0039-6109/98 $8.

00

GROIN HERNIA SURGERY

+ .OO

THE LICHTENSTEIN REPAIR

Martin Kurzer, FRCS, Philip A. Belsham, FRCS,
and Allan E. Kark, FRCS, FACS

Just twelve years ago Lichtenstein described a "tension-free" onlay

of polypropylene mesh for inguinal hernia repair. Surgeons who claim
that he introduced nothing new and that the use of polypropylene mesh
in groin hernia repair had been reported before 1986 misunderstand his
concept. He advocated his technique for all groin hernias, large and
small, complex and straightforward, and maintained that essential components included local anesthesia, immediate ambulation, and same-day
discharge, each contributing to the overall success.
PROSTHETIC MESH BEFORE LICHTENSTEIN'S
REPORT
Soon after the introduction of synthetic plastic mesh in the 1950s,
surgeons began experimenting with its use in bridging tissue defects.47
In 1958, Horwich18used a prosthesis made of elasticated nylon in patients with large or recurrent inguinal hernias. He recognized that any
recurrences would occur at the edges of the prosthesis and that an
implant of sufficient size to widely overlap the deficiency was required.
In the same year, Usher and Wallace5*reported their experimental work
on tissue reaction to prosthetic mesh and subsequently described the
clinical use of Marlex
Usher used a relatively thin strip (2.5 cm
X 7 cm) of Marlex as an additional buttress to reinforce conventional
repairs, and his initial experience was favorable, with no infective complications. He also commented on the benign postoperative course of
these patients, who had remarkably little postoperative pain. Neverthe-

From the British Hernia Centre, London, United Kingdom

SURGICAL CLINICS OF NORTH AMERICA

VOLUME 78 NUMBER 6 * DECEMBER 1998

1025

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KURZER et a1

less, he reserved prosthetic mesh for technically challenging cases, that

is, large direct, pantaloon, or recurrent hernias. He wrote in his 1960
paper,s1We have found that if the mesh is used to bridge the defect
instead of as a reinforcement for tissues approximated under stress, this
factor of tension is eliminated, and recurrence becomes less likely.
Those surgeons who used prosthetic mesh at that time reserved it
for large direct, large sliding, or recurrent inguinal hernias. Fear of
infection dominated their views, which meant that they were reluctant
to use mesh unless absolutely necessary. Thus, in 1962, UsherSoreported
results of the use of Marlex mesh in 183 inguinal hernia repairs carried
out by himself and by other surgeons whom he had contacted by postal
questionnaire. Most of the surgeons believed that a mesh prosthesis
should be used only for direct or recurrent inguinal hernias. In the
majority of cases, mesh was used to reinforce a Bassini repair, although
in 50 cases, mesh was placed in a subfascial (preperitoneal) position,
and no attempt was made to close the defect. The infection rate was
1.6%, and the recurrence rate in those 84 patients examined a year or
more postoperatively was 5.9%. Collier and Griswold,Io like Usher,
thought that tension was the prime reason for recurrence and used
Marlex mesh, also placed preperitoneally, through the floor of the inguinal canal; in 225 procedures, they reported only one recurrence, with a
90% follow-up from 6 months to 6.5 years.
Describing his use of Marlex mesh, Patt33acknowledged that his
peers had reserved it for large direct or pantaloon hernias but pointed
the way forward when he perceptively wrote more than 20 years ago:
Usher opposes the use of mesh reinforcement in simple indirect
inguinal hernia but the use of a mesh in this type of case should be
investigated. Complications associated with its use are minor in
character and relatively rare. Any measure which promises to reduce
the recurrence rate of inguinal hernia must be examined carefully
since even the most favorable cases of indirect inguinal hernia occasionally develop a direct recurrence. The efficacy of routine implantation of Marlex mesh will have to be established by a large series
in which all cases of simple indirect inguinal hernia in the adult
male are alternately repaired with Marlex mesh. The Marlex mesh
group should give a significantly lower recurrence rate than the
group repaired by all other methods in the surgeons armamentarium. Should a significant statistical difference in favour of the mesh
be established, its routine use would be advisable.

