Lichtenstein Tension-Free Mesh Hernioplasty - Surgical Steps

Overview

• Fischer's Mastery of Surgery, 8th ed., p. 6019
• Mulholland and Greenfield's Surgery, 7th ed., p. 3693

STEP 1 - Patient Positioning & Anaesthesia

• Patient supine, both arms abducted; surgeon stands ipsilateral to the hernia.
• Preferred anaesthesia: Local anaesthesia + monitored anaesthesia care (MAC/sedation). This avoids nausea, vomiting, and urinary retention associated with general anaesthesia and is appropriate for all reducible adult inguinal hernias.
• Local anaesthetic mixture: 50:50 of 1% lidocaine + 0.5% bupivacaine with 1:200,000 epinephrine.
• Injection sequence:
  • 5 mL subdermal along incision line
  • 5 mL intradermal along incision line
  • 10 mL deep subcutaneous (vertical insertions 2 cm apart)
  • 10 mL subaponeurotic - bathes the ilioinguinal, iliohypogastric, and genitofemoral nerves; hydro-dissects the cord away from external oblique
  • Additional 10 mL injected before closure for prolonged analgesia
• Skin prepped from above the umbilicus to past the inguinal ligament (extend to scrotum if scrotal hernia).
• Prophylactic antibiotics per local practice (coverage of skin flora).

STEP 2 - Skin Incision

• Oblique transverse incision, approximately 6 cm, starting 1-2 cm above the pubic tubercle, extending along Langer's lines.
• Divide subcutaneous tissue; ligate the superficial epigastric vein.

STEP 3 - Opening the External Oblique Aponeurosis

• Expose the external oblique aponeurosis.
• Incise it and separate the lower leaf from the spermatic cord; free the upper leaf from the underlying internal oblique until the internal oblique aponeurosis and conjoined tendon are fully exposed (~3 cm above the upper margin of the inguinal floor).
• Identify and protect three nerves throughout this step:
  • Ilioinguinal nerve
  • Iliohypogastric nerve
  • Genital branch of the genitofemoral nerve (the blue-colored external spermatic vein delineates the adjacent white line of the genital nerve)

Fig. 72.28 - Lichtenstein hernioplasty showing mesh placement. Mulholland & Greenfield's Surgery, 7th ed.

STEP 4 - Spermatic Cord Mobilisation

• Using an atraumatic Kittner dissector, separate the cord (with cremasteric muscle fibers) from the floor of the inguinal canal and pubic bone, extending 2 cm caudal to the pubic tubercle to create space for medial mesh overlap.
• Encircle all cord structures (ilioinguinal nerve, genitofemoral nerve, spermatic vessels) in a tape for handling.
• Avoid complete stripping of cremasteric fibers (increases morbidity, exposes the genital nerve, paravasal nerves, and vas deferens to mesh - raising risk of chronic pain and orchialgia).
• Incise the cremasteric sheath longitudinally at the level of the deep ring to detect an indirect hernia sac.

STEP 5 - Hernia Sac Management

Indirect hernia sac

• Dissect the sac free from cord structures toward the internal inguinal ring.
• Reduce it back into the preperitoneal space without ligation (ligation is unnecessary and increases early post-op pain without reducing recurrence).
• For a large sac: open it, inspect contents, resect redundant peritoneum, and ligate the proximal sac. Fenestrate the distal anterior wall to prevent hydrocele.

Direct hernia sac

• Invert the sac without tension to increase mesh-to-floor contact area and prevent pseudo-recurrence below the mesh.
• A broad direct defect: imbricate with an absorbable running suture to recreate the inguinal floor.
• A narrow direct hernia: purse-string suture circumferentially along the transversalis fascia.
• Important: these sutures must avoid the inguinal ligament (reserved for mesh fixation).

Femoral canal check

• Routinely evaluate the femoral canal via the space of Bogros:
  • Direct hernia: small opening in the canal floor
  • Indirect hernia: through the indirect sac
  • If femoral hernia found: open the transversalis fascia, repair simultaneously using a posteroinferior triangular mesh leaflet fixed along the Cooper ligament.

STEP 6 - Mesh Selection & Shaping

• Use a flat lightweight or midweight, monofilament, macroporous polypropylene mesh, 7.5 × 15 cm.
  • Lightweight mesh = lower post-op pain, less foreign body sensation, equivalent recurrence rates.
  • Macroporous mesh = more resistant to infection.
• Shape the mesh to an inverted-heel shape:
  • Inferior side aligned with the inguinal ligament
  • Rounded medial end matched to the angle of the inguinal ligament with the rectus sheath at the pubic tubercle
  • Superior curve covering the floor to the conjoined tendon

Fig. 220.10 - Standard mesh dimensions. Fischer's Mastery of Surgery, 8th ed.

STEP 7 - Mesh Fixation (Lower Edge)

• Place the medial end of the mesh at least 2 cm medial to the pubic tubercle - this overlap is critical; failure here is the most common cause of inferomedial recurrence as the mesh contracts over time.
• Avoid suturing into the periosteum of the pubic bone (prevents osteitis pubis).
• Using a permanent (non-absorbable) running suture (2-0 monofilament), fix the inferior edge of the mesh to the shelving edge of the inguinal ligament, running continuously from the pubic tubercle laterally to just proximal to the internal ring.
• Control suture depth carefully - too deep risks the femoral artery and vein passing deep to the inguinal ligament.

