Irving L. Lichtenstein

The tension-free hernioplasty

Since the first true herniorrhaphy was performed by Bassini over 100 years ago, all modifications and surgical techniques have shared a common disadvantage: suture line tension. The anatomic, physiologic, and pathologic characteristics of hernia recurrence are examined. The prime etiologic factor behind most herniorrhaphy failures is the suturing together, under tension, of structures that are not normally in apposition. With the use of modern mesh prosthetics, it is now possible to repair all hernias without distortion of the normal anatomy and with no suture line tension. The technique is simple, rapid, less painful, and effective, allowing prompt resumption of unrestricted physical activity.

Critical scrutiny of the open “tension-free” hernioplasty

Tension-free hernioplasty is rapidly gaining worldwide acceptance. Since June 1984, 3,125 consecutive adult male primary inguinal hernias have been repaired by employment of an open tension-free prosthetic repair without approximation of the margins of the defect. Since the original publication of our technique in the 1989 February issue of The American Journal of Surgery, we have encountered four recurrences. These recurrences were caused by technical errors early in our experience and have since been corrected. The purpose of this paper is to bring those errors to the attention of surgeons, as well as to suggest certain modifications to further simplify the operation. Three of the recurrences occurred at the pubic tubercle and were caused by placing the mesh in juxtaposition to the tubercle. This error has since been corrected by overlapping the mesh at the pubic bone. One recurrence was caused by disruption of the lower edge of the mesh from the shelving margin of Pouparts ligament. The error here was utilization of a patch that was too narrow and therefore under tension. It became apparent that a wider patch, fixed in place with an appropriate degree of laxity, was required.

Local anesthesia for inguinal hernia repair step-by-step procedure.

ObjectiveThe authors introduce a simple six-step infiltration technique that results in satisfactory local anesthesia and prolonged postoperative analgesia, requiring a maximum of 30 to 40 mL of local anesthetic solution. Summary Background DataFor the last 20 years, more than 12,000 groin hernia repairs have been performed under local anesthesia at the Lichtenstein Hernia Institute. Initially, field block was the mean of achieving local anesthesia. During the last 5 years, a simple infiltration technique has been used because the field block was more time consuming and required larger volume of the local anesthetic solution. Furthermore, because of the blind nature of the procedure, it did not always result in satisfactory anesthesia and, at times, accidental needle puncture of the illoinguinal nerve resulted in prolonged postoperative pain, burning, or electric shock sensation within the field of the ilioinguinal nerve innervation. MethodsMore than 12,000 patients underwent operations in a private practice setting in general hospitals. ResultsFor 2 decades, more than 12,000 adult patients with reducible groin hernias satisfactorily underwent operations under local anesthesia without complications. ConclusionsThe preferred choice of anesthesia for all reducible adult inguinal hernia repair is local. It is safe, simple, effective, and economical, without postanesthesia side effects. Furthermore, local anesthesia administered before the incision produces longer postoperative analgesia because local infiltration, theoretically, inhibits build-up of local nociceptive molecules and, therefore, there is better pain control in the postoperative period.

Biomaterials for abdominal wall hernia surgery and principles of their applications

This article focuses special attention on the porosity, cellular permeability and molecular permeability of biomaterials and their effect on infection, host tissue incorporation and seroma formation when mesh is used for the repair of abdominal wall hernias. Furthermore, the general principles of the application of biomaterials, regardless of the technique used for their employment, is discussed.ZusammenfassungDiese Arbeit befaßt sich mit der Durchlässigkeit sowohl zellulär als auch molekular von Biomaterialien und ihre Auswirkungen auf Infektion, Serombildung und Akzeptanz in Empfängergewebe bei der Implantation von Netzmaterialien in der Hernienchirurgie. Darüber hinaus werden die allgemeinen Prinzipien der Anwendung von Biomaterialien unabhängig von der jeweiligen Implantationstechnik diskutiert.

Simplified repair of femoral and recurrent inguinal hernias by a “plug” technic

Abstract A new technic for the repair of femoral and recurrent inguinal hernias is presented. The use of a polypropylene mesh “plug” to occlude the defect corrects the hernia without extensive dissection. A five year experience has verified the efficacy of this simplified procedure.

The Cause, Prevention, And Treatment Of Recurrent Groin Hernia

At present, groin hernia repair is associated with a 10% recurrence rate. Despite innumerable modifications of the Bassini technique, this depressing figure remains essentially unimproved. This article documents the two major reasons for failure and presents techniques that are simple, can be performed under local anesthesia in an outpatient setting, allow patients to return home within hours of their surgery, encourage rapid return to unrestricted activity, and are associated with a recurrence rate approaching 0%.

Herniorrhaphy. A personal experience with 6,321 cases.

The results of 6,321 consecutive herniorrhaphies have been reported. Over 20 percent of the cases were referred recurrences when first seen. Ninety-one percent of the patients were followed from 2 to 14 years, with an overall recurrence rate of 0.7 percent. A low recurrence rate was not unfavorably affected by the prompt resumption of activity postoperatively. Some recurrences are unavoidable; however, it is essential to accept the dictum that all hernias can be cured.

Cause and prevention of postherniorrhaphy neuralgia: A proposed protocol for treatment

The cause of severe and persistent neuralgia after hernia surgery is due to sensory nerve crushing. An operative technique has been described that prevents inadvertent crushing or division of the sensory nerves to the groin. With persistent postoperative pain, the offending nerve is usually difficult to identify. A protocol has been suggested to differentiate ilioinguinal from genitocrural causalgia. When the particular nerve is incriminated, its division will ordinarily cure the problem.

Exploding the myths of hernia repair

Sacred prinicples guiding surgical repair of groin hernias have remained basically unaltered since their inception. This may explain the failure of results to improve significantly over the years. Ten hallowed concepts have been critically analyzed in the light of modern technology and contemporary experience. Although challenging established surgical traditions invariably invites debate, it is essential to scientific progress.

The Lichtenstein open “tension-free” mesh repair of inguinal Hernias

All standard methods of hernia repair involve suturing together tissues which are not normally in apposition. This violates the basic surgical principle that tissue must never be approximated under tension and thus accounts for an unacceptable number of failures. A total reinforcement of the inguinal floor with a sheet of suitable biomaterial and the employment of a “tension-free” technique is a more effective approach. Since June 1984, 4,000 primary inguinal hernias have been repaired on an outpatient basis and under local anesthesia at the Lichtenstein Hernia Institute by the open “tension-free” technique using Marlex mesh. The patients were followed from 1 to 11 years by physician examination. The follow-up rate was 87%. There were four recurrences. The causes of recurrence and how to avoid them are herein discussed. Three of the recurrences occurred at the public tubercle and were caused by placing the mesh in juxtaposition to the tubercle. This error has since been corrected by overlapping the mesh at the public bone. One recurrence was caused by a disruption of the lower edge of the mesh from the shelving margin of Pouparts ligament. The error here was the utilization of a patch that was too narrow and therefore under tension. It became apparent that a wider patch, fixed in place with an appropriate degree of laxity, was required.