THE EVOLUTION OF LICHTENSTEINS TECHNIQUE

For many years before he began to use prosthetic mesh for primary
inguinal hernia repair, Lichtenstein had advocated the routine use of
local anesthesia followed by immediate ambulation and a 1-day hospital
stay.28In the first edition of his
he described the use of a 3 cm X
8 cm plastic mesh screen to reinforce the repair of direct and indirect

THE LICHTENSTEIN REPAIR

1027

hernias. He recognized that suture line tension was at the heart of failed
hernia repairs and that solving this problem would largely eliminate
recurrences. In 1974, 10 years before outlining the use of a tension-free
prosthetic onlay patch for primary inguinal hernias, he had described a
method of using a rolled-up piece of mesh in the form of a plug to
repair both femoral and discrete recurrent inguinal hernias, the aim
being the avoidance of any suture line tension.29
Tension-Free Hernioplasty
published in 1986, he reviewed
In the second edition of his
his total experience with all abdominal hernias and described a tensionfree repair carried out on 300 consecutive inguinal hernias, with a followup of just over 2 years. No attempt was made to bring the transversus
abdominis or the internal oblique muscle down to the inguinal ligament,
and no sutures were placed at the deep ring. His lucid description of
the procedure was as follows:
A sheet of prosthetic mesh measuring about 5 by 10 cm. is fashioned.
The lower edge is attached by a continuous suture of 000 prolene
which secures the mesh medially to the lacunar ligament and then
proceeds laterally along Pouparts ligament beyond the internal ring.
A slit in the mesh at the internal ring allows emergence of the
spermatic cord. The superior edge of the mesh is secured by a
similar continuous suture to the rectus sheath and conjoined muscle
and tendon above. . . . Nevertheless, this must be considered a
preliminary report and final evaluation will have to await a larger
experience over a longer period of study.

In 1989, Lichtenstein and c011eagues~~

reported their use of this
prosthetic screen onlay technique, the tension-free hernioplasty, in
1000 patients with minimal complications and a zero recurrence rate
after a follow-up of between 1 and 5 years. Unlike surgeons who had
reserved prosthetic mesh for difficult cases, Lichtenstein was proposing its routine use for all groin hernias. He commented as follows:
The advantages are many and apparent. The lack of post-operative
pain, minimal hospitalisation, immediate return to work, virtual
absence of anaesthetic or cardiac risk, the freedom from urinary
retention, gas pains, and post operative complications (pneumonia,
atelectasis, thrombosis, nausea and vomiting etc.) and the saving of
money are but a few.

Reaction to Lichtensteins 1989 Publication

The depth of feeling that this paper aroused among surgeons can
be gauged in a letter published 5 months later40:
The article by Lichtenstein and colleagues . . . represents another
attempt by this group to convince their surgical peers of the superi-

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KURZER et a1

ority of Lichtensteins novel approaches to repair of abdominal wall

hernias. However, like many of his past publications, it again contains a plethora of conjecture and assumptions, but no convincing
or believable facts. . . . The authors wish us to believe that in their
last 1,000 consecutive patients with primary repair . . . there were
no recurrences. Moreover, . . . Patients . . . were encouraged to
return to full unrestricted activity as soon as possible. I challenge
these statements. The results as presented are laughable.

The last part of this highly critical letter compares the Lichtenstein
Clinics style of reporting unfavorably with that of the Shouldice Hospital. The irony of this is twofold. Firstly, the Shouldice Hospital, in its first
15 years of existence, was the butt of widespread derogatory criticism by
the Anglo-American surgical establishment. Now that their multilayered
repair has become a benchmark of surgical excellence, this is conveniently forgotten. Secondly, apart from the highly experienced surgeons
at the Shouldice Hospital? l5 and with some notable exceptions? 11, 23,
25,41 few others have been able to emulate their superb
The Tension-Free Repair in the Hands of Other Surgeons
In 1992, under the aegis of Lichtensteins group, the results of 3019
hernia repairs from five different centers were published, revealing a
recurrence rate of 0.2%.43In 1995, this idea of nonexpert surgeons obtaining excellent results with the Lichtenstein method was confirmed in
a survey of 72 surgeons who had performed more than 16,000 tensionfree mesh repairs, which showed a recurrence rate of less than 0.5% and
an incidence of infection of 0.6%.44 Unlike the Shouldice repair, the
Lichtenstein technique of onlay tension-free mesh did not need a steep
learning curve to obtain highly acceptable results in the hands of general
surgeons.

