UDK 616.34-007.43-089 /PRIKAZ TEHNIKE · complex groin hernias such as huge hernias with massive...

The Lichtensein technique is modified for solvingcomplex groin hernias such as huge hernias withmassive transversal fascia destruction associatedwith the increased intraabdominal pressure or re-current hernias with the destroyed Poupart’s li-gament. Whilst these hernias are usually managedby preperitoneal techniques (open or laparosco-

pic) under general or regional anesthesia, as an "in-patient" procedure, they can be solved applying a mo-dified Lichtenstein technique, most frequently underlocal anesthesia, as an "out-patient" procedure. Themodifications of Lichtenstein technique include the fo-llowing: a) lateral movement and fixation of the lowercorner of the mesh, caudally to the tubercle, by 20-30degrees in relation to its lower border, fully protectingthe medial triangle (direct inguinal recurrence preven-tion); b) fixation of the lower border of the mesh by arunning "U" suture to both Poupart’s and Coopers’sligaments, from the tubercle to the femoral vein, fullyprotecting the femoral triangle (femoral recurrenceprevention); c) the lower mesh border fixation by a ru-nning suture, 2-3 cm laterally to the internal inguinalring, together with the "locking" of the internal ingui-nal ring by two interrupted sutures, one fixing the su-perior mesh tail to the inferior one - cranial to the spe-rmatic cord, 1-1,5 cm medially to the Poupart’s liga-ment, and the other fixing the lower border of the su-perior mesh tail and the lower border of the inferiormesh tail to the inferior part of the Poupart’s liga-ment, 1 cm cranially and laterally to the preceding su-ture, fully protecting the lateral triangle (indirect in-guinal recurrence prevention). One thousand eighteenpatients with 1236 (unilateral 800, bilateral 218) ingui-nal hernias were electively operated on by the modifi-ed Lichtenstein technique between January 2003 - Ja-nuary 2011. All operations were performed by a singlesurgeon. One hundred and thirty (10.5%) hernias we-re recurrent following one or more tension or tension-

free repairs, and 203 (16.4%) hernias had a > 5 cm he-rnial defect. In seven hundred and twentyfour (71.1%)patients, the operation was performed under local, in271(26.6%) under general, and in 23(2.3%) under re-gional anesthesia, while 635(62.4%) patients were op-erated on an "out-patient" basis, and 383(37.6%) onan "in-patient" basis. The ASA score was: 388 ASA I,450 ASA II, 153 ASA III, and 27 ASA IV. The meanstay at a day surgery unit was 2.5 (2-8) hours, and themean hospital stay was 1.6 (1-10) days. During the me-an follow-up of 37 (1-96) months, the rate of complica-tions was: 23(1.86%) haematoma, 5(0.4%) seroma, 5(0.4%) wound infections, 6(0.48%) ischaemic orcihitis,2(0.16%) testicle atrophy, 1 (0.08%) disejaculation,3(0.24%) hydrocoella, 21(1.7%) pain, and 2(0.16%)recurrence. There were 6 reoperations due to the com-plications. The modified Lichtenstein technique per-formed usually under local anesthesia as "a day-case"procedure is a good solution for challenging groin her-nias.

Key words: modified Lichtenstein technique, complexgroin hernia, local anesthesia, out-patientsurgery

INTRODUCTION

The main cause of both inguinal hernia developmentand the failure of inguinal herniorraphy is a collagen

tissue disease.1-2 The understanding of the significanceof collagen disorders in the pathogenesis of the inguinal

hernias and the consequent introduction of the prosthetichernia repair have led to a breakthrough in the treatmentof inguinal hernias. The number and variety of prostheticmethods for inguinal hernia repairs has induced The Eu-ropean Hernia Society to publish the guidelines for theirmanagement. Based on a comprehensive analyses of ran-domized controlled trials and metaanalyses, The EuropeanHernia Society Guidelines recommend Lichtenstein or en-

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The modified Lichtenstein technique for complexinguinal hernia repair - How I do it

Marinko @uvelaFirst Surgical Clinic, Clinical Center Serbia, UniversitySchool of Medicine, Belgrade

/PRIKAZ TEHNIKEUDK 616.34-007.43-089

DOI:10.2298/ACI1101015Z

rezi

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doscopic repair for primary unilateral and bilateral ingui-nal hernias in adults.3

The Lichtenstein technique was most frequently usedfor inguinal hernia repair in the late 20th century.4 Forchallenging situations in groin hernia repair, such as indi-rect, direct or combined inguinal hernias with massivetransversal fascial destruction, frequently associated withpotential weakness of the femoral canal and the increasedintra-abdominal pressure due to concomitant intra-abdo-minal diseases, or multiple recurrent groin hernias withdestroyed Poupart’s ligament in result of previous operati-ons, the preperitoneal techniques (open or laparoscopic)are the techniques of choice.5-7 They are normally perfor-med under general and less frequently under regional ane-sthesia, as an "in-patient" procedure.8 Its main princip-les4,9 having been taken into account, the Lichtenstein te-chnique is modified in order to solve these challengingdefects under local anesthesia, as an "out-patient" proce-dure.

MATERIAL AND METHODS

The modified Lichtenstein technique is performed underlocal infiltrative or, less frequently, under general anes-thesia. Local anesthesia - the combination of 20 ml 0.5%bupivacaine, 50 ml 2% procaine and 30 ml saline soluti-on, is administered by "step-by-step" principle. While, onaverage, less than half of this anesthetic mixture is neededto solve a single hernia, in case of huge or complex her-nias the whole quantity shall be used. At the administrati-on of the local anesthetics one should always be certain ofthe maximal dose which can be used in one patient (pro-caine dose 500 mg max, bupivacaine dose 175mg max).10

Sedation with midazolam was used in 1-3% of patients.Because of cardiotoxic effect of bupivacaine, it is recom-mendable to use its isomer levobupivacaine or ropiva-

caine, if available. In case of multiple hernias in one patie-nt, the above mentioned dose of anesthetics is multipliedin respect of the number of hernias simultaneously re-paired. The principle is that all existing hernias in one pa-tient (bilateral inguinal, inguinal and ventral, or inguinal

FIGURE 1A SEMI-CIRCULAR NOTCH (5-7 MM IN DIAMETER) OF THELOWER BORDER OF THE MESH, 2 CM FROM ITS CORNER,IS POSITIONED IN THE TUBERCLE REGION. THE MOEAPONEUROSIS SLIT 5-10 MM IN ITS LOWER PART PROVI-DES MORE FREE SPACE FOR FLAT MESH POSITIONING INTHE CONJOINED TENDON AND RECTUS MUSCLE REGI-ON, MEDIAL AND CRANIAL TO THE TUBERCLE.

