Open inguinal hernia repair (Lichtenstein)

Why are we operating?

Tension-free mesh repair of the commonest surgical lesion, built on knowing the canal better than the hernia does.

Indication: Symptomatic inguinal hernia; urgently when incarcerated, emergently when strangulation is suspected.

The operation in 5 steps

1. 01Opening the canal

   Groin incision, then the external oblique aponeurosis is opened along its fibres from the external ring.

2. 02Cord and sac

   The cord is lifted on a sling and the hernial sac separated from cord structures: indirect sacs travel with the cord through the deep ring, direct hernias bulge through the posterior wall.

3. 03Dealing with the sac

   The sac is reduced or, if large and indirect, transfixed and divided at the deep ring.

4. 04Tension-free mesh

   A shaped mesh is laid on the posterior wall from pubic tubercle to beyond the deep ring, slit to embrace the cord, and fixed without tension.

5. 05Closure

   External oblique is closed over the cord, recreating the canal, then subcutaneous tissue and skin.

Danger zones

• Ilioinguinal nerve

  It lies on the very cord the operation dissects and beside the mesh the operation places; entrapment by a suture or the mesh is as damaging as division.

• Inferior epigastric vessels

  The landmark separating direct from indirect, and a bleeding hazard at the triangle's lateral border.

• Vas deferens & testicular vessels

  Skeletonised with the cord at every repair; injury threatens fertility and the testis.

• Femoral vein

  Just below the inguinal ligament at the femoral canal, the structure a too-deep medial stitch finds.

Anatomy you need

The abdominal wall in layers: external oblique over internal oblique over transversus, the lattice the canal tunnels through.

What can go wrong

• Postoperative bleeding

  Tachycardia first, hypotension late; falling urine output; a distending abdomen or rising drain output.

• Surgical-site infection

  Wound erythema, warmth, discharge, and pain out of proportion, typically from postoperative day 4–7.