BRITISH HERNIA CENTRE EXPERIENCE

The British Hernia Centre is a private, free-standing outpatient

surgery clinic offering ambulatory abdominal wall hernia repair under
local anesthesia. Before 1992, the authors had used the Shouldice repair
for inguinal hernias, usually with the patient under general anesthesia,
but had found that it was not easily applicable in all cases, particularly
in the obese and in those with large, longstanding defects with much
distortion of the floor of the inguinal canal. Visits to several recognized
experts with experience in mesh repairs (Gilbert in Miami, Shulman at
the Lichtenstein Clinic, Wantz in New York, Stoppa in France, and
Kingsnorth in the United Kingdom) convinced the authors of the merits
of a tension-free prosthetic repair. The key features of the newly adopted
method were to be local anesthesia, tension-free onlay mesh, and sameday discharge.

THE LICHTENSTEIN REPAIR

1029

The authors rapidly became adept at obtaining complete local anesthesia with infiltration and very soon abandoned the use of regional
nerve blocks which were found to be of little or no use. The surgical
procedure itself proved to be straightforward, with a low incidence of
complications. The authors initial experience was favorable and received
high patient acceptance as a consequence of the much-reduced postoperative discomfort, which permitted immediate ambulation and an early
return to normal activities.22The authors continued its use for all cases
and have not rejected patients for repair in the last 5000 patients, apart
from those with small, asymptomatic, direct hernias in elderly men,
which were not repaired, and 24 patients with irreducible hernias who
required general anesthesia. Four patients with massive, longstanding,
irreducible hernias were not operated on. Age, physical infirmity, medical problems, or prostatic symptoms have not been reasons for rejection.
Preoperative Preparation

Routine preoperative investigations are not carried out. Patients

who appear clinically anemic or take diuretics have a hemoglobin and
basic blood biochemistry screen. Patients taking warfarin are asked to
stop 5 days preoperatively, and aspirin is discontinued 10 days preoperatively. Diabetic patients are asked to continue their normal regimen. All
patients are allowed to eat and drink in moderation up to 2 hours before
their operation.
Following admission, patients walk into the operating room, where
the operation site is shaved. All patients are monitored by pulse oximetry and cardiac monitor if they have a history of cardiac disease or are
more than 70 years of age. An anesthetist is present for all patients
over 70 and for any patients with a history of cardiopulmonary or
cerebrovascular disease. Prophylactic antimicrobial agents are not given
45
routinely unless specifically indicated.32,
Anesthesia

Local anesthesia consists of 0.5% lignocaine and 0.25% bupivacaine

administered by local-layer infiltration (Fig. l),supplemented by intravenous benzodiazepine sedation (midazolam, 1 mg/mL, up to 10 mg). The
authors have not found regional nerve blocks of value.
Operative Technique

Initial Dissection
A transverse skin crease incision is deepened down to the external
oblique aponeurosis. Before incising this layer, the infiltration needle tip

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KURZER et a1

Figure 1. Subcutaneous infiltration of the length of the wound with local anesthetic prior to
skin preparation and towelling up.

is inserted and 5 mL to 10 mL of local anesthetic solution is injected and

allowed to flood the space below the external oblique (Fig. 2). After
opening the external oblique, more local anesthetic is infiltrated into the
mesentery of the cord and the area of the pubic tubercle and the deep
ring (Fig. 3), with care taken to avoid the inferior epigastric vessels. The
spermatic cord is mobilized in the usual wayz0
Hernia Sac

Direct sacs are inverted and imbricated using a nonabsorbable suture to flatten the posterior wall (see Figs. 6 and 7). Indirect sacs are
dissected from the cord up to extraperitoneal fat and then either excised
or inverted (Fig. 4). High dissection, rather than high ligation, is the
important feature of this stage. In the authors early experience, they
routinely excised indirect sacs and carried out a plastic repair of a
dilated deep ring. The authors were, however, impressed with Rutkows
technique, having seen it in 1994, and since that time, if the deep ring is
widened (Gilbert classification 2 or 3), a cone of mesh is inserted and
anchored, usually superolaterally and sometimes inferiorly to the inguinal ligament by two or three nonabsorbable sutures (Fig. 5). Inguinoscrotal sacs are transected in the canal and the proximal portion closed and
dealt with as mentioned earlier, whereas the mouth of the distal portion
is left undissected but wide open.