FIGURE 2THE FIXATION OF THE LOWER MESH BORDER: A RUN-NING "U" SUTURE FIXATING THE SEMI-CIRCULARNOTCH TO THE TUBERCLE, THEN TO THE COOPER’S LI-GAMENT AND TO THE INFERIOR PART OF THE POUP-ART’S LIGAMENT; THE SUTURE IS PASSED 2 TO 3 TIMESUP TO 3-4 MM FROM THE FEMORAL VEIN.

FIGURE 3THE FIXATION OF THE LOWER MESH BORDER: THESAME RUNNING "U" SUTURE FROM THE FEMORAL VEINCONTINUES (WITHOUT TYING) AS A SIMPLE RUNNINGSUTURE FIXATING CRANIALLY THE LOWER MESH BOR-DER TO THE INFERIOR PART OF THE POUPART’S LIGA-MENT, BEING TIED 2-3 CM LATERAL TO THE INTERNALINGUINAL RING. THE RUNNING SUTURE IS COMPOSEDOF TWO CONSEQUENT PARTS - A RUNNING "U" SUTUREFROM THE TUBERCLE TO THE FEMORAL VEIN (PASSINGTHROUGH TF, THE COOPER’S AND POUPART’S LIGA-MENTS) AND A SIMPLE RUNNING SUTURE LATERAL TOTHE FEMORAL VEIN UP TO 2-3 CM CRANIAL TO THE IN-TERNAL RING (PASSING ONLY THROUGH THE POU-PART’S LIGAMENT).

16 M. @uvela ACI Vol. LVIII

and incisional) should be solved in a single operation un-der local anesthesia, if possible. Inguinal hernias are so-lved with modified Lichtenstein technique, and ventral(umbilical, epigastric and spigelian) or small/medium in-cisional hernias with "the open preperitoneal flat mesh te-chnique" (consisting of flat mesh positioning into the in-tra-abdominally restored hernial sac and securing it withmattress stitches on the front side of the fascia).11

The procedure of local anesthetic administration is asfollows: skin and subcutaneous tissue infiltration alongthe site of incision with 20-30 ml of anesthetic solutionmixture, followed by 2-3 ml anesthetic solution infiltrati-on under the external oblique muscle aponeurosis (MOE);after the MOE aponeurosis incision, 1-2 ml of anestheticsolution is infiltrated around (not into) the ilioinguinal ne-

rve, the iliohipogastric nerve and along the lower borderof the cremasteric muscle, i.e. the genital branch of thegenitofemoral nerve, in the spermatic cord at the level ofthe internal inguinal ring and in the internal inguinal ringitself; the additional 10-15 ml of anesthetics solution is in-filtrated around the tubercle, the Cooper’s ligament and inthe hernial sac wall; to relieve the postoperative pain forthe next 4 hours, a 1-2 ml of anesthetics solution is admi-nistered into all sites of mesh fixation after it has been po-sitioned.

The antibiotics and thromboembolic prophylaxis is notroutinely given to the patients operated on under local an-esthesia; second-generation cephalosporine and low-mo-lecular heparin are given exclusively to the patients whoare on anticoagulant therapy or have undergone heart sur-gery. All the patients operated on under general anesthesiaare given low-molecular heparin as thromboembolic pro-phylaxis.

In elective hernia repair, the inguinal canal is approa-ched through an oblique skin incision of 4-5 cm, the her-nial sac is dissected and restored into the Bogros spacewithout opening, regardless of hernia type (direct or indi-rect). After the direct hernial sac reposition into the Bog-ros space, the transversal fascia (TF) defect is reconstruc-ted with a running 3-0 resorbable monofilament suture.Following the tension-free principle and the need for thelower border of the mesh fixation to the Cooper’s liga-ment, TF should not be tight, but slightly bulged. Afterthe indirect hernial sac reposition into the Bogros space,

FIGURE 4THE FIXATION OF THE MESH CORNER CAUDAL TO THETUBERCLE BY 2 INTERRUPTED "U" 4-0 MONOFILAMENTNONRESORBABLE SUTURES, SHIFTING THE MESH COR-NER BY 20-30 DEGREES LATERAL TO THE LOWER MESH

FIGURE 5THE FIXATION OF THE UPPER MESH BORDER TO THERECTUS SHEATH OR CONJOINED TENDON BY ONE IN-TERRUPTED "U" 2-0 MONOFILAMENT NONRESORBABLESUTURE (THE DISTANCE BETWEEN THIS SUTURE ANDTHE SECOND "U" SUTURE ON THE MESH CORNER IS 1-2CM).

FIGURE 6THE OVERLAPPING OF THE LATERALLY SLIT TAILS OFTHE MESH AROUND THE SPERMATIC CORD AT THE AN-GLE OF 40-50 DEGREES AND THEIR FIXATION TO EACHOTHER BY 2 SUTURES: THE FIRST INTERRUPTED "U" 2-0MONOFILAMENT NONRESORBABLE SUTURE FIXATESTHE SUPERIOR TO THE INFERIOR TAIL CRANIAL TO THESPERMATIC CORD AT 1-1,5 CM MEDIAL TO THE POU-PART’S LIGAMENT; THE OTHER INTERRUPTED SIMPLE 4-0 MONOFILAMENT NONRESORBABLE SUTURE FIXATESTHE LOWER BORDER OF THE SUPERIOR TAIL AND THELOWER BORDER OF THE INFERIOR TAIL TO THE INFE-RIOR PART OF THE POUPART’S LIGAMENT 1 CM CRA-NIAL AND LATERAL TO THE PRECEDING "U" SUTURE.

