lichtenstein hernia repair

Ann Surg 2004; 240: 955-61. Starting medially at the pubic bone, anchor the mesh along the inferior border of the inguinal ligament. Surg Endosc. Over time, the mesh safely becomes incorporated into the muscle layer, creating a very strong, permanent repair. 9–11In Sweden and Denmark the most frequently used hernia repair is the Lichtenstein procedure. It can also be deployed in patients with recurrent groin hernias particularly when an alternate technique was used at the initial repair. The number of recurrences has been reduced to … Fascia of the external oblique, with lateral augmentation by fibers of the internal oblique → inguinal ligament and → cremaster. Clinical symptoms: Swelling without tenderness and discoloration. Antoniou SA, Pointner R, Granderath FA. Then divide the subcutaneous tissue down to the external oblique aponeurosis. Bringman S, Heikkinen TJ, Wollert S, Osterberg J, Smedberg S, Granlund H, Ramel S, Fellander G, Anderberg B. In the medium term, both TEP and Lichtenstein hernia repair had similar outcomes after 1 year, with high rates of patient satisfaction and low rates of chronic pain and recurrence. 2011 Apr 14. The most common symptoms are pain, swelling, or a bulge. The role of antibiotic prophylaxis in prevention of wound infection after Lichtenstein open mesh repair of primary inguinal hernia: a multicenter double-blind randomized controlled trial. An average of 45 mL of this mixture is usually sufficient for a unilateral hernia repair and is administered in the following fashion. Br J Surg 1998; 85: 790-2. Treatment: Small postoperative seromas are absorbed by the tissue and only require follow-up. Treatment: Revision surgery, identifying and managing the cause. Compared to sutured open herniorraphy in adults (particularly the Shouldice procedure), in surgical repair of (unilateral and bilateral) inguinal hernia by the Lichtenstein technique the following differences have been reported: The comparison fociused on heavy and light-weight meshes (100 g/cm2 and 30g/cm2 respectively). Postoperative testicular swelling is the sequela of hypoperfusion. After the operation a sand bag may be placed on the wound for a few hours; remove any Redon drain on postoperative day 1 or 2. In the standard Lichtenstein Repair, this mesh is placed between the layers of the abdominal wall. 2020 Mar;167(3):581-589. doi: 10.1016/j.surg.2019.08.021. (Figure 2). Surgery 1998; 123: 121-6. Less foreign body sensation in the groin (↑ [5; 19]), Trend of less chronic groin pain (↑ [5; 19]), No significant differences in the perioperative course (↑↑ [1; 4; 17]), After mesh fixation by sealant perhaps somewhat less postoperative pain (↑ [9; 10; 16]), With staples and tacks somewhat shorter operating time (↑ [7; 14]), Comparable recurrence rates overall (↑ [7; 9; 10; 14; 16]), Evidently no reduction in the rate of wound infection (↑ 2). In women: Round ligament of uterus passing from the uterus through the deep inguinal ring into the inguinal canal and then on through the superficial inguinal canal to the labia majora; lymphatic vessels; and in both sexes sometimes the ilioinguinal nerve. Note: Renal function, HIT II (history, platelet check). Scott NW, McCormack K, Graham P, Go PM, Ross SJ, Grant AM, on behalf of the EU Hernia Trialists Collaboration. The bleeding must be noted and its source oversewn. Lightweight mesh is recommended in open inguinal (Lichtenstein) hernia repair: A systematic review and meta-analysis Surgery. With some interrupted (absorbable) sutures anchor the superior part of the mesh on the internal oblique. This link will take you to the International Guideline Library. When the processus vaginalis testis closes, it obliterates the connection with the peritoneal cavity, typically leaving behind only the vestige of the vaginal process. Overall Number of Participants Analyzed : 122 : 110 : Measure Type: Number. Typically, small or large intestine or intra-abdominal fat herniates through the defect. Des traitements alternatifs à la chirurgie, comme les exercices pilates, ont été souvent suggérés, mais ils n'ont été ni corroborés ni réfutés par aucune étude empirique1. Preliminary experience of a prospective randomized trial. Close the base of the hernia sac with an outer purse string suture and remove the excess. Buttressing of the posterior wall of the inguinal canal by inserting a mesh between the external oblqie aponeurosis and the internal oblique muscle. Subcutaneous suture, continuous intracutaneous absorbable skin suture. Transversus abdominis and internal oblique (fibers running from inguinal ligament to the medial conjoint tendon). Definition: Wound infection by pathogens. Prior MJ, Williams EV, Shukla HS, Phillips S, Vig S, Lewis M. Prospective randomized controlled trial comparing Lichtenstein with modified Bassini repair of inguinal hernia. It is performed either under local or regional anesthesia. 