03.07.2020

Ventral hernia repair according to Lichtenstein. Stages and technique of hernioplasty of inguinal hernia with Lichtenstein mesh. What are the stages of hernioplasty?

The disadvantage of this technique is the severe pain syndrome that occurs due to suturing of deep fascia and muscles and compression of nerve trunks. After hernia repair according to C.B. McVay patients can start working no earlier than 3–4 weeks.

The introduction of multilayer plastic methods has reduced the number of relapses, especially when operating on complex and recurrent hernias. The disadvantage of these methods is the complexity of the surgical technique and its traumatic nature, which prevents their widespread use.

A common disadvantage of all autoplastic methods of treating inguinal hernias is the tension of the tissues used to close the defect, which leads to disruption of microcirculation and the development of trophic disorders in them. This becomes the main reason for relapse.

Repair of inguinal hernias using mesh allografts (Lichtenstein method, insertion method, Stopp method)

As noted, in the 60s of the XX century. Polymer materials began to be used in hernia surgery. However, due to the large number of complications when using nylon, nylon, and dacron allografts (wound suppuration, formation of seromas, inflammatory infiltrates, hematomas, fistulas), these techniques were not used for some time. F.C. Usher (1959) was one of the first to develop a fundamentally new plastic material based on polypropylene mesh. These meshes (Marlex mesh, Bard, USA), when used as a plastic material, unlike nylon and nylon, were not rejected and did not cause serious complications. American surgeon I.L. Lichtenstein (1986) developed and tested a method for the treatment of inguinal hernias based on the use of mesh allografts made of polypropylene. Unlike

methods E. Bassini, E.E. Shouldice, C.B. McVay, plastic surgery of inguinal hernias using the Lichtenstein method is performed without tension on tissues (aponeurosis, muscles, ligaments) by suturing a mesh graft into the hernia defect. It has been proven experimentally and clinically that in the absence of tissue tension, ischemic and degenerative changes do not occur in them, which prevents the occurrence of recurrent hernias. Polypropylene meshes were usually fixed in such a way as to strengthen the posterior wall of the inguinal canal. Quickly growing granulation tissue, the polypropylene mesh becomes an integral part of the abdominal wall and reliably prevents the development of hernias. Currently, plastics with polymer materials are experiencing a rebirth (I.L. Lichtenstein, 1989; L.M. Nyhus, 1995; R. Stoppa, 1995; P. Amid, 2000).

An important aspect of inguinal hernia surgery is the economic aspect: the time the patient loses ability to work after the operation, the time he spends in the hospital, the cost of the operation and anesthesia. Thus, the period of complete social and labor rehabilitation after autoplasty of an inguinal hernia is 4–6 months. In 1966, the American surgeon Lichtenstein first drew attention to the importance of the period of postoperative disability. Gradually, new criteria for assessing the effectiveness of inguinal hernia repair were introduced and legalized not only by the absence of recurrence for a certain time, but also by the time of postoperative disability, the severity of postoperative pain syndrome, and swelling of the spermatic cord.

Since 1984, the Lichtenstein Clinic began to perform surgical interventions using a new technique called “free tension”. The key point of this method was the use of alloplasty. In the mid-90s, this technique began to be introduced in various clinics around the world (A.I. Gilbert,

1992; A.G. Shulman, 1992; R.E. Stoppa, 1993; G.E. Wantz, 1993; Kingsnorth, 1994). Currently, data from more than 70 surgeons who performed 22,300 operations using the Lichtenstein method have been published.

According to the literature and our experience, it can be argued that the Lichtenstein method has become one of the modern optimal methods for treating inguinal hernias (P.K. Amid, 1999; I.M. Rutkov, 1999; G.E. Wantz et al., 1999; V.V. Grubnik et al., 1999). Its main advantages: simplicity, low cost, good immediate and long-term results.

Technique of inguinal hernia repair according to Lichtenstein.

Surgery is usually performed under local anesthesia. A skin incision is made from the pubic tubercle laterally, parallel to the inguinal ligament. Due to the fact that when performing an operation according to the Lichtenstein technique, there is no need for a wide dissection of the muscles and transverse fascia, the skin incision does not exceed 5–6 cm. After the skin incision and dissection of the subcutaneous fatty tissue, the aponeurosis of the external oblique abdominal muscle and the outer ring of the inguinal canal are opened . The upper layer of the aponeurosis of the external oblique abdominal muscle is mobilized from the underlying internal oblique abdominal muscle by 3–4 cm (Fig. 81). Sufficient mobilization of the external oblique aponeurosis is dually important because it allows visual identification of the iliohypogastric nerve and creates a large space for implantation of the mesh allograft. The spermatic cord is then mobilized, while avoiding possible damage to blood vessels and nerves. If the hernia is oblique, then a hernial sac is found among the elements of the spermatic cord. If the hernial sac is small, after isolation it is immersed in the abdominal cavity. For inguinal-scrotal hernias, the hernial sac is sutured

bases, bandaged and excised. In case of direct hernias, it is invaginated into the abdominal cavity. With large inguinoscrotal hernias, complete separation of the hernial sac from the elements of the spermatic cord is quite traumatic, in some cases requiring removal of the testicle into the wound, accompanied by damage to the vessels of the spermatic cord, which leads to ischemic orchitis and testicular atrophy in the future. Therefore, in such cases, a number of authors (G.E. Wantz, 1992, 1999; P.K. Amid, 1999) suggest not completely isolating the hernial sac, but crossing and ligating it at the level of the internal ring of the inguinal canal. To prevent testicular hydrocele from occurring, the anterior wall of the hernial sac is partially excised, and the distal part of the hernial sac is left in situ. After isolating the hernial sac, the inguinal canal is carefully examined, and through the Borgos space, the femoral canal is examined for the presence of femoral hernias.

For hernial orifice repair, most authors use polypropylene mesh. A patch of a certain shape (Fig. 82) measuring 6 x 12 cm is cut out of the mesh. Some authors (P.K. Amid, 1999; Kark, Kurzer, 1999) believe that the allograft should not be less than 8–10 x 16 cm.

Taking the cord upward, the rounded end of the mesh is fixed with a monofilament thread to the pubic tubercle (to the superior pubic ligament) (see Fig. 82). This is a decisive moment that ensures the reliability of all plastic. We consider it mandatory to capture the superior pubic ligament with the first 2–3 sutures in order to prevent the development of a femoral hernia. The mesh is fixed to the inguinal ligament with 4–5 interrupted sutures or a continuous suture. The last suture on the inguinal ligament should be located lateral to the internal inguinal ring.

Along the outer edge of the mesh, an incision is made parallel to the inguinal ligament, forming two ends: wide (2/3) at the top and

narrower (1/3) at the bottom (Fig. 83). The upper, wide end is passed over the spermatic cord, it crosses and is located on top of the narrow one (Fig. 84). Thus, the spermatic cord passes through the window in the mesh (Fig. 85). Both ends of the mesh are sewn together with interrupted sutures. The “window” in the mesh should have a diameter of about 1 cm. Then the superomedial edge of the mesh is fixed with 4–5 interrupted sutures to the internal oblique and transverse abdominal muscles and to the rectus sheath (see Fig. 84, 85). An important criterion for the quality of plastic surgery is the wrinkling of the mesh after the end of its fixation stage, which ensures tension-free plastic surgery. Crossing the two ends of the mesh to form a “window” creates a configuration similar to the natural one formed by the transversalis fascia, which is considered responsible for the integrity of the internal ring normally. Excess mesh along the lateral edge is trimmed, leaving at least 5–7 cm of mesh behind the inner ring. The remainder is brought under the aponeurosis of the external oblique muscle, which is then sutured over the cord with a non-absorbable end-to-end suture without tension. After the mesh has grown into granulation tissue, intra-abdominal pressure is evenly distributed over the entire area of the mesh. The aponeurosis of the external oblique muscle firmly holds the mesh in place, acting as an external support when intra-abdominal pressure increases.