Br. 1 The modified Lichtenstein technique for complex 17inguinal hernia repair

"annulorraphy" is performed which consists of tighteningthe internal inguinal ring caudally with one single 3-0 orrunning 3-0 resorbable monofilament suture (dependingon the defect size), heeding not to injure lower epigastricvessels. The procedure for infection-free incarcerated orstrangulated hernia (direct or indirect) is as follows: theopening of the hernial sac, the release and restoration ofits contents into the abdominal cavity, the reconstructionand reposition of the hernial sac into the Bogros space,and finally TF suture or "annulorraphy". In case of largeinguinoscrotal hernias, the scrotal part of hernial sac is notdissected so as to avoid testicle complications. The hernialsac contents is repositioned into the abdominal cavity, thesac itself transected at the level of the neck and ligated(the peritoneum is sutured with a 3-0 resorbable monofi-lament suture to prevent postoperative pain). The scrotalpart of the hernial sac is longitudinally incisioned on theanterior side to prevent hydrocoella formation.

During the procedure, the nerves should be left intact. Ifthe ilioinguinal nerve extends in the direction of the sper-matic cord and the hernial sac, it can be dissected in thecourse of hernial sac dissection. It should be pointed outthat the cremasteric muscle is not resected, and the ilio-hypogastric nerve and the genital branch of the genitofe-moral nerve are not dissected. The thin transparent fasciacovering the iliohypogastric nerve and the cremastericmuscle protecting the genital branch of the genitofemoralnerve are left intact. This procedure prevents direct con-tact between the mesh and the nerves. If injured duringthe mesh positioning and fixation procedure, the nervescan be resected. The proximal end of the resected nerve ispressed into the oblique internal muscle (MOI) through asmall incision and the site of incision is closed with a 3-0resorbable monofilament suture. Thereby, the muscle fi-bers completely cover the end of the resected nerve, pre-venting the direct contact between the mesh and the nerveas well as the neurinoma formation.

In the modified Lichtenstein technique, polypropylenemesh 15x10 cm is used (low-weight polypropylene withlarge pores is highly advisable), and fashioned accordingto the size, i.e. anatomic characteristics of the inguinal ca-nal floor after being positioned and fixed. Before positio-ning the mesh into the inguinal canal, a small part of themesh (5-7 mm in diameter) is semicircularly cut along itsinferior border, 2 cm from the caudal corner of the mesh.The mesh is positioned so that its corner extends 2 cm ca-udally to the tubercle and the semicircular notch is lyingon the tubercle. This notch prevents the mesh wrinklingduring the fixation of its lower border to the Cooper’s andPoupart’s ligaments and allows for lateral movement ofthe caudal mesh corner by 20-30 degrees in relation to thelower mesh border. It is sometimes necessary to notch thelower part of the MOE aponeurosis for 5-10 mm abovethe tubercle in medial direction, whereby more free space

FIGURE 7THE FIXATION OF THE UPPER MESH BORDER TO THE IN-TERNAL OBLIQUE MUSCLE BY THE "U" INTERRUPTED 2-0MONOFILAMENT NONRESORBABLE SUTURE PLACEDJUST LATERAL TO THE NEWLY CREATED INTERNALRING ON THE MESH.

FIGURE 8THE CUTTING OF THE EXCESS MESH TO THE ANATOMI-CAL FEATURES OF THE INGUINAL CANAL FLOOR.

FIGURE 9IN CASE OF SOLVING A LARGE HERNIAL DEFECT USINGLOW-WEIGHT MESH, THE UPPER MESH BORDER IS FIXEDBY 1 OR MORE ADDITIONAL INTERRUPTED "U" 3-0 MON-OFILAMENT RESORBABLE SUTURES BETWEEN THE TWOEXISTING SUTURES IN ORDER TO PREVENT DIRECT RE-CURRENCE OR MESH BULGING.


is obtained for flat mesh positioning in the region of theconjoined tendon and rectus muscle, medial and cranial tothe tubercle. /Figure 1/

In contrast to the original Lichtenstein technique, the fi-xation of the lower border of the mesh is performed in 3planes: to the tubercle, along the Cooper’s ligament lying1-1,5 cm lower, and finally, to the lower part of the Pou-part’s ligament lying 1 cm superior to the Cooper’s liga-ment. The notch of the mesh prevents its wrinkling whenshifting the plane of fixation from the tubercle to the Coo-per’s ligament (the lower mesh border caudal to the tuber-cle in relation to the lower mesh border, lying craniallyfrom the tubercle to the femoral vein, is fixed in 2 planesdiffering 1-1,5 cm in height). Lateral movement of the lo-wer mesh corner by 20-30 degrees in relation to its lowerborder provides complete caudal coverage of the tuberclein the lateral and medial direction in the duck’s foot sha-pe. This procedure enables mesh overlapping the tubercleand the symphysis by 2-3 cm, excluding the possibility ofmedial hernia recurrence next to the tubercle.

The running 2-0 nonresorbable monofilament suture isused for the fixation of the lower mesh border. The fixa-tion begins at the level of the semi-circular notch of themesh, 3-4 mm from its lower border with a running "U"suture to the fibrous tissue around the tubercle (not to theperiost in order to prevent chronic pain). After tying thefirst "U" suture at the region of the tubercle, the running"U" suture is passed through the lower mesh border, theCooper’s ligament and the inferior part of the Poupart’s li-gament. To place this suture, it is necessary for the bulgedand loosely reconstructed TF to be pushed by a finger do-wnwards along the ileopectineal line and the Cooper’s li-gament. This could not be performed if TF would be tig-htened during the reconstruction. Controlled by a finger,the suture passes through TF, the Cooper’s ligament andfinally, through the inferior part of the Poupart’s ligament.The suture is passed 2 to 3 times up to 3-4 mm from thefemoral vein. It is essential that the running "U" suturenear the femoral vein simultaneously passes through theCooper’s and Poupart’s ligaments to completely close thefemoral canal. /Figure 2/ The running suture continues la-terally to the femoral vein, anchoring the lower mesh bor-der to the inferior part of the Poupart’s ligament, and ter-minates 2-3 cm laterally to the internal ring. /Figure 3/The running suture anchoring the lower mesh border iscomposed of two consequent parts: a running "U" suturefrom the tubercle to the femoral vein (passing through TF,the Cooper’s and Poupart’s ligaments) and a running sim-ple suture, lateral to the femoral vein up to 2-3 cm cranialto the internal ring (passing only through the Poupart’s li-gament).

