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

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

LOCAL ANAESTHESIA – NON CLINICAL SKILLS

LOCAL ANAESTHESIA – PREPERATION AND AMOUNT

LOCAL ANAESTHESIA – INFILTRATION 1

LOCAL ANAESTHESIA – INFILTRATION 2

LOCAL ANAESTHESIA – INFILTRATION 3

OPERATIVE TECHNIQUE - INCISION

OPERATIVE TECHNIQUE – APPROACH TO EXTERNAL OBLIQUE APONEUROSIS

OPERATIVE TECHNIQUE – OPENING THE INGUINAL CANAL

OPERATIVE TECHNIQUE – OPENING THE INGUINAL CANAL 2

OPERATIVE TECHNIQUE – ELEVATION OF THE CORD

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

OPERATIVE TECHIQUE – INDIRECT SAC

A

B

C

D

OPERATIVE TECHIQUE – DIRCET SAC

BA

OPERATIVE TECHIQUE – MESH PLACEMENT 1

OPERATIVE TECHIQUE – MESH PLACEMENT 2

OPERATIVE TECHIQUE – MESH PLACEMENT 3

A B

C

OPERATIVE TECHIQUE – CLOSURE

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

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.

Dr David L Sandersand

Prof Andrew N Kingsnorth

Derriford Hospital, Plymouth, UK

Performed by: