The Lichtenstein Technique

Schwartz
A mesh prosthesis with a minimum size of 15x 8 cm for an adult is positioned over the
inguinal floor. The medial end is rounded to correspond to the patient's anatomy and
secured to the anterior rectus sheath a minimum of 2 cm medial to the pubic tubercle
(Fig. 36-21). Either nonabsorbable or long-acting absorbable suture should be used. The
wide overlap of the pubic tubercle is important as pubic tubercle recurrences are
commonly seen with other operations. The suture is continued in a running locking
fashion laterally, securing the prosthesis to either side of the pubic tubercle (not into it),
and then the shelving edge of the inguinal ligament. The suture is tied at the internal ring.

Lichtenstein tension-free hernioplasty. A. The medial border of the prosthesis has been
sutured to the anterior rectus sheath 2 cm medial to the pubic tubercle. The same suture is
continued in a running locking fashion to secure the inferior edge of the prosthesis to the
inguinal ligament. A second suture is shown approximating the inferior surface of the
superior tail to the inferior surface of the inferior tail and the inguinal ligament after the
prosthesis was split laterally to accommodate the cord structures. B. and C. A lateral view
of the repair. The hernia is reduced and the defect approximated merely for the
convenience of keeping the hernia contents out of the inguinal canal during the repair.
This adds no strength as the repair relies entirely on the overlying prosthesis. EOA =
external oblique aponeurosis; P = prosthesis; HD = hernia defect.

Maingot
The Lichtenstein inguinal hernia repair was the first pure prosthetic, tension-free repair to
achieve consistently low recurrence rates in long-term outcomes analysis. This operation
begins with the incision of the external oblique aponeurosis, and the isolation of the cord
structures. Any indirect hernia sac is mobilized off the cord to the level of the internal
ring. At this point, a large mesh tailored to fit along the inguinal canal floor is placed so
that the curved end lies directly on top of the pubic tubercle. The mesh patch extends
underneath the cord until the spermatic cord and the tails of the mesh patch meet laterally.
Here, an incision is made in the mesh, and the cord is inserted between the tails of the
mesh, thereby creating a new, tighter, and more medial internal ring. The tails are sutured
together with one nonabsorbable stitch just proximal to the attachment of the cord. The
mesh is then sutured in a continuous or interrupted fashion to the pubic tubercle
inferiorly, the conjoined tendon medially, and the inguinal ligament laterally.

Sabiston
In the Lichtenstein repair, a piece of prosthetic nonabsorbable mesh is fashioned to fit the
canal. A slit is cut into the distal, lateral edge of the mesh to accommodate the spermatic
cord. There are various preformed, commercially available prostheses available for use.
Monofilament, nonabsorbable suture is used in a continuous fashion beginning at the
pubic tubercle and running a length of suture in both directions toward the superior aspect
above the internal inguinal ring to the level of the tails of the mesh. The mesh is sutured
to the aponeurotic tissue overlying the pubic bone medially, continuing superiorly along
the transversus abdominis or conjoined tendon. The inferolateral edge of the mesh is
sutured to the iliopubic tract or the shelving edge of the inguinal (Poupart's) ligament to a
point lateral to the internal inguinal ring. At this point, the tails created by the slit are
sutured together around the spermatic cord, snugly forming a new internal inguinal ring.
The ilioinguinal nerve and genital branch of the genitofemoral nerve are placed with the
cord structures and are passed through this newly fashioned internal inguinal ring.

Figure 44-6 The Lichtenstein tension-free hernia repair. A, This procedure is performed by careful dissection of the inguinal canal. High ligation of an
indirect hernia sac is performed, and the spermatic cord structures are retracted inferiorly. The external oblique aponeurosis is separated from the
underlying internal oblique muscle high enough to accommodate a 6- to 8-cm wide mesh patch. Overlap of the internal oblique muscle edge by 2 to 3 cm
is necessary. A sheet of polypropylene mesh is fashioned to fit the inguinal canal. A slit is made in the lateral aspect of the mesh, and the spermatic cord is
placed between the two tails of the mesh. B, The spermatic cord is retracted in the cephalad direction. The medial aspect of the mesh overlaps the pubic
bone by approximately 2 cm. The mesh is secured to the aponeurotic tissue overlying the pubic tubercle using a running suture of nonabsorbable
monofilament material. The suture is continued laterally by suturing the inferior edge of the mesh to the shelving edge of the inguinal ligament to a point
just lateral to the internal inguinal ring. C, A second monofilament suture is placed at the level of the pubic tubercle and continued laterally by suturing
the mesh to the internal oblique aponeurosis or muscle approximately 2 cm from the aponeurotic edge. D, The lower edges of the two tails are sutured to
the shelving edge of the inguinal ligament to create a new internal ring made of mesh. The spermatic cord structures are placed within the inguinal canal
overlying the mesh. The external oblique aponeurosis is closed over the spermatic cord. (Reproduced from Arregui ME, Nagan RD [eds]: Inguinal
Hernia: Advances or Controversies? Oxford, England, Radcliffe Medical, 1994.)

Batas2 precordial
Atas : sela iga 3 kiri
Bawah : arkus costae kiri
Kiri : linea midclavicula kiri
Kanan : line parasternal kanan