Bard has proposed a special mesh graft design that greatly simplifies the operation using the Lichtenstein technique. The graft is made of a monofilament polypropylene mesh and consists of an inner round shape of small diameter and an outer ellipsoidal layer of large dimensions welded to it (Fig. 86). Plastic surgery using such a graft is carried out as follows: the lower mesh plate of the graft

inserted into the inner ring of the inguinal canal and straightened in the preperitoneal tissue. The outer plate is fixed to the superior pubic and inguinal ligaments and muscles. Performing hernioplasty using this mesh allograft is significantly simplified and takes no more than 15–20 minutes.

For small oblique inguinal hernias, Lichtenstein proposed strengthening the internal ring of the inguinal canal by introducing a mesh rolled into a “roller” (Fig. 87). This technique was first proposed for the repair of femoral hernias, and then it began to be used for inguinal hernias. A rolled mesh graft (in American literature this technique is called “plug”) is fixed with several sutures in the inguinal canal, preventing the hernia from coming out (Fig. 88). Studies have shown that in the human body, the size of a rolled mesh graft can be reduced by up to 75%. The latter can cause migration of the graft with the formation of a recurrent hernia. Such serious complications as perforation of the bladder or intestines as a result of transplant migration have also been described (P.K. Amid, 1997). Therefore, Bard currently produces special mesh grafts in the form of a pyramid or shuttlecock (Fig. 89). The top of such a graft is inserted into the hernial canal, and the petals of the base are fixed to the walls of the inguinal canal with several sutures. From above, the area of the inguinal canal is additionally covered with a sheet of mesh graft. A similar operation is widely used and promoted by American surgeons: Ira M. Rutkov and Alan W. Robbins (1993, 1999), who performed more than 2000 hernia repairs using the “plug” technique. Despite the fact that the authors report excellent immediate and long-term results of such operations, a number of surgeons (P.K. Amid, 1999; S.E. Stock,

1995, 1999; G.E. Wantz, 1999) believe that the “plug” technique is advisable to use for small femoral and oblique inguinal hernias. Even the latest design of branded mesh grafts in the form of shuttlecocks is not without drawbacks: when the connective tissue grows, the shuttlecock shrinks

And its diameter decreases by 10–15% (P.K. Amid et al., 1997), which may be the reason for the migration of the latter and the development of recurrent hernia. Therefore, the technique of inguinal hernia repair using mesh grafts in the form of shuttlecocks (“plugs”) is not widely used at present.

After surgery, patients are placed on the operated area with an ice pack for 1–2 hours and given analgesics, and after 6–8 hours they are allowed to get up and walk. As a rule, patients are discharged 6–12 hours after surgery. In the first 4 days after surgery, patients are prescribed non-narcotic analgesics (analgin, baralgin, tramadol, paracetamol). It should be noted that after hernioplasty according to Lichtenstein, the pain syndrome is significantly less pronounced than after classical herniotomy according to the method of Bassini, Shouldice, McVey, Girard. This is due to the fact that there is no tissue tension, constant tension of the muscles and ligaments in the groin area. The mesh graft quickly grows into granulation tissue; its complete ingrowth occurs within 3–6 weeks. after operation. Therefore, patients should be advised to limit physical activity in the first 2 weeks. Starting from the 3rd week, patients can begin active physical work and sports.

Observation by a surgeon is required in the first 10–14 days after surgery for early detection of postoperative complications (hematomas, seromas in the operation area, suppuration of the postoperative wound). During this period, special attention should be paid to

condition of the testicle, the presence of scrotal edema, detection of ischemic orchitis and, as a consequence, testicular atrophy. To study the long-term results of surgical interventions, patients should be examined by a surgeon after 3, 6, 12 months. after surgery, as well as in the long term (3 years, 5 years or more). When examining in the long term, special attention is paid to the presence of relapse, the severity of pain syndrome (chronic pain in the groin area, pain during exercise, urination, radiating pain along the nerves, pain during urination), as well as the appearance of hernias (inguinal, femoral) on the opposite side. side. A thorough study of the immediate and long-term results allows us to objectively assess the effectiveness of various types of hernioplasty.

Results of hernioplasty using the Lichtenstein method.

The Lichtenstein technique is currently widely used in clinics in the USA and Western Europe. The results of this method were most thoroughly studied at the Institute of Herniology, created by Liechtenstein himself. Liechtenstein's student P.K. Amid, at the first international congress on ambulatory surgery (Venice, 1999), reported the results of 5,000 hernioplasties using the Lichtenstein method performed over the past 10 years. The age of the operated patients ranged from 19 to 86 years. 44% of patients had oblique inguinal hernias, 43.1% had direct inguinal hernias, 12.5% had both direct and oblique inguinal hernias, and a combination of inguinal and femoral hernias – 5.8%. 27% of patients were operated on for bilateral inguinal hernias. 22% were overweight. Almost all patients (98.7%) were operated on under local anesthesia. The average duration of the operation is 30–45 minutes; 99% of patients were operated on as an outpatient basis and were discharged 3–6 hours after surgery.

Having studied the immediate and long-term results of Lichtenstein operations in 5000 patients, P.K. Amid (1999) noted a very low percentage of postoperative complications - not exceeding 1-2%. Recurrent hernias were observed in only 4 (0.08%) patients. Analysis of these cases showed that in 3 patients relapse occurred due to the use of small-sized meshes, in 1 – as a result of poor graft fixation. P.K. Amid indicates the need to use meshes of sufficient size (should overlap the Hesselbach triangle by 3–4 cm). It must be remembered that according to recent studies (A.G. Shulman, 1995; P.K. Amid, 1997), when a mesh graft grows with connective tissue, the size of the graft decreases by approximately 20%. The second important factor in the success of the operation is the careful fixation of the mesh to the superior pubic and inguinal ligaments, as well as to the muscles in the area of the internal inguinal ring. When the mesh graft is installed correctly, intra-abdominal pressure presses it against the anterior abdominal wall and thus provides additional fixation. If the size of the mesh is not large enough and it is poorly fixed, then in the early postoperative period it may become displaced, it may curl into a “roller,” which will inevitably lead to the development of a relapse. With proper technical performance of hernioplasty using the Lichtenstein method, as a rule, no relapses are observed.

From 1994 to 2000, 282 patients (263 men and 19 women) were operated on for inguinal hernias in our clinic. In 74 patients, hernioplasty was performed on both sides. 74 patients underwent surgery for recurrent hernias (Table 4). The patients' ages ranged from 16 to 86 years; the average age is 42.2 years.

Table 4. Nature of surgical interventions performed

Patients with	According to the Lichtenstein method		Autoplastic methods

	Unilateral	Double sided	Unilateral	Double sided

Primary

Recurrent

A total of 356 hernia repairs were performed, of which 209 were performed using the Lichtenstein method, 147 using autoplastic methods (according to Bassini, Girard-Kimbarovsky, Postemski, McVay). 175 patients (62%) had concomitant pathologies: coronary heart disease with varying degrees of circulatory failure, hypertension, varicose veins of the lower extremities, chronic nonspecific lung diseases, obesity, and urinary tract diseases.

Patients with hernias did not undergo special preoperative preparation. Most patients arrived at the clinic on the day of surgery. The method of anesthesia was chosen depending on the size of the hernial protrusion, the general condition of the patient, the presence of concomitant pathology and the need to perform simultaneous surgical interventions. The operation was performed under local anesthesia in 220,220 patients (78%), under spinal anesthesia - 14, under general anesthesia - 48.

According to the Lichtenstein method given above, 163 patients were operated on. During 43 surgical interventions, the plastic “patch” was supplemented by the use of an “insert” - “plug” (see Fig. 89), which was a shuttlecock made of mesh, 5 x 2 cm in size. The “insert” was inserted into the expanded internal inguinal ring and fixed to the transverse fascia with 4–5 interrupted sutures. Then plastic surgery was performed according to the method described above.

Early diagnosis of a hernia can be the key to success, since advanced cases are most often accompanied by complications. If you have been diagnosed with a hernia in the groin area, you may be offered Liechtenstein hernioplasty to remove it.

The essence of the operation

This surgical intervention is the “gold standard” for removing a hernia in the inguinal canal area, which is carried out without tension on the adjacent tissues. During the operation, new polymers are used, and recently composite meshes have gained wide popularity, which in turn have a resolving effect and promote a rapid regeneration process. The Liechtenstein operation is currently gaining enormous popularity due to its ease of execution and extremely low percentage of relapses and complications in all clinics in the world that specialize in hernia removal. Various videos on the operation and its results are available on the Internet.

