The Lichtenstein technique

The true tension-free hernioplasty using mesh and no suture closure of the hernial defect was introduced in 1984 by Irving Lichtenstein in Los Angeles. Repair of the posterior wall with a suture line is abandoned, except for a simple imbrication suture for large sacs that aided flattening of the posterior wall before placement of the mesh. In the UK, the Lichtenstein technique was first reported by Kingsnorth and colleagues, and subsequently by a private hernia clinic, The British Hernia Centre. Mesh repair is associated with three times fewer recurrences than non-mesh, in the repair of inguinal hernia. The incision, exposure, dissection of the canal and cord, and the dealing with indirect hernial sacs are identical to that described for the Shouldice operation. Polypropylene mesh precut to

Figure 14.11. The second layer of suturing in the multi-layered Shouldice repair: the lower lateral flap of fascia transversalis is sutured to the undersurface of the upper medial flap along the 'white line' or 'arch'.

8 cm X 16 cm is tailored to the individual patient's requirements. This will involve trimming 1-2 cm of the patch's width and the upper medial corner so that it will tuck itself between the external oblique and internal oblique muscles without wrinkles. After tailoring the mesh is sutured to the inguinal ligament and conjoint tendon and closed around the spermatic cord to recreate the internal ring. (Fig. 14.12)

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