As in the original Lichtenstein technique, the lateral endof the mesh is slit into 2 tails (superior tail of 2/3 and in-ferior tail of 1/3 of the mesh width) to pass the spermaticcord. The slit extends to the medial border of the internalring where the spermatic cord passes through the inguinalcanal floor. Any further slitting of the mesh would induceindirect hernia recurrence, caudal to a new internal ring onthe mesh. The spermatic cord and the ilioinguinal nerveare pushed together through the slit on the mesh, and themesh is placed flat over the floor of the inguinal canal.The tension-free principle requires the mesh to be slightlywrinkled, not tightened.

FIGURE 10 A, B, C(A) PATIENT WITH RIGHT PRIMARY HUGE HERNIA OPER-ATED ON WITH MODIFIED LICHTENSTEIN TECH-NIQUEUNDER LOCAL ANESTHESIA ON AN "OUT - PATIENT" BA-SIS - PREOPERATIVE FINDINGS; (B) HER-NIAL SAC ANDHERNIAL DEFECT LARGER THAN 5 CM; (C) RIGHT HUGEHERNIA SOLVED WITH MODIFIED LICHTENSTEIN TECH-NIQUE


The corner of the mesh, caudal to the tubercle is fixedby 2 interrupted "U" 4-0 monofilament nonresorbable su-tures. The first one is placed on the very corner of the me-sh, fixing it 20-30 degrees laterally to the lower mesh bor-der. The second one is placed 1 cm medially to the firstone along the caudal mesh border. /Figure 4/

These two sutures hold the mesh in flat position, cauda-lly to the tubercle. Otherwise, running suture along its lo-wer border at the tubercle and the Cooper’s ligament, dueto the fixati-on plane shift, may "raise" the caudal cornerof the mesh protecting the region around the tubercle, cau-sing the loss of 2 cm mesh/tubercle overlap in caudal andmedial direction.

The next interrupted "U" 2-0 monofilament nonresorba-ble suture anchors the mesh to the rectus sheath or theconjoined tendon 2-3 mm from the MOE aponeurosis,and 1-2 cm medial and cranial to the second "U" suture inthe caudal mesh corner. /Figure 5/

The placement of "U" suture at further distance makesthe adequate overlapping of the slit tails of the mesharound the spermatic cord impossible and leads to possi-ble indirect recurrence in the caudal area of the new inter-nal ring on the mesh.

FIGURE 11 A, B(A) PATIENT WITH BILATERAL PRIMARY HUGE HER-NIASOPERATED ON WITH BILATERAL MODIFIED LICHTEN-STEIN TECHNIQUE UNDER GENERAL ANE-STHESIA ONAN "IN-PATIENT" BASIS - PREOPERATIVE FINDINGS; (B)RIGHT HERNIAL SAC AND HERNIAL DEFECT LARGERTHAN 5 CM

FIGURE 11 C,D,E(C) RIGHT HUGE HERNIA SOLVED WITH MODIFIEDLICHTENSTEIN TECHNIQUE; (D) LEFT HERNIAL SAC ANDHERNIAL DEFECT LARGER THAN 5 CM; (E) LEFT HUGEHERNIA SOLVED WITH MODIFIED LICHTENSTEIN TECH-NIQUE


Then follows the overlapping of the slit tails around thespermatic cord at the angle of 40-50 degrees. The superiortail is fixed to the inferior one cranial to the spermatic

cord 1-1,5 cm medial to the Poupart’s ligament with aninterrupted "U" 2-0 monofilament nonresorbable suture.In addition, the internal ring is "locked" with an interrup-ted simple 4-0 monofilament nonresorbable suture fixat-ing the lower border of the superior tail and the lower bor-der of the inferior tail of the mesh to the inferior part ofthe Poupart’s ligament, 1 cm cranially and laterally to thepreceding "U" suture. /Figure 6/ The latter suture actuallyfixes the lower border of the superior tail to the runningsuture which had previously anchored the lower border ofthe inferior tail to the Poupart’s ligament, thus securingthe internal ring with two interrupted sutures instead ofone as in the original Lichtenstein technique. This thin 4-0suture fixing the tails to the Poupart’s ligament in modifi-ed Lichtenstein technique is the same suture by which anew internal ring is being created in the original Lichtens-tein technique, but 1 cm further apart cranially. The newinternal ring on the mesh should not be too tight nor tooloose, with the diameter of 7-8 mm. Owing to the way inwhich the tails are fixated around the spermatic cord, it isplaced 1 cm medial to the Poupart’s ligament, unlike itsposition next to the Poupart’s ligament in the original Li-chtenstein technique.

One interrupted "U" 2-0 monofilament nonresorbablesuture anchors the upper mesh border passing 2-3 mmfrom it, to the MOI 2-3 mm from the MOE aponeurosis.This "U" suture along the upper mesh border is just lateralto the newly created internal ring on the mesh. /Figure 7/During the fixation of the upper mesh border, special caremust be taken not to injure the iliohypogastric nerve. Themesh fixation being completed, excess part is trimmedstarting with the superior tail extending beyond the Pou-part’s ligament and the excess part beyond the superior li-ne of fixation in the shape of inguinal canal floor. The ta-ils are pulled underneath the MOE aponeurosis at least 5cm cranial to the internal ring. /Figure 8/ In case of largehernial defect or the use of low-weight mesh, it is recom-mendable to additionally fixate the upper mesh border wi-th 1 or more "U" 3-0 monofilament resorbable sutures be-tween the two existing sutures in order to prevent directrecurrence or mesh bulging. /Figure 9/

