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Lichtenstein Repair of Inguinal Hernia
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Anatomy of the inguinal region
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). 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.
- Both the external iliac artery and vein (→ femoral artery and vein; with the artery lateral to the vein) course through the vascular compartment which is lateral to the pubic bone. 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. In femoral hernias the lacuna vasorum is the deep weak spot (through the femoral septum along the femoral vein).
- 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.
Anterior abdominal wall and inguinal canal
During testicular development the tubular structure of the inguinal canal is formed by the externalization of the testicles, which are pulled into the scrotum by the gubernaculum testis. The peritoneum pulled along during this descent remains in the inguinal canal as a pouch (processus vaginalis testis). Thus, the layers of the abdominal wall turn into the corresponding sheaths in this pouch:
Transversalis fascia → internal spermatic fascia,
Internal oblique → cremaster,
Fascia of external oblique → external spermatic fascia,
No investment by the transversus abdominis since it terminates more cephalad.
The blood vessels (testicular artery and vein), spermatic duct (ductus deferens) and nerves (ilioinguinal nerve originating from the lumbar plexus) are also pulled into the scrotum, and together they form the spermatic cord. When the processus vaginalis testis closes, it obliterates the connection with the peritoneal cavity, typically leaving behind only the vestige of the vaginal process. 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. Incomplete obliteration of the processus vaginalis testis is a weak spot in the abdominal wall and therefore a possible starting point for inguinal hernia.
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.
Deep inguinal ring
- 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)
Superficial inguinal ring
- Superior to the pubic tubercle in the fascia of the external oblique, superior edge pointing cephalad, lower edge formed by inguinal ligament, sides = medial and lateral crus with stabilizing intercrural fibers.
Walls of the inguinal canal
- Fascia of the external oblique, with lateral augmentation by fibers of the internal oblique → inguinal ligament and → cremaster
- Transversalis fascia, with medial augmentation by the conjoint tendon (= tendon of the transversus abdominis and internal oblique).
- Transversus abdominis and internal oblique (fibers running from inguinal ligament to the medial conjoint tendon)
- Medial inguinal ligament (= reflected ligament) and a trough for the spermatic cord formed by the external oblique.
Contents of the inguinal canal
In men: Spermatic cord (funiculus spermaticus) with the spermatic duct; deferential artery (branch of the inferior vesical artery) and testicular artery (from the aorta); venous pampiniform plexus; cremasteric artery and vein; genital branch of the genitofemoral nerve to the cremaster muscle; sympathetic nerve fibers; and lymphatic vessels. All invested by the internal spermatic fascia, cremasteric fascia, and external spermatic fascia.
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.
Types of hernias
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).
Indirect inguinal hernia
- 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
Direct inguinal hernia
- 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.
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.
- Primary inguinal hernia in patients > 30 years, except for small lateral hernias
- Recurrent inguinal hernia
- Incarcerated inguinal hernia
- Patients who are absolutely inoperable
- No other contraindications since the procedure can be performed under local anesthetics
Preoperative diagnostic work-up
- Manual examination with patient standing
- 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 2nd generation cephalosporin
- Secondary healing
- Mesh infection
- Vascular and nerve injury
- (Secondary) bleeding
- Chronic groin pain such as ilioinguinal syndrome
- Injury to the spermatic duct
- Testicular atrophy
- Redo procedure
- Bowel resection
Operating room setup
Special instruments and fixation systems
- Basic instrument tray
- Lichtenstein mesh
Nonsteroidal anti-inflammatory drugs usually suffice; if necessary, they can be enhanced by opioid analgesics.
Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management).
This link will take you to the International Guideline Library.
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
Deep venous thrombosis prophylaxis:
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.
Note: Renal function, HIT II (history, platelet check)
This link will take you to the International Guideline Library.
Unrestricted; gradual return to physical activity; full physical activity, as tolerated, after one week; all activities permitted after four weeks the latest.
Respiratory therapy for prevention of pneumonia only in bedridden patients.
Laxatives may have to be started on postoperative day 2
Inguinal skin incision
Division of the external oblique aponeurosis
Now longitudinally divide the fibers of the external oblique, including the superficial inguinal ring. After clamping the aponeurotic flaps and retracting them upward, free the aponeurosis from the internal oblique and cremaster by blunt dissection.