THE LICHTENSTEIN REPAIR

1031

Figure 2. Instilling 5-10 mL of dilute local anesthetic beneath the unopened external
oblique aponeurosis-flooding technique.

Onlay Mesh

The posterior wall is covered by an appropriate size and shape of

polypropylene mesh onlay (initially 6 cm x 10 cm), slit longitudinally
partway from lateral to medial to give a one third lower leaf and two
thirds upper leaf (see Fig. 8). It must be sufficiently wide to ensure that
it can be tucked well up under the superior leaf of the external oblique
and that its lower edge reaches or overlaps Pouparts ligament. The
inferomedial corner of the mesh is secured to the soft tissues overlying
the pubic tubercle using a double-needle polypropylene suture. It is
critically important to obtain a 2-cm or 3-cm overlap here, and numerous
authors have commented on the mesh pulling away medially as a cause
of recurrence.l(5 , 1 3 , 55 The inferior border of the mesh is attached to
Pouparts ligament with a loose continuous suture, and the superior
edge is similarly attached high up under the superior leaf of the external
oblique aponeurosis. One or two sutures are used where the tails of the
mesh cross lateral to the cord and are placed to ensure a snug fit around

1032

KURZER et a1

Figure 3. Infiltrating local anesthetic near the neck of an indirect sac and the region of the
deep ring.

the cord (see Fig. 9). The wound is closed in a routine fashion with
absorbable deep and subcuticular sutures.
Points of Technique
The important technical features of the operation include:
Local anesthesia
Ensuring an adequate size of mesh
Using a mesh cone to deal with a dilated deep ring
Attachment of the inferomedial corner of the mesh well overlapping
the pubic tubercle
Attaching the mesh with a loose continuous suture; tight suturing
leads to tissue necrosis and pain
Overlapping the lateral tails of the mesh to provide a snug fit
around the cord
Encouragement of early mobilization

THE LICHTENSTEIN REPAIR

1033

Figure 4. Inverting the unopened indirect sac, having freed the margins of the neck
completely at the deep ring.

Postoperative Management

Patients are given a diclofenac suppository and then walk from

the operating table into the recovery area, where they are given light
refreshments. They are discharged approximately 2 hours later, only after
they have passed urine, with detailed written postoperative instructions.
Postoperative analgesia consists of diclofenac suppositories (self-administered), 12 hourly, and oral Co-proxamol tablets. Patients are encouraged to telephone their surgeons directly with any immediate concern.
All patients are telephoned the day following their operation and examined at the center within 1 month. They remove the dressing themselves
6 days after operation.
BRITISH HERNIA CENTRE RESULTS

The authors recently reported the results of 3175 inguinal hernia

repairs in 2906 consecutive patients.21A total of 97% of the patients were

1034

KURZER et a1

Figure 5. Placing a mesh cone in the deep ring. Inset: the cone in the deep ring.

men, and the age range was 15 to 92 years. Just 480 patients (17%) were
older than 70 years. There was a broad range of occupations and lifestyles; 31% were office workers, 37% were manual laborers, and 32%
were retired.
Postoperative Complications

No cases of urinary retention were reported despite the fact that

one third of patients were retired, with symptoms of prostatism present
in the majority. Because every patient is telephoned the day after operation, any urinary problems would be reported. Sixty-three patients (2%)
developed a wound hematoma, and two of these were drained. The
total number of wound infections was 45 (1.3%), and all responded to
appropriate antimicrobial treatment. Three abscesses required draining,
but all resolved, and no cases of chronic sinus formation occurred.
Testicular swelling occurred in 31 patients (1%),all of which settled.
Postoperative pain persisted for up to 2 months in 36 patients (1%)and

THE LICHTENSTEIN REPAIR

1035

Figure 6. Inverting a direct sac.

for up to 1 year in 13 patients (0.4%).There were 14 recurrences, with a

follow-up period from 18 months to 5 years.