Stages of implementation

The Lichtenstein operation is performed in all clinics under spinal anesthesia. After administration of anesthesia, a skin incision is made, not exceeding 5 cm, lateral to the pubic tubercle, parallel to the inguinal ligament.

The next step of the surgeon is to dissect the fiber and the aponeurosis of the external oblique muscle itself, down to the very superficial ring of the inguinal canal. The aponeurosis of the external oblique muscle is separated from the spermatic cord to the inguinal ligament, the spermatic cord is taken on a holder, then the hernia is isolated from the spermatic cord, followed by immersion into the depths of the abdominal cavity.

This is followed by the application of the mesh (the threads with which it is attached are identical in chemical composition to it). With the first suture, the medial edge of the mesh used is sutured to the periosteum of the pubic bone, then with a continuous suture the lower edge of the mesh is sutured to the inguinal ligament. The last suture secures the edges of the mesh behind the spermatic cord, while they are sutured to the inguinal ligament, which allows the diameter of the spermatic cord to be accurately determined.

The last step is suturing the aponeurosis of the external oblique muscle and cosmetic suture of the skin, both sutures are continuous. Complications after this type of surgery are minimal, but the risk remains.

Indications and contraindications for surgery

The indication for Lichtenstein plastic surgery is the presence of any type of hernia in the patient in the inguinal canal area. This surgical intervention is a universal means of combating hernias in our time. If you have been diagnosed with this disease, you need to remember that not a single folk remedy can get rid of it, only timely surgery can correct the current situation.

Like any other surgical intervention, the Lichtenstein method imposes a number of restrictions on patients:

The main contraindication is the patient’s individual intolerance to general anesthesia, which is mandatory for this operation, otherwise he risks complications.
In the case of a large inguinal hernia, the doctor has the right to refuse to perform this intervention, because the risk of nerve damage increases, which can lead to loss of sensitivity in the area.
If a person has blood diseases, for example, hemophilia, any operation is contraindicated for him. No drug can quickly and efficiently clot blood; in case of large blood loss, death is guaranteed.
If the patient has chronic heart and lung diseases, laparoscopy cannot be performed. During surgery, the load on the heart increases, which can aggravate an existing disease.
When the hernia is strangulated, the operation is postponed or replaced with another.
In the case of an acute abdomen of unknown etiology, the hernia cannot be removed. To do this, the doctor must establish an accurate picture of what is happening, whether there is a concomitant disease that could provoke the current condition.
In case of intestinal obstruction, this operation is prohibited.
If the patient has had surgery on the lower abdomen, any operation of this kind cannot be performed. This is done so as not to subject one area of the body to heavy loads, which has not yet fully recovered.

If the patient does not comply with these restrictions, he will suffer complications that will require additional time.

Rehabilitation period after surgery

The entire course of the operation to remove an inguinal hernia is carried out exclusively under general anesthesia, and the time it takes is about two hours, it depends on the degree of complexity of the hernia. In this regard, the patient does not require a long hospital stay; the patient stays in the ward for a day so that the doctor can observe how he recovers from anesthesia.

The hernia does not recur, the pain subsides after the third day, which helps the patient return to normal life (this can be seen in the video before and after surgery).

Sutures are removed on the day of discharge. It is not recommended to undergo strong physical activity for a month; the patient can return to work at any time. If you study the statistics in detail, you get a result that cannot but rejoice: complications in patients do not exceed 1-2%, recurrence of the hernia is only (0.08%).

Positive sides

The positive aspects of surgery to remove an inguinal hernia using the Lichtenstein method are:

Possible complications are observed only in 3-5% of patients; in all others, rehabilitation is within normal limits.
After removal of the inguinal hernia, a less pronounced pain syndrome is observed.
This technique contributes to a shorter rehabilitation period.
The patient experiences a low degree of discomfort long after the operation.
If a person is allergic to general anesthesia, then the doctor can perform this surgical intervention under local anesthesia, the patient will also not feel pain.
The operation to remove an inguinal hernia using the Lichtenstein method is the easiest to perform.

Disadvantages of plastic surgery according to Liechtenstein

Hernioplasty according to Liechtenstein has significant disadvantages:

There is a high risk of accidental injury to the inguinal nerves, which leads to partial or complete loss of innervation and sensation in the operated area.
There are scar changes in the area where the spermatic cord passes through the installed implant; the consequence of this is a disruption of the blood supply to the testicular tissue, which leads to its atrophy and disruption of endocrine function.
It is possible to intersect the circular ligament of the uterus, which guarantees its prolapse, and this, in turn, is characterized by severe pain, bleeding and even difficulty urinating.
With this operation there is a risk of infection, although doctors are doing everything in their power, suppuration and inflammatory processes are possible. If the doctor suspects a patient has inflammatory processes or an infection, he prescribes a whole course of antibiotics to prevent this.

Liechtenstein plastic surgery cost

The price for this operation in our country starts from 20 thousand rubles, it largely depends on the quality of the services provided, the length of stay in the hospital and the qualifications of the doctor. The outcome and the risk of complications directly depend on it. An important factor in pricing is the region of the country. Remember that you should not skimp on health, because it is given once in a lifetime and should be taken care of.

Lichtenstein operation for inguinal hernia

Removing a hernia is a fairly common operation. It is called hernioplasty and can be tension or non-tension. The most famous method for removing an inguinal hernia today was proposed back in the 70s of the 20th century. This is a non-tension plastic according to Liechtenstein. The operation is performed using a fairly simple method and does not require special preparation. A special mesh endoprosthesis is used to close the hernial orifice.

When to resort to the Lichtenstein technique

Hernia repair with Lichtenstein plastic surgery is performed for hernias of the inguinal canal. This method is considered universal today, however, like any surgical intervention, this operation may not always be performed.

Restrictions and contraindications

Poor blood clotting
Intestinal obstruction,
Symptoms of an acute abdomen of unknown origin,
strangulated hernia,
Serious cardiovascular pathologies.

Such operations are carried out as planned. If emergency intervention is required, then another type of operation is performed first, and Lichtenstein hernia repair is done later, as soon as possible. An absolute contraindication may be low blood clotting, when any operations are practically impossible. The presence of severe heart failure or other heart diseases may be an obstacle to surgery. In such cases, you should compare the possible risks and choose the option that is least dangerous for the patient. Surgery and anesthesia adversely affect the condition of the heart and its activity, which can lead to a significant deterioration in the patient’s general condition.

Pros and cons of the method

Like any treatment method, Lichtenstein inguinal hernia repair has both advantages and disadvantages that must be taken into account when choosing a surgical option. The characteristics of the individual patient’s body must be taken into account, so undesirable consequences can be avoided.

Advantages of Liechtenstein plastic surgery

Low risk of postoperative complications (3-5%),
Fast rehabilitation.

Cons of the operation

Risk of damage to the inguinal nerves,
Possibility of cicatricial changes and impaired blood supply to the testicle,
The likelihood of dissection of the circular ligament of the uterus, leading to its pathologies,
Risk of infection of the surgical wound.

How is the operation performed?

The Lichtenstein operation for inguinal hernia is the so-called gold standard of tension-free hernioplasty. It is performed using a mesh implant, which strengthens weakened tissue in the area of the hernial orifice. In this way, it is possible to close the gap in the tissue through which the hernial sac falls out.

The Lichtenstein plastic technique involves the use of an endoprosthesis in the form of a section of mesh made of polymers or composite materials. The most modern implants partially or completely dissolve in the body some time after their installation. Their composition is such that they affect surrounding tissues and stimulate their regenerative properties. In most cases, the final result of the operation can be considered the strengthening of tissue in the area of the former hernia and the absence of relapses.

Stages of intervention

There is no need for special preparation for this type of surgical treatment. The hernioplasty scheme is quite simple and does not require careful preparation. It can be performed under general anesthesia, but spinal anesthesia is most often used. This method of pain relief is the most gentle and quite effective. It allows the patient not to feel pain during surgery, and the risks and negative impacts are minimal.