1. Halfway between the pubic symphysis and the anterior superior iliac spine in the inner abdominal wall, lateral to the inferior epigastric artery and vein (within the lateral umbilical fold). 6. Inferior to the inguinal ligament the septum of the iliopectineal arch divides the inguinal canal into a vascular and muscular compartment – lacuna vasorum and lacuna musculorum respectively. The inguinal region (where the anterior abdominal wall transitions to the lower extremity) possesses several weak spots where a hernia sac (with or without contents) may protrude through the abdominal wall (femoral hernias are more frequent in women, while inguinal hernias are more common in men). Important: Postoperative neuralgia can be prevented by proceeding as follows: If you cannot spare the ilioinguinal and/or hypogastric nerves and/or the genital branch of the genitofemoral nerve, you must excise them and infiltrate their stumps with local anesthetic. Massive secondary hemorrhage must be explored by revision surgery. The effects of different hernia repair methods on postoperative pain medication and CRP levels. The surgical mesh acts as a bridge or scaffolding for ingrowth of new tissue to reinforce the abdominal wall. In addition, the femoral branch of the genitofemoral nerve passes through the very lateral part of this compartment, while the deep inguinal lymph nodes (Rosenmueller nodes) are located inferomedially. Nonsteroidal anti-inflammatory drugs usually suffice; if necessary, they can be enhanced by opioid analgesics. Unless contraindicated, the moderate risk of thromboembolism (surgical operating time > 30 min) calls for prophylactic physical measures and low-molecular-weight heparin, possibly adapted to weight or dispositional risk, until full ambulation is reached. Outcome of the light-weight meshes: In addition, several mesh materials were studied. Thus, for those in need of recurrence surgery, the procedure is much less invasive. Eur Surg Res 2004; 36: 367-70. Hernia 2005; 9: 242-4. Fascia of external oblique → external spermatic fascia. Prospective randomized comparison of the Shouldice and Lichtenstein hernia repair procedures. Lichtenstein technique. There were four recurrences.” The recurrence rate is less than 2 percent. This violates the basic surgical principle that tissue must never be approximated under tension and thus accounts for an unacceptable number of failures. Danielsson P, Isacson S, Hansen MV. Sparing the structures of the spermatic cord, free the hernia sac down to the hernia defect in the transversalis fascia. Hernia is a tear, or hole, in the musculature of the abdominal wall (Figure 1). 2014 Jun 20;1:20. 17(14):1791-6. . The abdominal wall is a sheet of muscle. Hernia 2003; 7: 80-4. In this procedure, repair is accomplished by covering the opening of the hernia with a patch of mesh, instead of sewing the edge of the hole together In my practice, the tension-free Lichtenstein technique is only applied on large (>3 cm) hernia or in case of weak connective tissue as frequently seen in the elderly. The patients were divided into 2 groups according to the surgical procedure performed: preperitoneal repair (Group I, n = 19) and Lichtenstein hernia repair (Group II, n = 20). Inguinal hernia repair with the Lichtenstein technique. Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management). Hernia 2004; 8: 127-34. Front Surg. Mostly acquired; in adults women > men; together with the femoral artery and vein through the femoral canal in the medial thigh (medial to the lacuna vasorum); femoral branch of the genitofemoral nerve; and lymphatic vessels. In iatrogenic division of these nerves they should be excised and infiltrated postoperatively with local anesthetics, since this will lower the risk of postoperative paresthesia. No investment by the transversus abdominis since it terminates more cephalad. 2014 Jun;399(5):553-8. doi:10.1007/s00423-014-1212-8. A prospective trial of primary inguinal hernia repair by surgical trainees. 