Return to Work
A postal questionnaire was returned by 2523 patients (87%), reporting their return to work or normal activities. The overall median
time was 8 days, with responses centered around 7 to 10 days. When
the return-to-work data were analyzed by work type, it was found,
perhaps not surprisingly, that manual workers took slightly longer (median of 12 days) than did desk workers or retirees (median of 7-8 days,
both groups) to return to normal routine. When the results were further
stratified according to the year in which the operation was carried out,
the authors observed that the recovery times had been shortening over
the 4 years of the study. This effect was most obvious in the manual
workers, in whom the median recovery time decreased from 14 days in
the first 12-month period to 8 days in the fourth 12-month period. This

1036

KURZER et a1

Figure 7. Imbrication/plication of a direct sac to flatten the floor of the inguinal canal.

effect may be explained by the authors encouragement of patients to

return to work and resume normal activities as early as possible as the
experience has increased. The authors have also found that attitudes of
patients and their doctors seem to be slowly changing from the traditional view of time required off work after inguinal hernia repair, and
patient preoperative expectation has certainly been shown to be an
important factor in determining this.3Some degree of technical improvement in the way the authors carried out the procedure may also have
played a part.

REPORTS OF OPEN TENSION-FREE MESH REPAIR

Martin and Shureth3I used Marlex mesh routinely in 299 primary
inguinal hernia repairs over a 10-year period, with no reported wound
infections and no recurrences after a follow-up of 1 to 10 years. Barnes4
used Marlex mesh for all groin hernias in 227 patients over an 11-year
period. During the last year of the study, 90% of operations were carried

THE LICHTENSTEIN REPAIR

1037

Figure 8. Mesh placement and attachment. It must be wide enough to ensure that it can
be tucked well up under the superior leaf of the external oblique, and that its lower edge
reaches or overlaps Pouparts ligament. It is attached with a loose continuous suture. The
inferomedial corner of the mesh (not shown) is secured to the soft tissues overlying the
pubic tubercle with a 2- or 3-cm overlap.

out on an outpatient basis. He noted high patient satisfaction and low

postoperative pain. With a mean follow-up of 6 years, he found three
recurrences. A similarly favorable experience using polypropylene mesh
for all adult inguinal hernias (745 repairs) over 10 years was reported
by Cappozzi and colleague^.^ They were able to follow up 651 patients
(mean follow-up, 5 years) and found four recurrences. Any theoretical
objections to mesh, such as foreign-body rejection or untreatable infection that would require mesh removal, were not substantiated.
want^^^ reported his experience with 1252 tension-free hernioplasties in 1076 patients with a follow-up of 1 to 6 years. Local anesthesia
was used in 97% of repairs, although he did not adhere rigidly to the
technique that Lichtenstein had described. Instead he combined it, when
appropriate, with a modification of Gilberts sutureless hernioplasty
and Rutkow and Robbins technique, i.e., he placed a cone-shaped

1038

KURZER et a1

Figure 9. Tails of the mesh encircling the spermatic cord. One or two sutures are placed
where the tails of the mesh cross lateral to the cord to ensure a snug fit. (Courtesy of
Gillian Lee.)

mesh plug in a dilated deep ring when an indirect hernia was present
and often did not use a continuous suture to attach the edges of the
mesh. Wantz made several technical observations gleaned from his vast
experience. Like Lichtenstein, he felt that the onlay of mesh should be
as wide as possible so as to extend beyond the superior border of the
myopectineal orifice, and with a large overlap he felt that a suture in
the pubic tubercle was rendered superfluous. Six hernias recurred (0.5%)
early on in his experience, all within a few months of the primary
procedure, suggesting a technical error. In the four indirect recurrences,
the primary hernia had also been indirect, and these were subsequently
dealt with by inserting a mesh plug in the deep ring. Wantz observed
that his recurrence rate of 0.5% using onlay mesh improved on the
1.3% recurrence rate he had ultimately obtained with the Shouldice
hernioplasty.%
Concerns regarding the routine use of mesh for all groin hernias
have, however, recently been expressed by Schumpelick and colleagues,4l who caution that little is known about its long-term (> 20