The Lichtenstein procedure involves making a small skin incision in the groin area. Next, the surgeon dissects the aponeurosis of the external oblique muscle, which is separated from the spermatic cord. A hernial sac is isolated and placed in a natural place deep in the abdominal cavity. This can be done without additional effort for small or medium-sized hernias. When the hernia is large, the usual release of the hernial sac can be traumatic, so additional manipulations are required. In case of inguinal-scrotal hernia, it is necessary to suture the hernial sac at the base, bandage it and partially excise it. Once the sac is removed, the surgeon examines the inguinal and femoral canals to determine the presence of other pathologies.

The next stage is plastic surgery of the hernial orifice, namely, the application of a mesh. To do this, a patch of the required size is cut out. For inguinal hernias, the average size of the finished implant section is approximately 6X10 cm. Threads of the same composition are used to secure the mesh. Fixation of the implant begins from the pubic tubercle. If everything is done efficiently and correctly with the capture of the superior pubic ligament, then all plastic surgery of the inguinal canal according to Lichtenstein, as a rule, is successful. Next, fixation is performed to the inguinal ligament and to the side of the deep inguinal ring. To pass the spermatic cord, a small incision is made in the mesh.

An important indicator of high-quality implant fixation is the wrinkling of the mesh after completion of the work. This means that the plastic is performed without tension, which provides good tissue support.

The last stage is suturing the aponeurosis and performing a cosmetic suture.

What happens after surgery

The mesh installed during the operation grows with granulation tissue and is firmly held by the aponeurosis, acting as a support for the internal organs. Complete ingrowth of the mesh lasts 3-6 weeks. In the first two weeks, restriction of physical activity and activity is required, during which time the patient needs to be monitored by a surgeon. From about the third week, you can return to normal life, having previously agreed on the load with your doctor.

Operation Liechtenstein

Video: Indirect inguinal hernia, hernia repair operation

If the inguinal hernia is oblique, then a hernial sac is found in the elements of the spermatic cord. If the bag is small, it is immersed in the abdominal cavity. For an inguinal-scrotal hernia, it is sutured near the base, bandaged and excised. In case of direct hernias, it is invaginated into the abdominal cavity. With large hernias, sufficient release of the hernial sac is quite traumatic, in some cases requiring removal of the testicle into the wound, and is accompanied by damage to the vessels of the spermatic cord, which leads to ischemic orchitis and testicular atrophy in the future. Therefore, in such cases, a number of authors suggest not to completely isolate the hernial sac, but to cross and ligate it at the level of the internal ring of the inguinal canal. To avoid testicular hydrocele, the anterior wall of the hernial sac is partially excised, leaving the rest of the hernial sac. After isolating the sac, the inguinal canal is carefully examined, and through the Borgos space, the femoral canal is examined for the presence of femoral hernias.

Video: Operation Liechtenstein

The mesh after the Lichtenstein operation quickly grows in granulation; complete ingrowth occurs in 3-6 weeks. Therefore, patients are recommended to have a certain limitation of physical activity after Lichtenstein surgery in the first 2 weeks. Starting from the third, patients begin physical work and sports.

Video: TAPP for recurrent inguinal hernia

Having studied the results of Lichtenstein’s operations on 5,000 patients, his student R.K. Amid noted a very low percentage of postoperative complications - not exceeding 1-2%. Recurrent hernias were observed in only 4 (0.08%) patients.

Operation Liechtenstein

Lichtenstein in the 70s proposed the concept of surgery for inguinal hernias based on the principle of non-tension of tissues using the implantation of a mesh endoprosthesis.

Hernialloplasty technique according to Lichtenstein

This method is quite simple to perform and does not require very careful preparation.

The Lichtenstein operation is usually performed under spinal anesthesia. A skin incision is made from the pubic tubercle laterally, parallel to the inguinal ligament.

When performing the Lichtenstein operation, there is no need for wide muscle dissection; the skin incision does not exceed 5-6 cm.

After making a skin incision and dissecting the subcutaneous tissue, the aponeurosis of the external oblique muscle is dissected to the very superficial ring of the inguinal canal.

The upper layer of the aponeurosis is mobilized from the underlying muscle over a distance of 3-4 cm.

Sufficient mobilization of the aponeurosis has a dual significance, as it allows visual identification of the iliohypogastric nerve and creates a large space for implantation of the mesh allograft. The spermatic cord is then mobilized, but possible vascular damage and nerve damage must be avoided.

Taking the cord upward, the rounded end of the mesh is fixed with a monofilament thread to the pubic tubercle. This is a decisive moment that ensures the reliability of all plastic. It is mandatory to capture the superior pubic ligament with the first 2-3 sutures to prevent a femoral hernia. The mesh is fixed to the inguinal ligament with 4-5 interrupted sutures or a continuous suture. The last suture should be located lateral to the deep inguinal ring.

Along the outer edge of the mesh, an incision is made parallel to the inguinal ligament, forming two ends: wide (2/3) at the top and narrower (1/3) at the bottom.

The upper, wide end is passed over the spermatic cord, it crosses and is located on top of the narrow one. Thus, the spermatic cord passes through the window in the mesh. Both ends of the mesh are sewn together with interrupted sutures. The “window” in the mesh should have a diameter of about 1 cm. Then the superomedial edge of the mesh is fixed to the muscles with 4-5 interrupted sutures. An important criterion for the quality of plastic surgery is the wrinkling of the mesh after the end of its fixation stage, which ensures tension-free plastic surgery. Crossing the two ends of the mesh to form a “window” creates a configuration similar to the natural one formed by the transversalis fascia, which is considered responsible for the integrity of the internal ring normally. Excess mesh along the lateral edge is cut off, leaving at least 5-7 cm of mesh behind the inner ring. The remainder is brought under the aponeurosis of the external oblique muscle, then sutured over the cord with a non-absorbable end-to-end suture without tension.

After the mesh has grown into granulation tissue, intra-abdominal pressure is evenly distributed over the entire area of the mesh. The aponeurosis firmly holds the mesh in place, acting as an external support when pressure increases in the abdominal cavity.

The mesh after the Lichtenstein operation quickly grows into granulations; complete ingrowth occurs in 3-6 weeks. Therefore, patients are recommended to have a certain limitation of physical activity after Lichtenstein surgery in the first 2 weeks. Starting from the third, patients begin physical work and sports.

Observation by a surgeon is required in the first two weeks after surgery for early detection of postoperative complications (hematomas, seromas in the operation area, suppuration of the postoperative wound).

Plastic surgery according to Lichtenstein for inguinal hernia

The Lichtenstein operation is a variant of plastic surgery for inguinal hernia with strengthening of the hernial orifice with a mesh implant. This hernia repair technique is performed on children and adult patients more often than others, but has both advantages and disadvantages.

The Lichtenstein operation for inguinal hernia is the “gold standard” of surgery for removing a defect in the groin without tension on the natural tissues surrounding the hernial sac. During the operation, polymer or composite meshes are used, which have the ability to dissolve over time and promote the healing of injured tissue.

How is hernioplasty performed?

The operation has a small number of contraindications and risks; special preparation for surgery is not required. Inguinal hernia repair according to Lichtenstein is performed under spinal anesthesia; less commonly, general anesthesia is used.

Creating access to the hernial sac - an incision of about 5 cm is made.
Dissection of the aponeurosis of the oblique muscle to the inguinal ring.
Fixation of the aponeurosis with a holder.
Isolation of the hernia, return of organs to their anatomical place.
Installation of surgical mesh.
Suturing the aponeurosis, applying absorbable sutures.

The Lichtenstein method is suitable for any type of groin hernia. This is one of the main options for getting rid of a hernia with minimal risk of recurrence. When other techniques involve suturing the defect with surrounding tissue, Lichtenstein hernioplasty uses a mesh that prevents re-protrusion, which is the main advantage of the method.

The criterion for the quality of the operation will be the wrinkling of the mesh implant, this indicates that the plastic surgery was performed without tissue tension, which guarantees good support of the hernial orifice.