The MOE aponeurosis is reconstructed with a running3-0 resorbable monofilament suture. The suture of MOEaponeurosis begins from the cranially incised end and ter-minates at 1,5-2 cm caudal to internal inguinal ring on themesh, so that the reconstructed MOE aponeurosis protectsthe internal ring (the "telescopic" recurrence as in Halstedherniorrhaphy is avoided). The complete MOE aponeuro-sis reconstruction should be avoided because of the post-operative pain arising from strain due to the spermaticcord tightening in the region of fully reconstructed exter-nal inguinal ring. After tying the running suture on theMOE aponeurosis in the newly-formed external ring area,the same running suture is passed through the 2 layers ofthe subcutaneous tissue (first, the suture cranially fixatesthe deeper layer of subcutaneous tissue to the suturedMOE aponeurosis, and then, the upper layer of the sub-cutaneous tissue 2-3 mm under the skin caudally). Thisprocedure suppresses the occurrence of any free space inthe operative incision area, which, together with careful

FIGURE 12 A, B, C,(A) PATIENT WITH LEFT RECURRENT HERNIA FOLLO-WING BASSINI HERNIORRHAPHY OPERATED ON WITHMODIFIED LICHTENSTEIN TECHNIQUE UNDER LOCALANESTHESIA ON AN "OUT-PATIENT" BASIS - PREOPE-RA-TIVE FINDINGS; (B) LEFT RECURRENT HERNIAL SAC ANDHERNIAL DEFECT LARGER THAN 5 CM; (C) LEFT RECUR-RENT HERNIA SOLVED WITH MODIFIED LICHTENSTEINTECHNIQUE


dissection, almost completely prevents fluid collectionssuch as seroma or haematoma. Finally, the skin is stitchedby a running intradermal suture.

RESULTS

Between January 2003 and January 2011 one thousandeighteen patients were electively operated on for 1236(unilateral 800, bilateral 218) inguinal hernias. All opera-tions were performed by a single surgeon. Seven hundredand eighty-one patients had unilateral inguinal hernia, 205patients had bilateral inguinal hernia, 19 patients had thecombination of unilateral inguinal and ventral or incisio-nal hernias (7 epigastric, 9 umbilical, 1 spigelian and 2 in-cisional), and 13 patients had the combination of bilateralinguinal and ventral or incisional hernias (1 epigastric, 10umbilical and 2 incisional). All inguinal hernias were sol-ved with the modified Lichtenstein technique, and all ven-tral or incisional hernias with "the open preperitoneal flatmesh technique".

Operations were performed under local anesthesia in724(71,1%) patients, under general in 271(26,6%), andunder regional (spinal or epidural) in 23(2,3%) patients.Local anesthesia was administrated in 606 patients withunilateral inguinal, in 97 with bilateral inguinal, in 13with unilateral inguinal and ventral or incisional, and in 8with bilateral inguinal and ventral or incisional hernias.General anesthesia was administrated in 160 patients withunilateral inguinal, in 100 with bilateral inguinal, in 6with unilateral inguinal and ventral or incisional, and in 5with bilateral inguinal and ventral or incisional hernias.Regional anesthesia was administrated in 15 patients withunilateral inguinal and in 8 with bilateral inguinal hernias.

One hundred and thirty (10.5%) hernias were recurrentand 203(16.4%) hernias had hernial defect >5 (5-10) cm./Figure 10-16/ Seventy-nine patients with 83 (75 unilate-ral, 4 bilateral; 72 after 1 or more tension repairs, 11 after1 or more tension-free repairs) recurrent hernias and 128patients with 135 (121 unilateral, 7 bilateral) hernias withhernial defect >5cm were operated on under local anaesthe-sia. Forty-two patients with 44 (40 unilateral, 2 bilateral;33 after 1 or more tension repairs, 11 after 1or more ten-sion-free repairs) recurrent hernias and 55 patients with62 (48 unilateral, 7 bilateral) hernias with hernial defect

FIGURE 13 A, B(A) PATIENT WITH RIGHT RECURRENT HERNIA FO-LLOWING LICHTENSTEIN HERNIOPLASTY OPERATED ONWITH MODIFIED LICHTENSTEIN TECHNIQUE UNDER LO-CAL ANESTHESIA ON AN "OUT-PATIENT" BASIS - PREOP-ERATIVE FINDINGS; (B) HERNIAL SAC AND PREVIOUSLICHTENSTEIN MESH EXCISION

FIGURE 13 C, D(C) PREVIOUS LICHTENSTEIN MESH EXCISED - INTRAOP-ERATIVE SPECIMENS; (D) RIGHT RECURRENT HERNIASOLVED WITH MODIFIED LICHTENSTEIN TECHNIQUE


>5cm were operated on under general anesthesia. Threepatients with unilateral recurrent hernia after1 or more te-nsion repairs and 6 patients with unilateral hernia with he-rnial defect >5cm were operated on under regional anes-thesia. Recurrent hernias were solved under local anesthe-sia in 63.9% of cases, under general in 33.8%, and underregional anesthesia in 2.3%. Huge hernias with hernial de-fect >5 cm were solved under local anesthesia in 66.5% ofcases, under general in 30.6% and under regional anesthe-sia in 2.9%.

ASA score was: 388 (38.1%) ASA I, 450 (44.3%) ASAII, 153 (15%) ASA III, and 27 (2.6%) ASA IV. Six hun-dred and thirty-five (62.4%) patients were operated on an"out-patient" basis and 383(37.6%) on an "in-patient" ba-sis. The mean stay at a day surgery unit was 2.5 (2-8) ho-urs, and the mean hospital stay was 1.6 (1-10) days.

During the mean follow up of 37 (1-96) months the rateof complications was: 23(1.86%) haematoma, 5(0.4%) se-roma, 5(0.4%) wound infections, 6(0.48%) ischaemic or-cihitis, 2(0.16%) testicle atrophy, 1(0.08%) disejaculation,

3(0.24%) hydrocoella, 21(1.7%) pain, and 2(0.16%) re-currence. Six reoperations were performed due to the fol-lowing complications: 1 operative wound exploration andhaemostasis because of large groin haematoma, 2 meshexcisions and McVay herniorrhaphy due to late mesh in-fection, 2 mesh excisions and triple neurectomy due tochronic pain and 1 mesh excision and Rives hernioplastythrough direct inguinal approach due to hernia recurrence.