THE LICHTENSTEIN REPAIR

1039

years) biologic compatibility. They recommend that mesh be used only

when the transversalis fascia is unusually weak, or in cases of multiple
recurrences, in which case the prosthesis should be placed in the preperitoneal plane. They also advise that the use of mesh should be restricted
to controlled clinical trials.
Nevertheless, many surgeons probably have used prosthetic mesh
almost routinely for many years to reinforce their primary groin hernia
although many have not written about it.
COMPARISON OF OPEN TENSION-FREE MESH WITH
CONVENTIONAL REPAIR

A retrospective comparison of 182 onlay mesh repairs and 170

Bassini repairs carried out by surgeons in training found five recurrences
(3.3%) in the mesh repair group and 13 (11.5%) in the Bassini
Friis and LindahP3 reported a randomized trial comparing open suture
repair with onlay mesh; however, patients were selected rather than
randomized, the choice of a particular procedure was frequently left up
to the operating surgeon, and both large inguinoscrotal and small hernias were excluded. Although 5% of hernias recurred in the onlay mesh
group, this was a better result than in those 100 patients having a
conventional repair in whom absorbable sutures had been used, where
the recurrence rate after only 2 years was 15%!
Recent studies have tended to report only short-term outcomes,
such as pain and return to work. Thus, a small, randomized study of 64
patients found no significant difference in postoperative pain between
those having a sutured repair or an onlay mesh.42A single-blind randomized trial of 105 patients comparing open mesh with Shouldice repair,
again looking only at short-term outcomes, found no significant difference with regard to postoperative pain, duration of analgesic use, and
time to resume full normal a~tivities.~
Kux and c0lleagues,2~confining their study to patients aged more
than 60 years and at high risk of recurrence, compared 107 Shouldice
repairs with 102 Lichtenstein onlay mesh repairs. The postoperative
pain medication required was significantly reduced in the mesh group,
although it was felt that both types of repair yielded good results when
performed correctly. Similar favorable experiences are being reported
from other institution^.'^, 38
COMPARATIVE TRIALS OF OPEN MESH AND
LAPAROSCOPIC REPAIR

True comparative studies are difficult to carry out. Nowadays, many

patients (and surgeons!) have already decided which operation they
prefer, and randomization without too many exclusions is difficult. If
the decision is made to carry out the open repair under general anesthesia (though this is not a true Lichtenstein repair), then patients unfit for

1040

KURZER et a1

general anesthesia will be excluded. Paradoxically these are the patients

who often benefit most in terms of quality of life from having their
hernia repaired. It is also almost impossible for the patient or assessing
doctor not to know which group he was in, thus precluding any form
of double blind trial. The inevitable bias that can result may markedly
influence patient expectation^.^^, 57
Wilson and colleagues58compared a Lichtenstein repair (unstated
whether under local or general anesthesia) with laparoscopic mesh repair in 242 patients and found no significant difference in operating time
between the techniques. Although no significant difference was found
in visual analogue pain scores between the groups, the use of oral
analgesia was greater in the open mesh group; the authors speculated
that this may have been related to their longer hospital stay. Return to
normal activities and return to work were significantly shorter in patients having laparoscopic repair (7 and 10 days, respectively) than in
those undergoing open repair (14 and 21 days).
One of the best-designed trialsMrandomized 100 patients to either
laparoscopic or open tension-free repair and carried out the open tension-free repair under local anesthesia in virtually all cases. Operative
and hospitalization times were not significantly different between the
groups, and several objective outcome measures were used to assess
the patients postoperatively. On average, patients having laparoscopic
unilateral repairs returned to work in 9 days compared with 17 days for
those having open repairs, and stratifying the patients by type of work
heightened these differences in those doing intense physical labor; however, this had to be balanced against the increased cost and complexity
of laparoscopic repair.8
Brooks study of 100 patients was of particular interest because it
reported the results obtained by a single surgeon using both techniques:
thus controlling for the single greatest variable in hernia surgery. The
laparoscopic group, having general anesthesia, required significantly
more unplanned postoperative admissions (28.0%versus 3.5%)for problems such as urinary retention, vomiting, or unexpected pain. Use of
narcotic analgesia and duration of analgesia were similar between the
groups, although patients in the open group required less oral analgesia.
The time to return to normal activities or full-time work was less in the
laparoscopic group (7.5 versus 11.8 days). This more rapid return to
work did not, however, compensate for the cost differences between the
two procedures. Brooks concluded that the open approach is appropriate
for the greatest number of patients, is the least expensive, and has the
fewest short-term and long-term complications.
Although it is generally recognized that the operative costs of laparoscopic repair can be more than twice those of open mesh repair, one
study calculated the total additional costs to the community in terms of
time lost from work.16 With 38 patients randomized to one of two
groups, Heikinnen and colleagues16found that postoperative pain was
less in the laparoscopic group, that their median time to return to work
was also less, and that more complications occurred in the patients