Contraindications for surgery

Limitations and contraindications for plastic surgery according to Liechtenstein:

intolerance to anesthesia may become an obstacle to the operation; pain relief in this case will result in complications;
in case of a strangulated hernia, an emergency open operation is performed, the plastic surgery is postponed or completely cancelled;
when there are symptoms of an acute abdomen, surgery is not performed until the exact clinic and cause of the serious condition are clarified;
if the hernia is large, some surgeons refuse to perform Lichtenstein surgery, predicting recurrence after repair;
Previous abdominal surgery is a contraindication to plastic surgery with mesh implant fixation;
chronic heart disease and bleeding disorders will also limit the choice of surgical treatment;
an absolute contraindication would be intestinal obstruction.

Advantages of plastic surgery according to Liechtenstein

The operation has become widespread due to the absence of a tension factor in the tissues surrounding the hernia, which has reduced the number of patients with relapse after surgical treatment. This technique also eliminates many postoperative complications associated with the cardiovascular system.

What other advantages does inguinal canal plastic surgery according to Lichtenstein have:

reduction in cases of postoperative complications by 10 times;
relatively short rehabilitation period;
absence of severe pain after surgery;
the possibility of performing plastic surgery under anesthesia without anesthesia;
simple technique, which reduces the risk of surgeon error.

Disadvantages of the method

Among the disadvantages of Lichtenstein plastic surgery, surgeons identify the following factors:

the risk of injury and damage to the nerves in the groin, which may result in loss of sensitivity of the tissues in the operated area;
there is always a risk of infection, but after surgery, doctors do everything possible to prevent purulent inflammation, and much depends on the patient;
women are at risk of damage to the uterine ligament, which will lead to its prolapse; this complication is characterized by bleeding and severe pain;
cicatricial changes can cause ischemia, testicular atrophy and dysfunction of the glands.

The likelihood of complications and recurrence of the hernia will depend on the accuracy of the diagnosis and the professionalism of the doctor, especially when it comes to operating on young children.

The cause of re-development of the disease can be the fixation of an implant that is not suitable in size and poor-quality treatment of the hernial sac. In addition to the recurrence of the inguinal hernia, there are other equally alarming consequences of the operation.

Possible complications

Before surgery, the surgeon always warns about the risk of complications:

wound infection and suppuration of sutures;
damage to organs in the hernial sac and trauma to surrounding tissues;
inaccurate fixation of the implant with its subsequent migration;
recurrence of the disease, development of a postoperative hernia;
complications after administration of an anesthetic drug;
hemorrhage with the formation of a hematoma.

Rehabilitation

Most complications can be prevented by following the rules of prevention in the early postoperative period. After plastic surgery performed under general anesthesia, the initial recovery lasts 2 days, then the patient is discharged home, but is observed by the surgeon for 2 weeks. In the first 14 days after plastic surgery, a gentle diet is prescribed, eliminating constipation and bloating. The patient should refrain from physical activity and wear a groin bandage regularly while performing daily activities.

In the early period after surgery, changes in the groin area can be observed:

swelling of the skin in the perineum;
darkening in the area of the surgical suture;
numbness or sensitivity;
minor bruising.

These symptoms are a normal reaction of the operated area to hernia repair. To ensure that the condition remains within normal limits, it is important to take precautions.

It is recommended not to drive for the first week, and it is also important to rule out conditions that would cause severe coughing or sneezing. For several days after plastic surgery, the scar should be protected from water. In the late period after surgery, the doctor may prescribe physical therapy and physiotherapy.

Methods of surgical removal of a hernia: tension and non-tension hernioplasty

One of the most popular tension-free operations is hernia removal using the Lichtenstein method. The stages of hernia repair include closing the weak spot of the anterior abdominal wall with the patient's own tissue.

Tension-free hernioplasty or hernia repair with alloplasty is preferable, since after such an intervention there are practically no relapses. And the use of a modern approach and high-quality implants allows us to minimize the risk of complications.

Hernioplasty using the Lichtenstein technique

Hernioplasty according to Lichtenstein is used for inguinal, femoral, umbilical hernias, as well as protrusions of the white line of the abdomen. During the intervention, the surgeon opens the hernial sac, then checks its contents and places it back into the abdominal cavity. After this, the main stage of the operation is carried out - plastic surgery of the hernial orifice. It is the quality of this stage that determines whether the patient will ever have a recurrence of the hernia or not.

The video shows how hernioplasty is performed according to Liechtenstein:

The operation is performed under spinal anesthesia or general anesthesia. The main advantage of this type of intervention is minimal trauma to healthy tissue. Almost all methods of hernioplasty involve an incision in the muscles, but the Lichtenstein technique does not allow such an incision. The synthetic mesh is sutured to the aponeurosis, which is located above the muscles.

The implant is sutured to the hernia gate with a reserve, eliminating the tension of the patient’s own tissues. After performing the Lichtenstein operation, the doctor performs a high-quality stop of bleeding and carefully sutures the wound in the inguinal canal area.

Due to the fact that the incision does not exceed 6 centimeters, and cosmetic sutures are used to close the wound, after recovery a small scar remains in the inguinal canal area.

Lichtenstein hernioplasty can be performed either open or laparoscopically. In this case, to access the protrusion, several small incisions, 1-2 centimeters long, are made. A laparoscopic camera with a light source is inserted into these incisions, the image from which is transmitted to a monitor in front of the surgeon. Surgical instruments are also introduced, with which the doctor performs the same stages of hernioplasty as with open access.

Laparoscopic hernioplasty according to Lichtenstein has a number of invaluable advantages over traditional intervention. Due to small incisions, a smaller area of healthy tissue is damaged, which ensures a rapid recovery period. The intensity of pain in the early postoperative period is less pronounced, and complications during laparoscopy rarely occur.

Types of hernia repair for the treatment of inguinal hernia

To treat an inguinal hernia using tension-free hernioplasty, the Lichtenstein operation is used. In cases where it is necessary to use a tension version of the intervention, Bassini's inguinal canal plastic surgery is most often used. Indications for its use are newly formed direct and oblique inguinal protrusions of small size. The main difference between this method of hernioplasty and the others is the plastic surgery of the inguinal canal by suturing the internal oblique and transverse abdominal muscles and transverse fascia to it.

Hernia repair according to Shouldice is the most acceptable from an anatomical point of view. With this operation, the posterior wall of the inguinal canal is strengthened and a deep opening is formed. In order to reduce the hernial orifice, a circular excision of a section of the inguinal canal is performed, followed by suturing with a double continuous suture.

Hernia repair according to Postemsky is performed to remove the inguinal canal. Thus, after the intervention there is completely no risk of re-development of an inguinal hernia on the operated side. Since the spermatic cord passes through the inguinal canal, during the intervention it is sutured to the muscle groups of the anterior abdominal wall and is located in the subcutaneous fat.

Other types of hernioplasty

The method by which herniotomy will be performed is selected individually for each patient. There are many options for hernia formations and ways to remove them. Each method has its own advantages and disadvantages.

However, if you choose the right option for the operation, then only the advantages will be realized.

For example, an option such as hernia repair according to Martynov is used only for oblique inguinal hernias. Mayo hernioplasty is used for umbilical protrusions and formations of the white line of the abdomen.

Hernia repair according to Sapezhko is a variant of tension hernioplasty of an umbilical hernia. A special feature of the intervention is the removal of the navel followed by plastic surgery of the umbilical ring using the rectus abdominis muscles.

Hernia repair according to Duhamel and according to Krasnobaev also refers to tension methods of plastic surgery of the inguinal canal. They are used in children after 6 months. These operations provide good strengthening of the hernial orifice and the absence of relapse. Moreover, tension hernioplasty in children is preferable to non-tension hernioplasty. This is due to the fact that as the child grows, the implant is stretched and must be replaced after some time.

Recovery after hernia repair

The recovery period after treatment of a hernia, including after hernia repair according to Liechtenstein, proceeds favorably if the operation was carried out without complications and the patient complies with all medical prescriptions. Of course, the duration of rehabilitation varies depending on the treatment option. As for hospitalization, after laparoscopic surgery the patient is hospitalized for 2-3 days, and after open surgery - for 5-8 days.

Successful rehabilitation after hernia repair is achieved through the following measures:

Avoid lifting heavy weights;
Limit physical activity;
Follow a diet;
To refuse from bad habits;
Do physical therapy.

Optimally selected and high-quality hernia repair ensures a good postoperative result without relapses or complications.

How is hernioplasty performed?