Caution: The iliohypogastric nerve courses immediately below the aponeurosis!
Mobilization and taping of the spermatic cord
Pass a tape around the spermatic cord, gently lift it and free the cord by blunt dissection from the transversalis fascia below and direct hernai sac respectively.
After dividing the cremaster muscle longitudinally, excise its fibers leaving generous stumps, thereby freeing the cord. In this step of the procedure the ilioinguinal nerve and the genital branch of the genitofemoral nerve must be spared.
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
Preparation and identification of the hernia sac
Hernia sac management in direct hernia
Hernia sac management in indirect hernia
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. Splay open the hernia sac and reduce its contents. Close the base of the hernia sac with an outer purse string suture and remove the excess.
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. In case of any bleeding you can easily pull up the stump with the stay sutures and institute the necessary hemostatic measures. If the stump does not retract out of sight spontaneously, reduce and submerge it by suture.
Fitting and tailoring the mesh
Mesh fixation at inguinal ligament
Starting medially at the pubic bone, anchor the mesh along the inferior border of the inguinal ligament. Ensure that medially the mesh covers the pubic bone by at least 2 cm because this is where most recurrences are seen. Anchor the mesh on the inguinal ligament with a continuous suture (polypropylene 2-0) up to the deep inguinal ring. It is important not leave any gaps along the inguinal ligament since this heightens the risk of recurrence.
Creating a new deep inguinal ring
Anchoring the mesh on the internal oblique
Closure of the external oblique aponeurosis
End of procedure
Irritation, entrapment and injury of the inguinal nerves with persistent postoperative pain (ilioinguinal syndrome, genital nerve syndrome)
- The nerves were injured or divided during dissection. The particular nerves at danger are: lateral femoral cutaneous; ilioinguinal; iliohypogastric; genital and femoral branches of the genitofemoral nerve.
- 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.
- If the nerves are not divided but only irritated or touched, this may result in postoperative paresthesia which often is amenable to local anesthetics.
Injury to the spermatic duct
- How to proceed in any injury of the spermatic duct depends on the following aspects: Has the spermatic duct been divided completely or only partially? How old is the patient? Does the patient want to preserve his fertility?
- In elderly patients no longer sexually active the spermatic duct may be transected. After the operation the patient must always be informed of what had happened and the consequences for him.
- In case of accidental iatrogenic bowel injury during the procedure the lesion should be immediately closed by suture.
Injury to the femoral artery and arterial hemorrhage
- Arterial hemorrhage from the femoral artery will result in rapid massive blood loss with the clinical sequela of hypovolemic shock. The bleeding must be noted and its source oversewn,
- If the bladder has been injured the lesion must be oversewn. Relieve the bladder for seven to ten days with a suprapubic catheter.
- Definition: Hemorrhage or secondary bleeding in or around the wound
- Clinical symptoms: Tender and discolored swelling
- Diagnostic work-up: Ultrasonography and ruling out systemic cause (such as coagulation disorders)
- Treatment: Small hematomas only need to be observed and usually do not entail any further treatment.
- Larger hematomas should undergo paracentesis or be evacuated. Massive secondary hemorrhage must be explored by revision surgery.
- Definition: Spaces in the surgical field filled with secretions and lymph.
- Clinical symptoms: Swelling without tenderness and discoloration.
- Diagnostic work-up: Ultrasonography
- Treatment: Small postoperative seromas are absorbed by the tissue and only require follow-up. If the size of the seroma results in clinical symptoms, in rare cases this may require paracentesis (absolutely sterile conditions!). Usually, after informing the patient the seroma only needs to be followed up. 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. This also applies to those rare cases where the seroma results in an infection.
Infection and secondary healing
- Definition: Wound infection by pathogens.
- Clinical symptoms: The five cardinal symptoms of infection: Calor, dolor, rubor, tumor, functio laesa.
- Treatment: Reopen and force apart the wound, cleanse extensively, and continue with open wound treatment and systemic antibiotic protocol.
- 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.