THE LICHTENSTEIN REPAIR

1041

having open repair. Although operating costs were higher for laparoscopy, because of the increased time off work for patients who underwent
open repair, they found that in their hands laparoscopic repair was
marginally less expensive. These conclusions, however, were of course
not applicable to the one third or more patients who were not at work.
Horeyseck and colleague^'^ carried out a prospective study comparing 100 inguinal hernias treated by transabdominal preperitoneal patch
(TAPP) with 108 hernias treated by an open Lichtenstein technique. No
significant difference was found between the groups regarding duration
of the operation, postoperative complications, and return to work. Only
one surgeon carried out the TAPP procedure, which was found to be a
difficult technique to master compared with onlay mesh, and which
gave an early recurrence rate of 8%. In contrast, 11 surgeons, including
trainees, used the Lichtenstein technique, with a zero recurrence rate.
The overall efficiency (i.e., ease of use and speed of learning), combined
with the obvious economic benefits of the open repair, led this unit to
abandon the laparoscopic method. Filipi and colleagues'* randomized
53 patients to undergo either TAPP or Lichtenstein repair. Visual analogue scales were used to assess postoperative pain, which was less in
the laparoscopic group but did not reach statistical significance. Return
to normal activity was also slightly faster in this group; however, no
difference was found between the groups regarding analgesic use or
length of hospital stay.
Four surgeons operating over a 12-month period randomized 120
patients for a comparison of endoscopic groin hernia repair with open
anterior mesh repair.59All operations were performed with the patient
under general anesthetic, and all were given prophylactic antimicrobials
and subcutaneous heparin. A 33% wound hematoma rate and 13%
incidence of scrota1 hematoma were fairly high and doubtless related to
this routine anticoagulation. General anesthesia, the delay in mobilization, and the high incidence of complications (e.g., hematoma or urinary
problems) presumably all contributed to the increased stay in hospital
in the open mesh group. If one defines the Lichtenstein procedure, as
described by Amid,' as a tension-free onlay mesh repair with the patient
under local anesthesia with immediate ambulation and discharge, this
was not a Lichtenstein repair. Therefore, the authors agree with their
conclusions that in their hands significant short-term disadvantages
existed for open tension-free repair.
The study by J a m and colleague^^^ over 9 years was complex and
ambitious, comparing four groups: (1) open anterior mesh, (2) open
nonmesh, (3) open preperitoneal mesh, and (4) laparoscopic mesh in
more than 800 patients. Their conclusion was that the open mesh repair
was the most technically straightforward and yielded the lowest recurrence rate without increasing the risk for infection, other complications,
or the length of hospital stay.
A two-centre randomized controlled trial, comparing short-term
outcomes and costs after laparoscopic or Lichtenstein repair in 400
patients with groin hernia has recently been reported by Wellwood and