Operation stages:

Creating access to the hernial sac - an incision of about 5 cm is made.
Dissection of the aponeurosis of the oblique muscle to the inguinal ring.
Fixation of the aponeurosis with a holder.
Isolation of the hernia, return of organs to their anatomical place.
Installation of surgical mesh.
Suturing the aponeurosis, applying absorbable sutures.

The criterion for the quality of the operation will be the wrinkling of the mesh implant, this indicates that the plastic surgery was performed without tissue tension, which guarantees good support of the hernial orifice.

Contraindications for surgery

Limitations and contraindications for plastic surgery according to Liechtenstein:

intolerance to anesthesia may become an obstacle to the operation, pain relief in this case will result in complications;
with a strangulated hernia emergency open surgery is performed, plastic surgery is postponed or completely cancelled;
when there are symptoms of acute abdomen the operation is not performed until the exact clinic and cause of the serious condition are clarified;
with a large hernia size some surgeons refuse to perform Lichtenstein surgery, predicting relapse after plastic surgery;
previous abdominal surgery is a contraindication to plastic surgery with mesh implant fixation;
chronic heart disease, bleeding disorders will also limit the choice of surgical treatment;
an absolute contraindication would be intestinal obstruction.

Advantages of plastic surgery according to Liechtenstein

What other advantages does inguinal canal plastic surgery according to Lichtenstein have:

reduction in cases of postoperative complications by 10 times;
relatively short rehabilitation period;
absence of severe pain after surgery;
the possibility of performing plastic surgery under anesthesia without anesthesia;
simple technique, which reduces the risk of surgeon error.

Disadvantages of the method

Among the disadvantages of Lichtenstein plastic surgery, surgeons identify the following factors:

risk of injury and nerve damage in the groin which may result in loss of tissue sensitivity in the operated area;
risk of infection there is always, but after surgery doctors do everything possible to prevent purulent inflammation, and much depends on the patient himself;
Women are at risk of damage to the uterine ligament, which will lead to its descent; this complication is characterized by bleeding and severe pain;
scar changes can cause ischemia, testicular atrophy and dysfunction of the glands.

The likelihood of complications and recurrence of the hernia will depend on the accuracy of the diagnosis and the professionalism of the doctor, especially when it comes to operating on young children.

Possible complications

Before surgery, the surgeon always warns about the risk of complications:

wound infection and suppuration of sutures;
damage to organs in the hernial sac and trauma to surrounding tissues;
inaccurate fixation of the implant with its subsequent migration;
recurrence of the disease, development of a postoperative hernia;
complications after administration of an anesthetic drug;
hemorrhage with the formation of a hematoma.

Rehabilitation

In the early period after surgery, changes in the groin area can be observed:

swelling of the skin in the perineum;
darkening in the area of the surgical suture;
numbness or sensitivity;
minor bruising.

These symptoms are a normal reaction of the operated area to hernia repair. To ensure that the condition remains within normal limits, it is important to take precautions.

Hernioplasty is a surgical method for eliminating hernias. It can be tensioned, and this method is good for newly formed and small-sized protrusions. And it can be tension-free; this is an invasive way to eliminate a hernia using mesh implants. One of the frequently used methods of tension-free hernia repair is Lichtenstein plasty. The operation is performed for inguinal hernias and does not require special preparation of the patient.

Inguinal hernia: definition, description

Protrusion of the organs of the abdominal cavity beyond the boundaries of their anatomical location through the inguinal canal is called an inguinal hernia. In surgical gastroenterology, of all pathological protrusions of the abdomen, about 80% are inguinal hernias. Men are much more susceptible to the disease than women.

A hernia consists of elements, each of which has its own name.

The hernial sac is an area closely connected to the wall of the peritoneum, which emerges through weak spots in the serous membrane covering the walls of the abdominal cavity.
Hernial orifices are defective places in the abdominal wall through which the hernial sac with its contents protrudes.
Hernial contents are usually movable organs of the abdominal cavity.
Shell of hernia. For a direct inguinal hernia - the transverse fascia, for an oblique - the membrane of the spermatic cord or round ligament of the uterus.

Protrusions are classified according to anatomical features and are divided into straight, oblique, and combined. For inguinal hernias, the ICD 10 code is K40. This class includes all types of protrusion of organs through an elongated gap in the lower abdominal wall.

Surgical methods for treating inguinal hernia

The main and radical method of treating hernias is surgery. The use of a bandage is a dubious measure and is used only if the operation cannot be performed.

It is preferable that the operation be extremely simple and accessible, low-traumatic and reliable. Manipulation includes surgical removal and repair of damage in the abdominal wall. Reconstruction of the integrity of the abdominal wall and closure of the hernial injury can be done using an aponeurosis (own tissue) or a non-biological graft.

The most effective is the use of a non-tension invasive method using a mesh prosthesis. The hernial orifice is reinforced with a polypropylene mesh from the inside, which serves as a frame and an obstacle to the re-extrusion of organs. In surgery, there are several methods of performing an operation: according to Shouldice, Bassini, according to Trabucco. Plastic surgery according to Lichtenstein is the most preferred in surgical gastroenterology. This method of surgical intervention significantly reduces the risk of recurrence of an inguinal hernia and can be used both in childhood and in old age.

Lichtenstein method: the essence of the operation

Tension-free hernioplasty is more preferable, since the risk of a recurrent hernia is minimal. Hernioplasty according to Lichtenstein is used not only for inguinal hernias, but also for hernias of the abdominal wall (umbilical) and protrusion of abdominal organs under the skin.

The process itself can be divided into two main stages. At the beginning of the operation, the surgeon opens the hernial sac, examines its contents for the presence of fecal stones, gallstones, and assesses the likelihood of inflammation. If there are no complications, it is removed back into the abdominal cavity. The final stage of the operation, which is also the main stage, is plastic surgery of the hernial orifice using a composite mesh. The likelihood of relapse depends on how professionally the plastic surgery is performed. Unlike other methods, this method does not involve cutting the muscles. The implant is sutured to the aponeurosis located under the muscles.

Indications and contraindications

Hernia repair according to Lichtenstein is prescribed to everyone who has a pathological protrusion of the peritoneal organs into the area of the inguinal canal. Doctors strongly recommend the use of this particular method if the course of the disease is complicated by the following factors.

Recurrent inguinal hernias. Especially if the protrusion appears as a result of an incorrectly selected hernioplasty method.
High probability of necrosis when the hernial sac is compressed (strangulated hernia).
Intolerance to previously installed implants.
Danger of rupture of the hernial sac.

The use of Lichtenstein plastic surgery is not possible in the presence of certain indications.

Individual intolerance to synthetic implants.
Recent surgery on abdominal or reproductive organs.
Blood diseases: coagulation disorders, leukemia.
Cardiovascular diseases.
Chronic respiratory diseases.
Pathologies in the acute phase.
The presence of malignant tumors in the abdominal cavity.
Very old age.
Inoperable condition.
Patient's refusal to undergo surgery.

How is hernia repair performed according to Liechtenstein?

Hernioplasty can be performed either traditionally or using a laparoscope.

Children over the age of seven who have an abdominal wall hernia are treated using laparoscopic hernioplasty according to Lichtenstein. Three small incisions of 1-2 cm are made on the abdomen in the navel area. Trocars and a laparoscope with a camera are inserted into them. The camera reflects the progress of the operation on the monitor, and through tubes (trocars) an instrument is inserted into the cavity, with the help of which all stages are performed, as with traditional intervention. This operation has a number of advantages. Small incisions reduce blood loss during the process and ensure quick recovery, which is especially important in childhood.

Stages of hernioplasty

The operation is performed under spinal anesthesia or general anesthesia. A 5 cm long incision is made in the area of the pubic tubercle parallel to the inguinal ligament.

The surgeon gradually cuts the parenteral tissue, connective tissue membrane, external oblique muscle to the superficial canal. The aponeurosis is separated from the spermatic cord and captured by a holder. The hernia is isolated, examined and returned to the abdominal cavity.

A mesh is measured and a longitudinal cut is made in the lower half of it. The implant is sutured with a continuous suture from the pubic tubercle to the inner ring. Separate sutures are placed to secure the mesh to the internal oblique muscle. The manipulation is performed with special care, trying not to touch the iliohypocranial and ilioinguinal nerves.