DISCUSSION

Mesh techniques have been preferred in the manageme-nt of inguinal hernias regarding their origin in the colla-gene tissue disease ("herniosis").12,13 Inguinal hernia re-pairs can be performed under local, regional or generalanesthesia. According to the experience of the British He-rnia Centre14, "a day-case" surgery under local anesthesiais recommendable for 95% of noncomplicated primarygroin hernias, and many noncomplicated primary umbili-cal and epigastric hernias. Amid15 recommends using lo-cal anesthesia for all reducible adult inguinal hernias.Acevedo and Leon16 recommend elective repair of pri-mary or reccurent small- or medium-sized inguinal, umbi-

FIGURE 14 A, B(A) PATIENT WITH LEFT RECURRENT HERNIA FOLLO-WING PROLENE HERNIA SYSTEM HERNIOPLASTY OPER-ATED ON WITH MODIFIED LICHTENSTEIN TECHNI-QUE UNDER LOCAL ANESTHESIA ON AN "OUT-PATIE-NT"BASIS - PREOPERATIVE FINDINGS; (B) HERNIAL SAC ANDPREVIOUS PROLENE HERNIA SYSTEM MESH EXCISION

FIGURE 14 C, D(C) PREVIOUS PROLENE HERNIA SYSTEM MESH EXCI-SED - INTRAOPERATIVE SPECIMENS; (D) LEFT RECUR-RENT HERNIA SOLVED WITH MODIFIED LICHTENSTE-IN TECHNIQUE


lical, epigastric, and incisional hernias on "a day-case" ba-sis using local anesthetic. From the author’s point of view,all patients with hernias, when justifiable for medical rea-sons, should be operated on under local anesthesia as anout-patient procedure. The basic principle is that all pati-ents with reducible inguinal hernias either unilateral or bi-lateral, primary or recurrent, regardless of the size of her-nial sac or defect, or the presence of the prosthetic materi-al in the groin from previous repairs should be operatedon under local anesthesia. All hernias in one patient (bilat-eral inguinal, or inguinal and ventral or incisional) shouldbe simultaneously operated under local anesthesia if thepatient’s condition and surgical findings so allow. Generalanesthesia should be used in patients with non-reponable,incarcerated or strangulated hernias.

Local anesthesia is as ideal for the patient as for "a daycase surgery" - local analgesia is provided, muscular mo-torics preserved and urinary retention and systematic effe-cts avoided.17 The author’s experience is complying withthe European Hernia Society guidelines on the treatment

of inguinal hernia in adult patients where it is said that"we will have to acknowledge the level 1 evidence datathat indicate strongly reduced morbidity with local anaes-thesia".3

The principle is that an anesthesiologist is present in theoperative room during the surgery.16 For local anesthesia,the mixture of 2% procaine and 0,5% bupivacaine is used.Procaine has quick but short effects (analgetic effect oc-curs almost immediately and duration is 20-30 minutes),while bupivacain has slow and long effects (analgetic ef-fect occurs in 1-5 minutes and duration is 120-240 min-utes).10 The increase of the dose of the anaesthetic de-pends on the duration of the surgery in the simultaneousrepairs of 2 or more hernias in one patient, i.e. the dura-tion of the surgery, being up to 60 minutes for one ingui-nal hernia, which is now prolonged to 120 or 180 minutesdepending on the number of hernias. According to Berdeand Strichartz10 "the dosage of local anesthetic requiredfor adequate infiltration anesthesia depends on the extentof the area to be anesthetized and the expected duration ofthe surgical procedure". During the simultaneous operati-on of 2 or more hernias, the dose of the administered an-esthetics is gradually increased under continuous monitor-

FIGURE 15 A, B(A) PATIENT WITH LEFT RECURRENT HERNIA FOLLO-WING PERFIX PLUG AND PATCH HERNIOPLASTY OPER-ATED ON WITH MODIFIED LICHTENSTEIN TECHNI-QUE UNDER GENERAL ANESTHESIA ON AN "IN-PATI-ENT" BASIS - PREOPERATIVE FINDINGS; (B) HERNIALSAC AND PREVIOUS PERFIX PLUG AND PATCH MESH EX-CISION

FIGURE 15 C, D(C) PREVIOUS PERFIX PLUG AND PATCH MESH EXCI-SED- INTRAOPERATIVE SPECIMENS; (D) LEFT RECU-RRENTHERNIA SOLVED WITH MODIFIED LICHTENSTEIN TECH-NIQUE


ing of the patient’s vital functions (non-invasive bloodpressure, pulse oxymetry, ECG monitoring and generalcondition) by the surgeon and the anesthesiologist. If bra-dycardia or hypotension occurs, the anesthesiologist res-ponds accordingly to vital parameters, by administeringfluid solutions (saline) and, if necessary, atropine, amino-philline, ephedrine, dopamine, noradrenaline or crystallo-id solutions.

The surgeon and the anesthesiologist make decisionwhether the patient should be operated on an "out-patient"or "in-patient" basis, which primarily depends on the ASAscore and not on the hernia type. All ASA I-II status pati-ents and some of ASA III status patients are operated un-der local anesthesia as "a day case" and discharged 2-8hours after the surgery. The patients are only required tourinate before discharge. Some of ASA III status patientsand all ASA IV status patients are operated under localanesthesia, if medical reasons so allow, but are required tospend at least 24 hours in hospital. The mean hospital stayin patients with commorbidities is 1-2 days. In practice

there are no indications for longer stay. General anesthe-sia is used in very young, anxious or psychiatric patients.Regional anesthesia (spinal or epidural) is rarely used inelective inguinal hernia operations because it may causeurinary retention in middle-aged or elderly male patientswho frequently suffer from prostate adenoma and makethe majority of the patients with inguinal hernia.