STEP 8 - Creating the Tails (Lateral Slit)

• At the lateral end of the mesh, make a slit creating two tails:
  • Upper (wider) tail: approximately 2/3 of the mesh width
  • Lower (narrower) tail: approximately 1/3 of the mesh width
• The slit extends to a point just medial to the internal inguinal ring.
• Grasp the wider upper tail with forceps and pass it cephalad (toward the head) from underneath the spermatic cord - this positions the cord between the two tails of the mesh.
• Cross the upper tail over the narrower lower tail and hold with a hemostat.

STEP 9 - Mesh Fixation (Upper Edge & Tails)

• Retract the cord downward and the upper leaf of the external oblique aponeurosis upward.
• Fix the upper edge of the mesh with typically 3 interrupted 2-0 absorbable sutures:
  • One suture to the rectus sheath
  • Two sutures to the internal oblique aponeurosis medial to the internal ring
  • Suture parallel to the iliohypogastric nerve direction; tie knots loosely to avoid entrapment.
• Using a single non-absorbable monofilament suture, fix the lower lateral edges and overlapping tails to the inguinal ligament just lateral to the last knot of the lower running suture - this reconstructs the internal ring out of mesh.
• The new internal ring should accept the tip of a forceps but not the surgeon's index finger.
• Trim excess mesh leaving at least 4 cm lateral to the internal ring (to cover any coexisting interstitial or Spigelian hernia).
• Tuck the excess mesh tail underneath the external oblique aponeurosis.

STEP 10 - Wound Closure

1. Close the external oblique aponeurosis over the cord with an absorbable running suture - also reconstructs the external inguinal ring.
2. Reapproximate Scarpa's fascia with an absorbable suture.
3. Close the skin with an absorbable subcuticular suture in a running fashion.

Key Anatomic Landmarks to Protect

Outcomes

• Fischer's Mastery of Surgery, 8th edition, Chapter 220 (Lichtenstein-Amid Tension-Free Hernioplasty), pp. 6019-6030
• Mulholland and Greenfield's Surgery, 7th edition, Chapter 72, pp. 3692-3693
• Medscape - Open Inguinal Hernia Repair Technique

Inguinal Canal - Boundaries

Openings (Rings)

Boundaries (Walls)

Anterior Wall

• External oblique aponeurosis - present throughout the entire length of the canal
• Reinforced laterally by the lowermost fibers of the internal oblique muscle

Posterior Wall

• Transversalis fascia - throughout the entire length
• Reinforced medially by the conjoint tendon (inguinal falx) - the merged aponeurosis of internal oblique and transversus abdominis, which descends to the pubic tubercle
• (Also partially thickened by the interfoveolar ligament)

Roof (Superior Wall)

• Arching fibers of internal oblique and transversus abdominis muscles, which curve over the canal from lateral to medial before descending to form the conjoint tendon

Functional note: When the internal oblique and transversus abdominis contract, the roof closes down against the floor (shutter mechanism), actively narrowing the canal and preventing herniation during rises in intra-abdominal pressure.

Floor (Inferior Wall)

• Laterally - iliopubic tract
• Centrally - superior (gutter-like) surface of the inguinal ligament (Poupart's ligament) - the thickened, rolled-inward inferior edge of the external oblique aponeurosis
• Medially - lacunar ligament (Gimbernat's ligament)

Summary Table

Anatomical Diagrams

Close relationships of direct inguinal, indirect inguinal and femoral hernias - Bailey & Love's Surgery, 28th ed.

Parasagittal section showing muscular aponeurotic layers of the inguinal canal anterior and posterior walls - Sabiston Textbook of Surgery

Clinical Relevance to Hernias

• Superolateral: inferior epigastric vessels
• Medial: lateral border of rectus sheath
• Inferior: inguinal ligament and pectineal (Cooper's) ligament

• Campbell-Walsh-Wein Urology, 3-Volume Set, Chapter 109, p. 3231
• Bailey and Love's Short Practice of Surgery, 28th ed., Chapter 64, p. 1087
• Sabiston Textbook of Surgery, Chapter 82, p. 1681
• THIEME Atlas of Anatomy - General Anatomy and Musculoskeletal System, Section 5.7

Conjoint Tendon (Inguinal Falx) - Where It Is Present

What It Is

• Internal oblique muscle (medial fibers)
• Transversus abdominis muscle (medial fibers)

Important note: True fusion only occurs in about 5% of individuals. In most people, the aponeuroses of the two muscles remain partially separate but lie closely apposed and function together as a unit. The term "conjoint tendon" is still used clinically to describe this region.

Exact Location

• It lies directly posterior to (behind) the superficial inguinal ring
• It forms the medial one-third of the posterior wall of the inguinal canal
• It is situated between the deep inguinal ring (laterally) and the pubic tubercle (medially)

How It Is Formed

1. Originate laterally from the inguinal ligament
2. Arch superiorly over the deep inguinal ring (forming the roof of the inguinal canal)
3. Curve medially and downward
4. Fuse into a common tendinous insertion at the medial end = the conjoint tendon

Fig. 4.45 - Internal oblique muscle and conjoint tendon in relation to the inguinal canal. Gray's Anatomy for Students

Insertion (Attachment)

Role in the Inguinal Canal

Clinical Significance

Summary

• Gray's Anatomy for Students, Chapter 4 (Posterior wall of inguinal canal), p. 353
• Sabiston Textbook of Surgery, Chapter 82 (Internal Oblique Muscle and Aponeurosis), p. 1680
• StatPearls - Conjoint Tendon (Inguinal Aponeurotic Falx)