The extreme tail of the mesh, formed as a result of the cut, is laid and secured with one interrupted seam. The operation ends by suturing the wide tendon plate of the external oblique muscle over the implant with subcutaneous sutures.

Rehabilitation

All inguinal hernias have the same ICD 10 code, and postoperative measures are similar for all surgical interventions after treatment of the bulge.

After hernioplasty, short medical care is provided. It includes active drainage, administration of pain medications and assessment of the condition of the operated organ. If there are no complications, the patient is discharged after a few days. After surgery for an inguinal hernia, rehabilitation proceeds quickly and without complications, provided that medical recommendations are followed. Usually they are as follows:

restriction, or better yet, exclusion of physical activity for 2 weeks;
It is highly advisable to wear a bandage for 2 months;
dieting.

Complications

These include:

decreased sensitivity in the lower abdomen;
there is a high probability of constipation (if the operation was performed on an abdominal wall hernia);
prolapse of the uterus, accompanied by severe pain (can occur when the circular ligament of the uterus is cut);
suture dehiscence followed by recurrence of the hernia;
inaccurate or incorrect fixation of the synthetic mesh with its subsequent migration;
internal hematomas.

In general, the operation goes well, with a mortality rate of less than 0.1% of all cases.

Advantages and disadvantages of the method

Lichtenstein hernia repair has a number of advantages over other operations.

The chance of relapse is almost zero.
Complications occur in only 5% of patients and in most cases are associated with non-compliance with recommendations in the postoperative period.
Composite meshes are made from high-quality materials; their rejection by the body is rare.
Short rehabilitation period, especially if the operation was performed using a laparoscope. The opportunity to return to normal life in 7-8 weeks.
The operation can be performed from the age of seven.

The Lichtenstein method, like any other, has its disadvantages:

the formation of scars near the spermatic cord can lead to impaired blood circulation in the tissues of the testicle and, as a consequence, to its atrophy;
wound infection: although doctors try to maintain sterility, statistics show that the occurrence of infection during surgery was observed in 2% of patients;
there is a high probability of damage to the sensory nerves located near the inguinal ligament, which can lead to disruption of innervation.

When diagnosing an inguinal hernia, it is important not to delay surgical treatment. High-quality plastic surgery according to Liechtenstein will allow you to avoid complications and relapses and return to your usual rhythm of life.

All materials on the site were prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative in nature and are not applicable without consulting a doctor.

Hernias of the anterior wall of the abdomen and groin area are perhaps the most common pathology in general surgery, the only radical treatment method for which is considered to be surgery - hernioplasty.

A hernia is a protrusion of abdominal organs covered with peritoneum through natural canals or those places that are not sufficiently strengthened by soft tissues. The study of the features of this pathological process formed the basis of an entire branch of medical science - herniology.

Hernial protrusion is not a new pathology, it has been known to man for several millennia. Shortly before the beginning of our era, attempts were made to surgically treat hernias; in the Middle Ages, barbers and even executioners did this, piercing and cutting off sections of the contents of the hernial sac or injecting various solutions into it.

The lack of basic knowledge in the field of the anatomical structure of hernias, non-compliance with the rules of asepsis, and the impossibility of adequate pain relief made hernia repair operations practically useless, and more than half of the patients were doomed to death after such treatment.

The turning point in the surgical treatment of hernias was the end of the 19th century, when operations became possible to perform under anesthesia and principles for the prevention of infectious complications were developed. An invaluable contribution to the development of hernioplasty was made by the Italian surgeon Bassini, who made a real breakthrough - after his operations, relapses occurred in no more than 3% of cases, while for other surgeons this figure reached 70%.

The main disadvantage of all known methods of hernioplasty until the second half of the last century remained the fact of tissue tension in the area of suturing the hernial orifice, which contributed to complications and relapses. By the end of the twentieth century, this problem was solved - Lichtenstein proposed using a composite mesh to strengthen the abdominal wall.

Today, there are more than 300 modifications of hernioplasty, operations are performed through open access and laparoscopically, and the Lichtenstein method is considered one of the most effective and modern in this century.

Types of operations for hernias

All interventions carried out to eliminate hernial protrusions are conventionally divided into 2 types:

Tension hernioplasty.
Non-tension treatment.

Tension method of treatment hernia is carried out only using the patient’s own tissues, which are compared in the area of the hernial orifice and stitched together. The main disadvantage is tension, which is associated with a high probability of suture failure and improper scarring, which leads to a long rehabilitation period, pain after surgery and a relatively high percentage of recurrence.

Tension-free hernioplasty– a more modern and highly effective method of surgical treatment of hernias, when the absence of tension is achieved using meshes made of polymeric inert materials. This plastic surgery of the hernial orifice reduces the likelihood of organ re-emergence to 3% or less, healing occurs quickly and painlessly. The tension-free method is the most commonly used today.

Depending on the access, hernioplasty can be:

Open;
Laparoscopic.

If possible, preference is given to laparoscopic hernioplasty as the least traumatic treatment option, with a lower risk of complications. In addition, these operations are possible in patients with severe concomitant diseases.

Hernioplasty is performed both under general anesthesia and under local anesthesia, which is preferable in patients with pathologies of the respiratory system and cardiovascular system. Endoscopic hernioplasty (laparoscopy) requires endotracheal anesthesia and muscle relaxation.

Despite the great variety of methods for hernial orifice plastic surgery, all these operations have similar stages:

First, the surgeon cuts the soft tissue and finds the location of the protrusion.
The contents of the hernia are either “sent” back into the abdominal cavity or removed (as indicated).
The final stage is hernia repair, which occurs in many known ways, depending on the type, structure and location of the hernia.

When is hernioplasty performed and to whom is it contraindicated?

Any hernia can be radically eliminated only surgically; conservative treatment can only slow down the progression and alleviate the unpleasant symptoms of the disease, so the very presence of a hernial protrusion can be considered a reason for surgery, which, however, surgeons are not always in a hurry.

When planning hernioplasty, the doctor evaluates the benefits of the proposed intervention and possible risks. This is especially true for elderly patients and those with severe concomitant pathologies. In most cases, elective surgery is well tolerated, but sometimes it happens that living with a hernia is safer than undergoing surgery, especially if it requires general anesthesia.

Relative indication For surgical treatment of an abdominal hernia, the presence of a small reducible protrusion is considered when the risk of strangulation is minimal and the general condition of the patient is not impaired. The method is selected individually, taking into account the location of the hernia.

If the hernia cannot be reduced, then the likelihood of dangerous complications, including strangulation, increases significantly, so surgeons strongly advise such patients to undergo surgery without delaying treatment too much.

The absolute indications for hernioplasty are:

Strangulated hernia - treatment will be emergency;
Relapse after a previous hernia repair operation;
Protrusion in the area of postoperative scars;
The likelihood of a hernia rupturing if the skin over it is thinned or inflamed;
Adhesive disease of the abdominal cavity with obstruction of intestinal patency;
Obstructive intestinal obstruction.

There are also obstacles to surgical excision hernial protrusions. Thus, for patients over 70 years of age with heart or lung diseases in the stage of decompensation, surgery is contraindicated even with gigantic hernias (this does not apply to cases of strangulation that require emergency treatment).

For pregnant women with abdominal hernias, the surgeon will almost certainly advise you to postpone the operation, which will be safer to perform after childbirth; laparoscopy is completely prohibited.

Acute infectious diseases, sepsis, shock, and terminal conditions are contraindications to all types of hernioplasty, and severe obesity makes laparoscopy impossible.

Patients with cirrhosis of the liver who have high portal hypertension with ascites and varicose veins of the esophagus, with diabetes mellitus not corrected by insulin, severe renal failure, serious pathology of blood coagulation, as well as patients with postoperative hernias that appeared after palliative treatment of cancer, during surgery will be refused due to the high risk to life.

The modern level of surgical technology, the possibility of local anesthesia and laparoscopic treatment make hernioplasty more accessible for seriously ill patients, and the list of contraindications is gradually narrowing, so in each case the degree of risk is assessed individually and, perhaps, the doctor will consent to the operation after careful preparation of the patient.