In the execution of hernioplasty, close attention shouldbe paid to certain maneuvers in hernial sac dissection andmesh positioning. In elective inguinal hernia repair, thehernial sac is restored into the Bogros space without ope-ning, and the TF is reconstructed. The hernial sac is neverexcess since it is always desirable to have as much tissue(peritoneum) between the mesh and the intestine as possi-ble. The TF reconstruction (direct hernia) or the narrowi-ng of the internal inguinal ring (indirect hernia) is not her-niorraphy but only serves the purpose of easier flat meshpositioning during the operation impeding the hernial sacto "fall out or push" the mesh. It should be pointed outthat the internal ring narrowing is performed caudally, notcranially in order not to injure the nerves or disturb the"shutter" action of the internal ring. Some surgeons, mis-understanding this maneuver, perform the real herniorrha-

FIGURE 16 A, B(A) PATIENT WITH RIGHT RECURRENT HERNIA FO-LLOWING 2 LICHTENSTEIN HERNIOPLASTIES OPERATEDON WITH MODIFIED LICHTENSTEIN TECHNIQUE UNDERLOCAL ANESTHESIA ON AN "OUT-PATIENT" BASIS - PRE-OPERATIVE FINDINGS; (B) HERNIAL SAC AND 2 PRE-VIOUS LICHTENSTEIN MESHES EXCISION

FIGURE 16 C,D(C) 2 PREVIOUS LICHTENSTEIN MESHES EXCISED - IN-TRAOPERATIVE SPECIMENS; (D) RIGHT RECURRENTHERNIA SOLVED WITH MODIFIED LICHTENSTEIN TECH-NIQUE


phy adding the mesh in onlay position. This may inducerisk of postoperative pain (tension repair) as well as ofhernia recurrence because herniorraphy does not allow foradequate mesh positioning and fixation, as mesh serves as"the roof of the house" while recurrence occurs "in thefoundations" at the level of herniorraphy. For the solutionof large inguinoscrotal hernias, Wantz procedure18,19 isused avoiding the hernial sac dissection at the scrotum(hernial sac is cut at the neck, peritoneum is sutured andscrotal part of the hernial sac is incised at the anterior wallfor hydrocella prevention). This maneuver is safe, avoid-ing the damage of the spermatic cord and the testicle inextensive hernial sac dissection. In the postoperative peri-od, the scrotal part of the hernial sac is manifest as thick-ness above the testicle which disappears in time.

In mesh hernioplasty, cremasteric muscle is routinelypreserved (preventing the contact between the vas defer-ens and the mesh as well as the injury of the genital bra-nch of genitofemoral nerve). The genital branch of the ge-nitofemoral nerve (the external spermatic nerve) is alwaysnext to the external spermatic vein ("blue line" accordingto Amid4) which is situated along the inferior border ofthe spermatic cord so that the preservation of the vein me-ans the preservation of the nerve itself. In patients whohave had large indirect hernia for years, there may ariseadhesions to the spermatic cord. In that case, the cremas-teric muscle must be sometimes cut in the hernial sac di-ssection. The cutting of the cremasteric muscle providesbetter exploration of the internal inguinal ring and theadequate indirect inguinal sac dissection at its level. If theindirect hernial sac is not adequately dissected, and itspart adhered to the spermatic cord is left near the internalinguinal ring, despite the mesh placement, indirect recur-rence is likely because the spermatic cord in these cases"pulls" the hernial sac through a new internal ring on themesh. When the cremasteric muscle is transected, its endsare sewn with a 3-0 resorbable monofilament suture. Itsdistal end is fixed to the reconstructed MOE aponeurosiswith a 3-0 resorbable monofilament suture leaving the tes-ticle in "high" position. In some patients, the cremastericmuscle resection can cause the testicle to fall into thescrotum. The position of this testicle is then lower thanthe one of the testicle on the opposite side and in timecontinues to drop, which causes great discomfort in somepatients, even greater than the recurrence itself. The cutti-ng of the cremasteric muscle means the simultaneous cut-ting of the external spermatic nerve and the external sper-matic vein. This proceeding is a part of Shouldice hernior-raphy and does not affect the increase of chronic pain.

The nerves are not dissected during the hernial sac pre-paration, unless it is necessary. If the nerve lies on theway of the dissection or mesh fixation, it is resected be-cause it is always better to cut the nerve than risk postope-rative pain occurrence.

The modified Lichtenstein technique may provide bothprotection and closure of the medial, lateral and femoraltriangles of the myopectineal orifice regardless of the typeand size of hernia. The fashion in which the lower meshborder is fixed to the Cooper’s ligament provides a strongsupport to hernioplasty. This support is significant in the

solution of large direct or recurrent hernias (where the Po-upart’s ligament is very weak and thin, "worn out" by pre-vious operations), and also prevents femoral hernia occur-rence. The fashion in which the mesh is positioned andfixed in the tubercle region, as well as its fixation to boththe Cooper’s and Poupart’s ligaments fully protects themedial (Hesselbach) and femoral triangle. The lowermesh border fixation 2-3 cm lateral to the internal ingui-nal ring (in the original Lichtenstein technique the lowermesh border is fixed just to the lateral border of the inter-nal inguinal ring) has its certain advantages. The patientswith large indirect hernias whose defect may extend evenseveral centimeters cranial to the internal inguinal ring,often have the increased intra-abdominal pressure pushingthe lateral part of the mesh downwards which may lead toindirect recurrence, cranial to the lateral mesh border.This is why it is important to fix the lower mesh border 2-3 cm lateral to the internal inguinal ring. It should be poi-nted out that the running suture, lateral to the internal in-guinal ring must not be placed deep into the tissue, butonly through the thin layer of the Poupart’s ligament inorder to avoid the lesion of the femoral and the lateral cu-taneous femoral nerves. The indirect recurrence in the la-teral triangle (the internal inguinal ring and the region 5-6cm lateral to the internal inguinal ring) is altogether avo-ided owing, on the one hand, to the fashion of mesh tailsfixation around the spermatic cord providing complete"locking" of the internal inguinal ring, and, on the otherhand, to the inferior mesh tail fixation to the Poupart’sligament 2-3 cm lateral to the internal inguinal ring.

