve Identification & Preservation

1. Ilioinguinal nerve — lies on the cord, most commonly encountered first
2. Iliohypogastric nerve — runs along the internal oblique above the canal
3. Genital branch of the genitofemoral nerve — runs within the cord

Step 4 — Mobilisation of the Spermatic Cord (male) / Round Ligament (female)

• Cord is encircled at the pubic tubercle using a Penrose drain
• Cremasteric fibres may be divided to expose the cord contents fully
• Cord lipomas are resected if present

Step 5 — Hernia Sac Identification & Management

• Sac identified anteromedially on the cord, within the cremasteric fibres
• Dissected off the cord to the level of the internal ring
• Small sac: twisted and ligated at the neck, excess excised
• Large sac: divided, distal sac left open (prevents ischaemic orchitis), proximal sac ligated

• Sac/transversalis fascia defect in Hesselbach's triangle
• Sac reduced or inverted and held with a suture; no ligation required

Step 6 — Mesh Preparation

• A sheet of mid-weight polypropylene mesh (~15 × 7 cm) is used
• The medial end is rounded to match the contour of the medial inguinal canal
• A slit (keyhole) is cut laterally to create:
  • A wider upper tail (two-thirds width)
  • A narrower lower tail (one-third width)
• These tails will straddle the spermatic cord at the internal ring

Step 7 — Mesh Placement & Fixation (Key Step)

1. Medial edge — mesh placed so it overlaps the pubic tubercle by 1.5–2 cm (reduces risk of medial recurrence); fixed to the anterior rectus sheath
2. Inferior margin — using a continuous permanent monofilament suture (e.g., 1-0 Prolene), the inferior edge is sutured to the shelving edge of the inguinal ligament from medial to lateral, ending at the internal ring. Care is taken to avoid the periosteum of the pubic tubercle (prevents osteitis pubis) and femoral vessels laterally
3. Superior margin — upper edge fixed to the internal oblique aponeurosis/conjoined tendon using an absorbable synthetic suture
4. Internal ring — the two tails are brought around the cord so the wider upper tail crosses over the narrower lower tail; a "shutter valve" stitch is placed just lateral to the cord, incorporating the inferior surface of both tails and the inguinal ligament, to reconstruct the internal ring snugly without constricting the cord

Step 8 — Tail Tuck Under EOA

• Lateral tails are tucked beneath the external oblique aponeurosis, extending to the level of the ASIS
• No excess mesh should bunch or fold

Step 9 — Wound Closure

• EOA closed with a continuous absorbable suture, recreating the superficial inguinal ring (ensuring the ring is not too tight around the cord)
• Subcutaneous fat approximated (Scarpa's fascia sutured)
• Skin closed with subcuticular absorbable suture or staples

Surgical Diagram

Key Principles to Remember

Laparoscopic Inguinal Hernia Repair: TAPP & TEP

Common Prerequisites for Both

TAPP — Transabdominal Preperitoneal Repair

Trocar Placement (TAPP)

• 12-mm camera port — infraumbilical midline (at least 15 cm from pubis)
• Two 5-mm working ports — placed lateral to the camera port, one on each side, avoiding the inferior epigastric vessels

Step-by-Step TAPP

• Abdominal cavity accessed via dissecting trocar or open Hasson technique
• Pneumoperitoneum to 15 mmHg

• Patient placed in Trendelenburg
• Identify: bladder, median and medial umbilical ligaments, external iliac vessels, inferior epigastric vessels
• Type and location of hernia confirmed: direct (Hesselbach's triangle), indirect (lateral to inferior epigastrics), or femoral

• Incise peritoneum at the medial umbilical ligament, 3–4 cm superior to the hernia defect
• Carry the incision laterally to the ASIS
• For bilateral repair: bilateral peritoneal incisions with a midline bridge of tissue preserved to avoid injuring a patent urachus