1042

KURZER et a1

his colleagues. This detailed study was well executed, although there
was inevitable patient selection as those unfit for general anaestesia were
excluded; many of those exclusions would have been suitable for open
repair with local anaesthetic. Patients undergoing open repair were
found to have more local complications (bruising, swelling, prolonged
pain) than the laparoscopic group, and a higher than expected incidence
of wound infection (11%vs. 3%). The open group also took longer to
return to work, particularly when comparing bilateral repairs. The total
cost per patient of day case laparoscopic repair was estimated at 355
(about $500) more than open repair under local anaesthetic. This figure
may however underestimate the cost differential when compared with
dedicated outpatient units with their reduced number of operating room,
anesthetic and recovery room staff. The authors concluded that laparoscopic repair had short term clinical advantages compared with open repair.
Length of hospital stay, time to return to work or normal activities,
and even amount of analgesics consumed are, however, often related to
subjective factors, such as patient expectation and physician recommendations. W e ~ l e has
r ~ ~convincingly demonstrated how patients preoperative opinion of when they would return to work influenced the time of
their subsequent return to full activities. He has also pointed out how
this inherent bias, as he calls it, may have been operative in a comparative trial of laparoscopic versus open nylon darn (not tension-free mesh)
repair of inguinal hernia.48The time of return to work in the group
having an open operation was 28 days compared with 14 days in the
endoscopic group, but the instruction to patients of when to resume full
normal activities was given not by the surgeon but by the referring
primary care physician.
When short-term patient outcomes are comparable between patients
either having open (under local anesthetic) or laparoscopic repair, or
even if they are marginally better in those having laparoscopic repair,
surgeons with experience in both still express an overall preference for
open repair.61This group has recently reported the results of a prospective study comparing three groups of 80 patients each, randomized to
having laparoscopic repair, open mesh repair, or a Shouldice repair, with
virtually all of the patients in the latter two groups operated on under
local anesthesia.6oThe open mesh group in fact underwent a plugand-patch repair using Rutkows technique (rather than a Lichtenstein
repair). The overall incidence of postoperative complications did not
differ significantly between any of the groups, and no recurrences occurred after a mean follow-up of 25 months. Postoperative pain, analgesic requirements, limitation of daily activity, and return to work were
the same for laparoscopic and open mesh repair but were significantly
lower in both of these groups compared with patients having a Shouldice
repair, whereas the cost of materials used in the operating room during
laparoscopic repair was approximately 10 times higher than in either of
the open repairs. The conclusion was that open tension-free mesh repair
was the most promising technique of the three when all factors were

THE LICHTENSTEIN REPAIR

1043

taken into account, offering the same excellent patient comfort as the
laparoscopic repair but with far less expense.
Variations in Technique

Surgeons are innovative and change the way they do a particular

procedure to suit the given circumstances. The use of a mesh cone35or
plug to deal with a dilated deep ring is one obvious example of an
improvement on a classic Lichtenstein onlay mesh. Similarly, not using
a continuous suture but simply tacking the piece of mesh (particularly
if it is lying flat) at four or five points at its periphery is another.55Other
surgeons have varied the shape of the prosthesis and altered the way
the tails of the mesh encircle the spermatic cord. These minor variations
are inevitable and are a form of continuous improvement; however, they
are acceptable only if the basic principles of the operation (see discussion
under Points of Technique) are not violated.
Nowadays, patients are frequently assured by their surgeons that a
Lichtenstein mesh repair will be done, but too often some or most of
Lichtensteins methods and requirements are altered or omitted. General
anesthesia instead of local, a Bassini-like suturing of muscle and tendon
overlaid by a small piece of mesh, hospitalization and immobility in
place of home and early activity, and instructions to avoid work, lifting,
or driving for 6 to 10 weeks all combine to produce a corrupted version
of this operation: When interpreting the results of a Lichtenstein repair,
these factors must be borne in mind.
Assessing the Success of the Operation

Despite relatively short follow-up periods, the outstanding feature

of all open tension-free mesh repairs is the exceedingly low recurrence
rate now being widely reported. Many of these are large series in their
thousands, often the results from specialized hernia centers, and are at
least as good as those reported from the Shouldice Hospital; however,
judging the success of hernia operations solely in terms of recurrence
rates is too limiting.35It is clear that other factors need to be taken into
consideration when assessing the choice of operation, and Rutkow has
suggested several outcome measures. These should include ease of operation, reproducibility by junior staff, likelihood and severity of possible
complications, postoperative discomfort, time of return to work and
daily activities, and the financial costs involved.38,39
SUMMARY

The description of the Lichtenstein tension-free mesh repair 12 years

ago opened a new era in groin hernia repair. Without the risk for severe

1044

KURZER et a1

morbidity, it can be readily carried out on patients previously considered

unsuitable for hernia repair. Fears of complications related to mesh
implantation have proved to be without foundation. As a local anesthetic
outpatient procedure without the need for complex and expensive instrumentation, combined with the ability of patients to return to work
in a short time, overall costs can be kept to a minimum without in any
way compromising the safety or the long-term success of the procedure.
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Address reprint requests to

Martin Kurzer, FRCS
British Hernia Centre
87 Watford Way
London NW4 4RS
United Kingdom