It is important that the mesh should not be taut, but sli-ghtly bulged. While positioning the mesh, a surgeon sho-uld bear in mind two important points: mesh contraction("shrinkage") due to the connective tissue ingrowing intothe mesh and the impact of the intra-abdominal pressuregreatly varying from 8 - 12 cm H20 in supine and standingposition to 80 cm when coughing and vomiting.20 Thus,the procedure is in compliance with the tension-free prin-ciple preventing chronic postoperative pain at maximalstrain.9

The use of low-weight polypropylene mesh with largeporous induces less fibrous reaction, less shrinkage, andless pain compared to the use of heavy-weight small po-rous polypropylene mesh.21-23

However, less fibrous reaction following low-weightpolypropylene mesh hernioplasty in large hernia defectsmay lead to mesh bulging, so it is recommendable to usemore sutures for fixation. In case of very large hernial de-fects sizing 7-8 cm or more and the increased intra-ab-dominal pressure, it is advisable to use heavy-weightpolypropylene mesh which is fixed in the above men-tioned fashion, taking care that the upper border of themesh is fixed with several interrupted non-resorbable su-tures, only two being insufficient.

In conclusion, it can be said that the modified Lichten-stein technique performed under local anesthesia as an"out-patient" procedure is one of better solutions in the re-pair of huge or recurrent inguinal hernias in the presenceof the increased abdominal pressure.


SUMMARY

MODIFIKOVANA LICHTENCTEIN TEHNIKA URE[AVANJU KOMPLEKSNIH PREPONSKIH KILA

Lichtenstein tehnika je modifikovana radi uspešnijeg re-šavanja kompleksnih preponskih kila - velikih kila sa ma-sivnom destrukcijom transverzalne fascije i povišenim in-traabdominalnim pritiskom ili recidivantnih kila sa uniš-tenim Poupartovim ligamentom. Kompleksne kile naj~e-š}e se rešavaju preperitonealnim tehnikama (otvorenim ililaparoskopskim) u opštoj ili regionalnoj anesteziji na hos-pitalnom principu, dok se sa modifikovanom Lichtensteintehnikom mogu rešiti u lokalnoj anesteziji na ambulant-nom principu. Modifikacija Lichtenstein tehnike sastoji seu slede}em: a) lateralno pomeranje i fiksacija donjeg }oš-ka mre‘ice kaudalno od tuberculuma za 20-30% stepeni uodnosu na njenu donju ivicu obezbedjuje potpunu protek-ciju unutrašnjeg trougla (prevencija direktnog recidiva);b) fiksacija donje ivice mre‘ice od tuberculuma do femo-ralne vene produ‘nim "U" šavom za Poupartov i Coope-rov ligament potpuno štiti femoralni trougao (prevencijafemoralnog recidiva); c) fiksacija donje ivice mre‘ice pro-du‘nim šavom 2-3 cm lateralno od unutrašnjeg ingvinal-nog otvora, zajedno sa "zaklju~avanjem" unutrašnjeg ing-vinalnog otvora pomo}u 2 pojedina~na šava, jednog kojifiksira gornji za donji zase~eni krak mre‘ice kranijalnooko spermati~ne vrpce 1-1,5 cm medijalno od Pouparto-vog ligamenta, i drugog, koji fiksira donju ivicu gornjegzase~enog kraja mre‘ice i donju ivicu donjeg zase~enogkraja mre‘ice za donji deo Poupartovog ligamenta 1 cmkranijalno i lateralno u odnosu na prethodni šav, potpunoštiti spoljašnji trougao (prevencija indirektnog recidiva).U periodu januar 2003 - januar 2011, 1018 bolesnika sa1236 (800 jednostrane, 218 obostrane) ingvinalne kile ele-ktivno je operisano modifikovanom Lichtenstein tehni-kom. Sve operacije izvršio je jedan hirurg. Recidivantnihkila nakon jedne ili više tenzione ili beztenzione operacijebilo je 130(10,5%), a velikih kila sa defektom > 5cm 203(16,4%). U lokalnoj anesteziji operisano je 724(71,1%), uopštoj anesteziji 271(26,6%) a u regionalnoj anesteziji 23(2,3%) bolesnika.

Na ambulantnom principu rešeno je 635 (62,4%), a nahospitalnom 383(37,6%) bolesnika. ASA scor: 388 ASAI, 450 ASA II, 153 ASA III i 27 ASA IV. Prose~an bora-vak u bolnici bio je: 2,5 (2-8) sati nakon ambulantne pro-cedure i 1,6 (1-10) dana nakon hospitalne procedure.

Tokom srednjeg perioda pra}enja od 37 (1-96) mesecijavile su se slede}e komplikacije: 23(1,86%) hematoma,5(0,4%) seroma, 5(0,4%) infekcija rane, 6(0,48%) ische-mi~nih orhitisa, 2 (0,16%) atrofije testisa, 1(0,08%) dise-jakulacija, 3(0,24%) hidrocele, 21(1,7%) bola, i 2(0,16%)recidiva. Uradjeno je 6 reoperacija zbog komplikacija.Modifikovana Lichtenstein tehnika izvedena u lokalnojanesteziji kao ambulantna procedura predstavlja dobrorešenje za kompleksne preponske kile.

Klju~ne re~i: modifikovana Lichtenstein tehnika,kompleksna preponska kila, lokalnaanestezija, ambulantna hirurgija.

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18. Wantz GE. Testicular atrophy and chronic residualneuralgia as risk of inguinal hernioplasty. Surg Clin NorthAm 1993;73(3):571-581.

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23. O’Dwyer PJ, Kingsnorth AN, Molloy RG, SmallPK, Lammers B, Horeyseck G. Randomized clinical trialassessing impact of a lightweight or heavyweight mesh onchronic pain after inguinal hernia repair. Br J Surg2005;92:166-170.

Acknowledgments:I wish to express my sincere gratitude and eternal re-

spect to my late friend, an exceptional artist, Milorad Sto-jadinovi}, for all the artwork he has produced in my manyyears of dealing with hernias. I shall always rememberhim.


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