The Tension-Free Hernioplasty

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Lichtenstein et al. "The Tension-Free Hernioplasty". The American Journal of Surgery. 1989. 157(2):188-193.
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Clinical Question

Among individuals undergoing elective inguinal hernia repairs, does a tension free technique with mesh decrease recurrence rate?

Bottom Line

Tension free repair of inguinal hernias with polypropylene mesh offers decreased rates of recurrence compared to prior techniques.

Major Points

Originally described in this pioneering paper, the Lichtenstein repair utilizing open mesh has since been the gold standard for open elective inguinal hernia repair. The goal of this technique, to minimize tension on tissues, is a core Halstedian surgical principle. The adoption of the Lichtenstein repair decreased rates of inguinal hernia recurrence recurrence.

Guidelines

International Guidelines for Groin Hernia Management [1]

  • For open repairs, the Lichtenstein technique continues to be the standard for open inguinal hernia repair

Technique

  • 1. 5x10cm prosthetic mesh placed anterior to the transversalis fascia
  • 2. Continual prolene suture secures the inferior portion of the mesh, running medially along the lacunar ligament, then laterally to the inguinal ligament (Poupart’s ligament) beyond the internal ring
  • 3. Split the mesh at the internal ring to allow passage of the spermatic cord
  • 4. Secure superior mesh edge to the rectus sheath/conjoint tendon with continuous prolene suture
  • 5. A single suture holds the tails of the mesh laterally to the inguinal ligament
  • 6. Absorbable suture closes the external oblique aponeurosis over the cord

Outcomes

  • The paper is primarily a description of technique, although the authors do report 1,000 consecutive cases with 0 recurrences with 1 to 5 years follow-up (data not shown)

Criticisms

  • Complicated hernias, specific anatomic considerations, and situations in which mesh repair are undesirable are situations in which the Lichtenstein technique may not be appropriate

Funding

The authors do not report any conflicts of interest

Further Reading

  1. HerniaSurge Group International guidelines for groin hernia management. Hernia 2018. 22:1-165.