10 13 Adverse Events. The follow-up rate was 87%. Lightweight mesh should be used in open (Lichtenstein) inguinal hernia repair. This video demonstrates the steps and technique in performing a Lichtenstein's tension-free open repair.The patient had a small indirect hernia sac, which was mobilized and reduced, and the mesh was secured over the posterior inguinal canal to control the hernia defect. If the nerves are not divided but only irritated or touched, this may result in postoperative paresthesia which often is amenable to local anesthetics. Vatansev C, Belviranli M, Aksoy F, Tuncer S, Sahin M, Karahan O. At present, many guidelines refer to the Lichtenstein technique as a standard reference surgical method, which has the advantages of being a short operation time and the need for relatively low surgical skill. Laxatives may have to be started on postoperative day 2. More common; men > women; congenital (patent processus vaginalis) or acquired (also via the deep inguinal ring in the lateral inguinal fossa, mostly in adults); hernia sac passes lateral to the epigastric vessels into the scrotum and labia majora respectively. With this type of surgery, only a small repair is needed while the rest of the repair remains intact. Nordin P, Bartelmess P, Jansson C, Svensson C, Edlund G. Randomized trial of Lichtenstein versus Shouldice hernia repair in general surgical practice. 12During the last decade minimally invasive hernioplasties have been developed using either a laparoscopic or an open technique. Post S, Weiss B, Willer M, Neufang T, Lorenz D. Randomized clinical trial of lightweight composite mesh for Lichtenstein inguinal hernia repair. The "tension-free" mesh technique was pioneered by the Lichtenstein Hernia Institute in 1984 and is currently considered the gold standard of hernia repair by the American College of Surgeons. The Lichtenstein tension-free repair has persisted as one of the most commonly performed procedures in the world. In this step of the procedure the ilioinguinal nerve and the genital branch of the genitofemoral nerve must be spared. 2009;249:33-8. After clamping the aponeurotic flaps and retracting them upward, free the aponeurosis from the internal oblique and cremaster by blunt dissection. Incomplete obliteration of the processus vaginalis testis is a weak spot in the abdominal wall and therefore a possible starting point for inguinal hernia. La chirurgie n'est désormais plus conseillée dans la plupart des cas, depuis que la survei… Medial inguinal ligament (= reflected ligament) and a trough for the spermatic cord formed by the external oblique. http://www.pubmed.com, Phone +49(221) 6 77 82 67 - 0 Transversalis fascia, with medial augmentation by the conjoint tendon (=  tendon of the transversus abdominis and internal oblique). Make the skin incision, measuring about 4 cm, in the line of the inguinal canal 2 fingers medial to it (solid line), or make a transverse incision 2 fingers superior to the pubic bone. At the deep inguinal ring place the superior tail of mesh over the inferior tail. Friis E, Lindahl F. The tension-free hernioplasty in a randomized trial. Relieve the bladder for seven to ten days with a suprapubic catheter. Design: Prospective, randomised, trial. Fashionable since 1994, the postoperative pain ends up being minimal because there is no pressure placed on the wound. New mesh materials have been continuously introduced to achieve this goal. The surgical hernia repair is generally divided in three groups: open repair with a mesh (Lichtenstein, Rutkow-Robbins), open repair without the use of a mesh implant (Bassini, Shouldice, Lotheissen- McVay) and laparoscopic repair with a mesh. Definition: Spaces in the surgical field filled with secretions and lymph. Am J Surg 1996; 172: 315-9. Barth RJ, Jr., Burchard KW, Tosteson A, Sutton JE, Jr., Colacchio TA, Henriques HF, Howard R, Steadman S. Short-term outcome after mesh or shouldice herniorrhaphy: a randomized, prospective study. Now longitudinally divide the fibers of the external oblique, including the superficial inguinal ring. Prospective randomized controlled trial to compare skin staples and polypropylene for securing the mesh in inguinal hernia repair. Lateral to the lacuna vasorum, the muscular compartment is traversed by the psoas major and iliacus muscles (together they comprise the iliopsoas muscle), the femoral nerve, and lateral femoral cutaneous nerve. To fix the small repair, Lichtenstein invented the technique of “plugging” the defect with a small piece of rolled mesh. . La chirurgie demeure la seule option établie pour réparer les hernies inguinales. Treatment: No reasonable treatment known at this time. Several safe and effective anesthetic agents are currently available. The European Hernia Society recommends that in cases where an open approach is indicated, the Lichtenstein technique be utilized as the preferred method. Kux M, Fuchsjäger N, Feichter A. Lichtenstein-Patch versus Shouldice-Technik bei primären Leistenhernien mit hoher Rezidivgefährdung. Patients scheduled for elective repair of unilateral or bilateral, primary or recurrent inguinal hernia by the Lichtenstein technique were randomized to receive either a conventional densely woven polypropylene mesh (100–110 g/m 2) or a lightweight composite multifilament mesh (polypropylene 27–30 g/m 2). Unfortunately, simple suturing often recreates the tension that created the hernia causing pain and a higher risk of recurrence. In elderly patients no longer sexually active the spermatic duct may be transected. In case of accidental iatrogenic bowel injury during the procedure the lesion should be immediately closed by suture. For this reason, it is recommended that most hernias should be repaired in the elective setting. Open mesh versus non-mesh for repair of femoral and inguinal hernia. Introduction. Webop uses cookies to enable you to visit the website securely and conveniently. (Figure 1) The black spot represents the hernia opening in the muscular wall of the abdomen. If left untreated, hernias can incarcerate where the contents remain trapped in the defect or develop in to an emergency if the hernia strangulates causing symptoms such as pain, nausea and vomiting with intestinal blockage and compromise. In laparoscopic repair, the mesh is placed behind the abdominal wall muscles. Since postoperative mesh infections are frequently hard to manage by nonsurgical means, in extreme cases the mesh will have to be removed by revision surgery and the hernia defect closed without any foreign body. Open surgery is required to improve venous drainage. In case of recurrent seroma repeat paracentesis is not recommended, but rather insert a drain under sonographic guidance and leave in place for several days. For comparison of the Lichtenstein repair with other procedures please see there: Inguinal herniorraphy with Rutkow plug, TAPP and TEP. Are you sure you want to perform this action? Important: Spare the iliohypogastric and ilioinguinal nerves! If the hernia sac is too large, it is reduced, suture ligated at its base and submerged below the level of the transversalis fascia; another option is to reduce the sac with a continuous purse string suture. Rarely, other abdominal organs can herniate. If the stump does not retract out of sight spontaneously, reduce and submerge it by suture. In the female embryo the pull of the gubernaculum does not result in a complete descent of the ovaries, which remain close to the uterus, but rather the remains of the original gubernaculum persist in the inguinal canal as the round ligament of uterus. Unrestricted; gradual return to physical activity; full physical activity, as tolerated, after one week; all activities permitted after four weeks the latest. The approximately 4 cm long oblique inguinal canal, slanting downwards and medially, parallels the inguinal ligament immediately superior to it, with the cephalic end of the canal originating at the deep inguinal ring and the opening to the external abdominal wall at the superficial inguinal ring. After the operation the patient must always be informed of what had happened and the consequences for him. Pisanu A, Podda M, Saba A, Porceddu G, Uccheddu A. Meta-analysis and review of prospective randomized trials comparing laparoscopic and Lichtenstein techniques in recurrent inguinal hernia repair. Lichtenstein repair of inguinal hernia involves a state-of-the-art tension-free mesh. (Lichtenstein) inguinal hernia repair – A randomized, multicenter trial with 5 year follow-up. Tip: Once you have excised the excess hernia sac, rule out any bleeding along the stump resection line of the sac by slackening the stay sutures first before cutting them off. Within only two to three weeks, the patient's native tissue grows into the mesh, making it a part of the body. Surgeons who choose this technique should be prepared to make the appropriate technique modifications that are based on the specific type of hernia … 1715. The parallel lines represent normal muscle fibers. The deep inguinal ring is the weak spot for indirect hernias, while direct hernias originate in the middle inguinal fossa (medial to the deep inguinal ring and the inferior epigastric artery and vein). 