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OBJECTIVES OF THIS LESSON

Learn surgical repair of inguinal hernia using Lichtenstein technique: operative steps, anaesthetic options, nerve handling, mesh placement, closure, common pitfalls, and further reading.

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OBJECTIVES OF THIS LESSON

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  1. OBJECTIVES OF THIS LESSON • To prepare surgeons to perform a proper surgical repair of an inguinal hernia using the Lichtenstein technique: • by describing the operative technique • General plan of our lesson • anaesthetic options/ application of local anaesthesia • optimum surgical approach • how to handle the nerves • the indirect sac • the direct sac • mesh placement • closure • common pitfalls • further reading

  2. ANAESTHETIC OPTIONS • Anaesthetic options • general anaesthetic • spinal anaesthetic • local anaesthetic • Local anaesthetic • patient must be prepared to be awake • there are few contraindications • particularly useful in older patients and those with co-morbidity • caution with younger, anxious patients and those with irreducible or partially reducible hernias

  3. LOCAL ANAESTHESIA – NON CLINICAL SKILLS

  4. LOCAL ANAESTHESIA – PREPERATION AND AMOUNT

  5. LOCAL ANAESTHESIA – INFILTRATION 1

  6. LOCAL ANAESTHESIA – INFILTRATION 2

  7. LOCAL ANAESTHESIA – INFILTRATION 3

  8. OPERATIVE TECHNIQUE - INCISION

  9. OPERATIVE TECHNIQUE – APPROACH TO EXTERNAL OBLIQUE APONEUROSIS

  10. OPERATIVE TECHNIQUE – OPENING THE INGUINAL CANAL

  11. OPERATIVE TECHNIQUE – OPENING THE INGUINAL CANAL 2

  12. OPERATIVE TECHNIQUE – ELEVATION OF THE CORD

  13. OPERATIVE TECHIQUE - HOW TO HANDLE THE NERVES • Visualise and protect the ilio-inguinal, ilio-hypogastric and genital branch of the genito-femoral nerves throughout the operation

  14. OPERATIVE TECHIQUE – INDIRECT SAC A C B D

  15. OPERATIVE TECHIQUE – DIRCET SAC A B

  16. OPERATIVE TECHIQUE – MESH PLACEMENT 1

  17. OPERATIVE TECHIQUE – MESH PLACEMENT 2

  18. OPERATIVE TECHIQUE – MESH PLACEMENT 3 A B C

  19. OPERATIVE TECHIQUE – CLOSURE

  20. OPERATIVE TECHIQUE – COMMON PITFALLS • Opening external oblique aponeurosis • Care should be taken to avoid opening the aponeurosis too close to the rolled edge of the inguinal ligament • Dissection of the sac • Ensure that the dissection is carried out on the sac itself to avoid damaging adherent cord structures • Transect a fixed scrotal sac • Mesh fixation • Ensure adequate medial overlap of the mesh • Avoid the ilio-hypogastric nerve when securing the lateral edge of the mesh

  21. OPERATIVE TECHIQUE – FURTHER READING • Monographs and papers • Lichtenstein, I.L., Hernia repair without disability. 2nd ed. ed. 1987, St. Louis, Mo.: Ishiyaku EuroAmerica. • Amid, P.K., Lichtenstein tension-free hernioplasty: its inception, evolution, and principles. Hernia, 2004. 8(1): p. 1-7. • Amid, P.K., How to avoid recurrence in Lichtenstein tension-free hernioplasty. Am J Surg, 2002. 184(3): p. 259-60. • Amid, P.K. and I.L. Lichtenstein, The Lichtenstein open "tension-free" mesh repair of inguinal hernias. Rozhl Chir, 1995. 74(6): p. 296-301. • Books • Bendavid, R., Abdominal wall hernias : principles and management. 2001, New York ; London: Springer. • Kingsnorth, A.N. and K.A. LeBlanc, Management of abdominal hernias. Fourth Edition. ed. 2013, New York ; London: Springer.

  22. Performed by: Dr David L Sanders and Prof Andrew N Kingsnorth Derriford Hospital, Plymouth, UK

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