Injury to the femoral vein with subsequent thrombosis
- Iatrogenic injury to the vein with subsequent thrombosis in the surgical field must be regarded as deep venous thrombosis of the pelvis.
- Diagnostic work-up: Duplex and doppler ultrasonogrpahy or phlebography
- Treatment of deep venous thrombosis of the lower extremity Compression, ambulation, full heparinization (Caution: Risk of secondary bleeding!).
- This link will take you to the International Guideline Library.
Entrapment or division of the spermatic vessels, postoperative testicular swelling
- Postoperative testicular swelling is the sequela of hypoperfusion. This may result in total loss of the testicle. Open surgery is required to improve venous drainage.
- Definition: Irreversible epithelial injury of the seminiferous tubules with subsequent loss of spermatogenesis.
- Clinical symptoms: Initially swelling and warming, followed later on by shrinking and dyesthesia.
- Diagnostic work-up: Ultrasonography, urology consult.
- Treatment: No reasonable treatment known at this time.
- Definition: Inguinal hernia newly developed after previous inguinal herniorraphy.
- The clinical symptoms and diagnostic work-up correspond to that in inguinal hernia.
- Treatment: Herniorrhaphy with implanted mesh, primarily as TAPP or TEP procedure.
Overlooked bowel lesion
- Clinical symptoms: Patient does not recover from surgery, suffers from abdominal pain, nausea, guarding, and displays symptoms of peritonitis.
- Treatment: Reoperate, expose the lesion and suture it closed or resect it and perform abdominal lavage, if necessary. If peritonitis is present, institute an antibiotic protocol for at least one week.
Postoperative bowel atony
- Treatment: Administer prokinetic medication such as metoclopramide, neostigmine.
- Clinical symptoms: Distended abdomen; gas crescents on abdominal radiographs; in case of ischemia possibly elevated lactate levels and clinical signs of transmural peritonitis
- 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:
- Lower recurrence rate (↑↑ [6; 8; 11; 12; 15; 21])
- Probably somewhat shorter operating time (↑↑ [6; 12; 15; 20; 21])
- Perhaps somewhat less postoperative pain, in the long run apparently comparable pain (↑↑ [3; 11; 13; 18; 20-22])
- Perhaps somewhat speedier recovery (↑↑ [3; 6; 18; 21])
- Comparable rate of infection (↑↑ 21)
- May be performed under local anesthetics (↑↑ 11)
- More expensive because of cost of mesh (↑ 18)
- For comparison of the Lichtenstein repair with other procedures please see there: Inguinal herniorraphy with Rutkow plug, TAPP and TEP.
The comparison fociused on heavy and light-weight meshes (100 g/cm2 and 30g/cm2 respectively). Outcome of the light-weight meshes:
- Less foreign body sensation in the groin (↑ [5; 19])
- Trend of less chronic groin pain (↑ [5; 19])
- Comparable recurrence rates (↑ 5)
In addition, several mesh materials were studied. The comparison of Prolene®, Vypro II®, Premilene® and Surgisis® resulted in the following:
- No significant differences in the perioperative course (↑↑ [1; 4; 17])
Sutures, sealants, skin staples and spiral tacks used in mesh fixation were also studied. The outcome was as follows:
- 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])
Routine prophylactic antibiotic protocol in Lichtenstein repair resulting in:
- Evidently no reduction in the rate of wound infection (↑ 2)
Ongoing trials on this topic
References on this topic
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- 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. Surgery 1998; 123: 121-6.
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- Bringman S, Wollert S, Osterberg J, Smedberg S, Granlund H, Heikkinen TJ. Three-year results of a randomized clinical trial of lightweight or standard polypropylene mesh in Lichtenstein repair of primary inguinal hernia. Br J Surg 2006; 93: 1056-9.
- Danielsson P, Isacson S, Hansen MV. Randomised study of Lichtenstein compared with Shouldice inguinal hernia repair by surgeons in training. Eur J Surg 1999; 165: 49-53.
- Douglas JM, Young WN, Jones DB. Lichtenstein inguinal herniorrhaphy using sutures versus tacks. Hernia 2002; 6: 99-101.
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