4. The hernia repair approaches in the present study consisted of primary hernia repair methods (Bassini, Mcvay),, Lichtenstein technique,, mesh-plug technique, transabdominal preperitoneal approach (TAPP), and total extraperitoneal (TEP) repair. Hernia 2007; 11: 335-9. You will find further information in our privacy statements. Treatment: Administer prokinetic medication such as metoclopramide, neostigmine. Langenbecks Arch Surg. Usually, after informing the patient the seroma only needs to be followed up. Treatment In the open Lichtenstein operation, an incision approximately 6 to 8 cm long is made in the groin. All open procedures were Lichtenstein repairs (LR). La chirurgie de la hernie inguinale est l'opération chirurgicale pour la correction d'une hernie inguinale. Primary inguinal hernia in patients > 30 years, except for small lateral hernias, No other contraindications since the procedure can be performed under local anesthetics, Digital rectal examination in men > 50 years, Marking the side of the hernia examined with the patient standing, 1/2 hour before skin incision a single-shot antibiotic regimen is recommended, e.g., with 2, Chronic groin pain such as ilioinguinal syndrome. It can also lead to recurrence of the hernia. Anchor the mesh on the inguinal ligament with a continuous suture (polypropylene 2-0) up to the deep inguinal ring. Objective: To compare the outcome following Lichtenstein open mesh technique or Shouldice repair for inguinal hernia operated on by surgeons in training. In indirect hernia, free the deep inguinal ring completely and follow the cord into the ring in order to positively identify and spare the spermatic vessels. Mostly acquired; in adults men > women; pouching of the peritoneum and transversalis fascia in the middle inguinal fossa (inguinal triangle, medial to the epigastric artery and vein); delimited medially by the transversus abdominis and inferiorly by the inguinal ligament; emerges most often through the superficial inguinal ring → scrotum/ labia majora. 2012 Dec;26(12):3355-66. All invested by the internal spermatic fascia, cremasteric fascia, and external spermatic fascia. … Treatment: Reoperate, expose the lesion and suture it closed or resect it and perform abdominal lavage, if necessary. Treatment: Herniorrhaphy with implanted mesh, primarily as TAPP or TEP procedure. In direct hernia the hernia sac usually does not have to opened. Ansaloni L, Catena F, D’Alessandro L. Prospective randomized, double-blind, controlled trial comparing Lichtenstein’s repair of inguinal hernia with polypropylene mesh versus Surgisis gold soft tissue graft: preliminary results. 4Many different tension-free techniques have been developed, 4–8and the use of mesh is common and increasing. Clinical symptoms: Patient does not recover from surgery, suffers from abdominal pain, nausea, guarding, and displays symptoms of peritonitis. Definition: Inguinal hernia newly developed after previous inguinal herniorraphy. The technique with the Lichtenstein Plug since1989 has allowed to obtain a lower rate of complications and recurrences as well as an early recovery of the patients usual activities. Strangulation was defined by failure of manual reduction of an inguinal hernia. During the pre-mesh era, a great number of patients suffered from prolonged pain reaction due to tension caused by sutures and they had more recurrences when compared to the Lichtenstein method [1, 2]. Ensure that medially the mesh covers the pubic bone by at least 2 cm because this is where most recurrences are seen. Clinical symptoms: The five cardinal symptoms of infection: Calor, dolor, rubor, tumor, functio laesa. The SF-36 form was used to assess quality of life. Data was recorded prospectively and each TEP repair was matched with a LR for analysis. Jorgensen LN, Hope WW, Bisgaard T. Risk Factors for . Clinical symptoms: Distended abdomen; gas crescents on abdominal radiographs; in case of ischemia possibly elevated lactate levels and clinical signs of transmural peritonitis. Treatment: Reopen and force apart the wound, cleanse extensively, and continue with open wound treatment and systemic antibiotic protocol. Diagnostic work-up: Ultrasonography, urology consult. Ligate and excise any preperitoneal lipoma. Acta Biomed Ateneo Parmense 2003; 74 Suppl 2: 10-4.

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