• Identify and dissect past the pubic tubercle to the midline
• Expose Cooper's ligament ipsilaterally (and contralateral for large direct hernias)
• Visualise Hesselbach's triangle and clear any fat obscuring a direct defect
• Develop space of Retzius (≥2 cm between Cooper's ligament and bladder — prevents mesh "clamshelling" with bladder distension)
• Dissect femoral orifice between external iliac vein and Cooper's ligament
• Parietalize the cord structures: dissect indirect sac and peritoneum off gonadal vessels/vas deferens until cord elements lie flat
• Extend dissection lateral to ASIS so peritoneal reflection will lie inferior to mesh
• Identify and reduce/excise cord lipomas

• Direct hernia: sac inverted and fixed to Cooper's ligament with a tack (prevents haematoma/seroma)
• Indirect hernia: sac grasped, elevated superiorly from cord; space below developed bluntly; sac dissected free and cord skeletonised

• Mesh (10 × 15 cm or larger) rolled lengthwise, placed through the 12-mm trocar
• Unrolled in the preperitoneal space to completely cover the MPO
• Medial fixation: tacked to Cooper's ligament (surgeon palpates tacker tip externally for proper angle)
• Lateral fixation: fixed to the anterior superior iliac spine
• ⚠️ All tacks/fixation placed above the iliopubic tract (to avoid lateral cutaneous nerve of thigh and femoral branch of genitofemoral nerve)
• Mesh should NOT be split for cord pass-through

• Peritoneal edges reapproximated using tacks or intracorporeal sutures — must be completely closed to exclude mesh from bowel contact and prevent adhesions
• Confirm mesh lies flat without folds during closure

• Abdomen desufflated
• Trocars removed
• 12-mm port fascia closed with suture
• Skin closed

TEP — Totally Extraperitoneal Repair

Trocar Placement (TEP)

• 12-mm port — infraumbilical (camera port, placed through the anterior rectus sheath)
• 5-mm port — suprapubic midline
• 5-mm port — inferior to the camera port (all ports in the midline)

Step-by-Step TEP

• Small horizontal incision inferior to the umbilicus
• Dissect subcutaneous tissue to the anterior rectus sheath
• Incise the anterior rectus sheath lateral to the linea alba
• Place stay sutures on the sheath edges
• Retract the rectus muscle superolaterally, revealing the posterior rectus sheath beneath

• Manually develop the retromuscular/preperitoneal space from the incision down to the pubic tubercle using finger/blunt dissection

• Insert dissecting balloon directed toward the pubic symphysis
• Under direct vision with a 30° laparoscope, slowly inflate the balloon to bluntly dissect the preperitoneal space (Space of Retzius)
• Balloon is then deflated and removed

• 12-mm balloon trocar placed at the infraumbilical incision
• Pneumopreperitoneum to 15 mmHg achieved by CO₂ insufflation
• Two 5-mm trocars placed: one suprapubic midline, one inferior to the camera port

• Identical dissection goals as TAPP (see above)
• Identify: pubic tubercle, Cooper's ligament, direct/indirect/femoral spaces, cord structures, inferior epigastric vessels
• Parietalize cord, reduce hernia sac, excise cord lipomas
• Extend laterally beyond ASIS

• Direct hernia: sac/transversalis fascia reduced into the preperitoneal space
• Indirect hernia: sac carefully dissected off cord; if sac is large, divide it, close the peritoneal defect, leave the distal sac in situ
• ⚠️ Any peritoneal rents must be repaired before desufflation to prevent mesh contact with bowel

• Identical to TAPP: ≥10 × 15 cm mesh placed to cover entire MPO
• Fixed medially to Cooper's ligament; laterally to ASIS
• All fixation above the iliopubic tract
• Mesh lies flat without creases; do NOT split the mesh

• Preperitoneal space desufflated slowly under direct vision to confirm mesh does not fold or migrate
• Reposition mesh if folding occurs
• Trocars removed
• Anterior rectus sheath closed with an interrupted suture
• Skin closed

TAPP vs TEP — Key Differences

Mesh Coverage: The Myopectineal Orifice

Danger Zones ("Triangle of Doom / Triangle of Pain")

• Triangle of Doom (medial): bounded by vas deferens and gonadal vessels — contains external iliac artery and vein → no tacks here
• Triangle of Pain (lateral): bounded by iliopubic tract and gonadal vessels — contains lateral cutaneous nerve, genitofemoral nerve → no tacks below iliopubic tract laterally