How is the mesh placed and fixed in the Lichtenstein tension-free mesh repair?

Updated: Jan 17, 2018
  • Author: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS; Chief Editor: Kurt E Roberts, MD  more...
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Answer

A 7.5 × 15 cm piece of polypropylene mesh is commonly used for a Lichtenstein hernioplasty. On the medial side, the sharp corners of the mesh are trimmed to conform to the patient’s anatomy. For a femoral hernia, the mesh is tailored so that it has a triangular extension from its lower edge on its medial side.

To compensate for future shrinkage, the mesh should be wide enough to extend 3-4 cm beyond the boundary of the inguinal triangle. To compensate for increased intra-abdominal pressure when the patient stands up, the mesh should be placed lax in the posterior wall of the inguinal canal in such a way that it acquires a domelike wrinkle.

The first medialmost stitch fixes the mesh 2 cm medial to the pubic tubercle, where the anterior rectus sheath inserts into the pubic bone (see the image below). Care should be taken not to pass the needle through the periosteum of the bone or through the pubic tubercle; this is one of the most common causes of chronic postoperative pain.

Open inguinal hernia repair. First medialmost stit Open inguinal hernia repair. First medialmost stitch in mesh, fixed about 2 cm medial to pubic tubercle, where anterior rectus sheath inserts into pubis.

The same suture is then used as a continuous suture to fix the lower edge of the mesh to the free lower border of inguinal ligament up to a point just lateral to the internal ring (see the images below). No more than four or five passes are required.

Open inguinal hernia repair. Same suture is utiliz Open inguinal hernia repair. Same suture is utilized as continuous suture to fix lower edge of mesh to reflected part of inguinal ligament up to internal ring.
Open inguinal hernia repair. Fixation of lower edg Open inguinal hernia repair. Fixation of lower edge of mesh.

For a femoral hernia, the medial portion of the iliopubic tract is excised, and the Cooper ligament is exposed. The lower triangular extension on the medial side of the mesh is stitched to the Cooper ligament, and the suture is continued to fix the lower edge of the mesh to the inguinal ligament, as above.

Next, a slit is made in the lateral end of the mesh to create a narrower lower tail (the lower one third) and a wider upper tail (the upper two thirds). The slit extends up to a point just medial to the internal inguinal ring (see the image below).

Open inguinal hernia repair. Lower edge of mesh su Open inguinal hernia repair. Lower edge of mesh sutured to inguinal ligament up to internal inguinal ring. To accommodate cord structures, lateral end of mesh is divided into wider upper (two thirds) tail and narrower lower (one third) tail.

The upper tail is then passed underneath the cord in such a way as to position the mesh posterior to the cord in the inguinal canal (see the image below), and the spermatic cord is placed between the two tails of the mesh. The upper tail is then crossed over the lower one, and the two tails are held in an artery forceps.

Open inguinal hernia repair. Wider upper tail of m Open inguinal hernia repair. Wider upper tail of mesh is passed underneath cord, and mesh is placed posteriorly in inguinal canal behind spermatic cord.

With the mesh kept lax, its upper edge is then fixed to the rectus sheath and the internal oblique aponeurosis with two or three interrupted nonabsorbable sutures (see the first image below). On occasion, the iliohypogastric nerve is found to be in the way of upper edge of the mesh. In such cases, the mesh may be split to accommodate the nerve (see the second image below).

Open inguinal hernia repair. Fixation of upper edg Open inguinal hernia repair. Fixation of upper edge of mesh.
Open inguinal hernia repair. Slit made in mesh to Open inguinal hernia repair. Slit made in mesh to accommodate iliohypogastric nerve. Two interrupted sutures are taken under vision to fix upper edge of mesh while safeguarding iliohypogastric nerve.

The two tails are then tucked together and fixed to the inguinal ligament just lateral to the internal ring, thus creating a new internal ring made of mesh (see the first image below). The tails are trimmed 5 cm beyond the internal ring and placed underneath the external oblique aponeurosis (see the second image below).

Open inguinal hernia repair. Upper tail is crossed Open inguinal hernia repair. Upper tail is crossed over lower tail around spermatic cord, thus creating internal ring. Lower edges of two tails are tucked together to inguinal ligament just lateral to internal ring.
Open inguinal hernia repair. Tails are then passed Open inguinal hernia repair. Tails are then passed underneath external oblique aponeurosis to give overlap of about 5 cm beyond internal ring.

Suturing the mesh beyond the internal ring is unnecessary; doing so may cause injury to the femoral nerve. Similarly, fixation of the tails of the mesh to the internal oblique muscle, lateral to the internal ring, may cause entrapment of the ilioinguinal nerve. Trying to suture the two tails without crossing them or trimming the tails shorter than 5-6 cm beyond the internal ring may result in recurrence at the deep inguinal ring. [54]

If any of the nerves is injured or of doubtful integrity, it can be resected and its proximal end ligated and buried within the fibers of the internal oblique muscle to keep the stump of the nerve away from scarring.

In male patients, the testes should always be gently pulled back down to their normal scrotal position after fixation of the mesh.


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