Preoperative preparation

Preoperative preparation for planned hernioplasty is not much different from that for any other intervention. During a planned operation, the surgeon sets the optimal date by which the patient undergoes the necessary tests in his clinic:

General and biochemical blood tests;
Urine examination;
Fluorography;
Tests for HIV, hepatitis, syphilis;
Determination of blood group and Rh status;
Coagulability test;
Ultrasound of the abdominal organs.

Other procedures may be performed according to indications.

If the patient is taking any medications, it is imperative to inform the doctor about this. Anticoagulants and aspirin-based blood thinners can pose a great danger when planning surgery. taking them can cause severe bleeding. They do not need to be canceled a day or two in advance, so it is better to discuss this issue in advance, when the date of the operation is just being chosen.

At the latest, one day before the operation, the patient comes to the clinic with ready-made test results; some studies can be repeated. The surgeon examines the hernial protrusion again, the anesthesiologist necessarily talks about the nature of pain relief and finds out possible contraindications to this or that method.

On the eve of the intervention, the patient takes a shower and changes clothes, does not eat anything after dinner, and drinking is allowed only in agreement with the doctor. In case of severe anxiety, mild sedatives may be prescribed; in some cases of ventral hernias, a cleansing enema is required.

In the morning, the patient is sent to the operating room, where general anesthesia is performed or a local anesthetic is injected. The duration of the intervention depends on the type of treatment of the hernial orifice and the structure of the hernia itself.

A feature of a very large ventral hernia is considered to be an increase in intra-abdominal pressure during the immersion of the intestines back into the abdomen. At this stage, the height of the diaphragm may increase, due to which the lungs will expand to a smaller volume, the heart may change its electrical axis, and from the intestine itself the risk of paresis and even obstruction increases.

Preparation for large ventral hernias necessarily includes maximum bowel movement through an enema or the use of special solutions to prevent the above complications.

Options for hernia repair operations and methods of hernia repair

After processing the surgical field and making a soft tissue incision, the surgeon reaches the contents of the hernia, examines it and determines its viability. The hernial contents are removed during necrosis or inflammation, and if the tissues (usually intestinal loops) are healthy, they are set back spontaneously or by the surgeon’s hand.

In order to solve the problem once and for all, it is very important to choose the optimal method of treating the protrusion gate - plastic surgery. The vast majority of operations at this stage are performed using a non-tension method.

Lichtenstein method

Hernioplasty according to Lichtenstein is the most common and most popular option for closing the hernial orifice, which does not require lengthy preparation of the patient, It is relatively simple to perform and produces a minimum of complications and relapses. Its only drawback is the need to implant a polymer mesh, the price of which can be quite high.

operation in Liechtenstein

This type of operation is possible for most types of hernias - umbilical, inguinal, femoral. The exit site of the organs is reinforced with a mesh made of synthetic material, inert to the patient’s tissues. The mesh implant is installed under the muscular aponeurosis, and there are no cuts to the muscles and fascia - the operation is low-traumatic, and this is one of its main advantages.

Hernioplasty according to Lichtenstein is performed under general anesthesia or local anesthesia, open access or through endoscopic intervention. With laparoscopy, through one incision, it is possible to install meshes on both inguinal or femoral canals at once if the pathology is bilateral.

Obstructive hernioplasty, which is very similar to the Lichtenstein technique, is considered less traumatic. but does not require opening the hernia and is accompanied by a much smaller skin incision.

Video: hernioplasty according to Liechtenstein

Tension hernioplasty according to Bassini

The classic operation developed by Bassini is still used today. It is indicated for repair of inguinal hernias and gives the best results when the volume of protrusion is small, especially if it arose for the first time.

An incision up to 8 cm in length is made slightly upward from the inguinal ligament, without cutting the peritoneum. The surgeon finds the spermatic cord, opens it and identifies a hernial sac, the contents of which return to the abdomen, and part of the membranes is cut off. After the hernia is eliminated, plastic surgery of the posterior wall of the inguinal canal occurs according to Bassini - the rectus abdominis muscle is sutured to the ligament, the spermatic cord is placed on top, and then the aponeurosis of the external oblique muscle and integumentary tissue are sutured.

plastic surgery of the posterior wall of the inguinal canal according to Bassini

Mayo method

Hernia repair according to Mayo is indicated for umbilical protrusions. It is classified as a tension method. The skin is cut longitudinally, bypassing the navel on the left, then the skin and tissue are separated from the wall of the hernial sac and the umbilical ring is dissected.

With the Mayo method, the umbilical ring is cut across; with another type of umbilical hernia repair - according to Sapezhko - the incision goes along the navel.

Mayo plastic surgery

When the hernial sac is completely isolated, its internal part is returned back to the abdomen, and the hernia membrane is excised, suturing the serous cover tightly. During an operation using the Mayo method, the upper aponeurotic edge of the rectus muscle is first sutured, then the lower one, while the latter is placed under the upper one and fixed, and when the plastic surgery is completed, the free upper edge of the aponeurosis is fixed to the lower one with a separate suture. This complex sequence of sutures ensures multi-layering and strength of the abdominal wall at the site of the former hernial protrusion.

Laparoscopic hernioplasty

Laparoscopic surgical treatment is the most gentle method for any surgical pathology. Endoscopic hernioplasty has been successfully used for many years and shows not only high efficiency, but also safety, even for those patients who may be refused open surgery.

The advantages of laparoscopic hernioplasty are, first of all, a quick recovery with minimal pain and a good aesthetic result, and main disadvantages– the need for general anesthesia using muscle relaxants and a significant duration of the intervention.

In endoscopic hernia repair, the surgeon makes three small incisions in the abdominal wall through which instruments are inserted. Gas is injected into the abdominal cavity to improve visibility, then the surgeon carefully examines the organs, looks for a hernia, determines its exact volume, location, and anatomical features. The plastic option is selected individually - both suturing and implantation of a polymer mesh are possible.

For large hernias, when laparoscopy can be traumatic as a method of isolating the sac, and also in the absence of technical capabilities to isolate the contents through laparoscopy, a combination of open access with a skin incision at the first stage of the operation and endoscopic installation of the mesh at the final stage is possible.

Postoperative period and complications

If the postoperative period is favorable, the sutures on the skin are removed by the end of the first week, after which the patient is discharged home. Over the next few weeks, operated patients gradually return to their normal lifestyle, following the doctor’s recommendations and following some restrictions. Full recovery may take from three months to six months.

In the early postoperative period, analgesics are prescribed if necessary. It is important to follow a diet that prevents constipation, since any tension in the abdominal wall can cause relapse or suture dehiscence.

For the first few weeks, active physical exercise and heavy lifting are prohibited for a long period of time; wearing special bandages is useful. After the stitches have healed, the doctor will recommend starting exercises to strengthen the abdominal muscles to prevent recurrent herniation.

Hernioplasty operations are almost always well tolerated and relatively rarely give complications, but they are still possible:

Inflammatory and purulent process in the area of the postoperative wound;
Recurrence;
Damage to surrounding organs, nerves or blood vessels during surgery;
Strong tissue tension, cutting through suture threads;
Displacement of the mesh implant relative to the site of its initial installation;
Adhesive disease;
Implant rejection.

Hernia repair operations are most often performed free of charge in regular surgical departments, but those who want to increase the comfort of treatment and the quality of the materials used, as well as choose a specific specialist, can undergo surgery for a fee. The price for hernioplasty starts from 15-20 thousand rubles for hernias up to 5 cm; larger protrusions will require large investments - up to 30 thousand. Installing a mesh implant will cost an average of 30-35 thousand rubles.

Video: umbilical hernia repair

Composite order Tools and materials

Tuscan order. Tuscan order, one of the five Roman architectural orders. The name is associated with Etruscan architecture...
What is a libretto: history of the term What is a libretto in brief

LIBRETTO. If you love music (which you undoubtedly do, since you needed this book), then you've probably had...
Events during the reign of Svyatoslav Igorevich

Religion: paganism Birth: 942 (0942) Death: March on the Dnieper Family: Rurikovich Father: Igor...
“Madonna and Child”, Masaccio - description of the painting Famous paintings by Masaccio

Masaccio (actually Tommaso di Giovanni di Simone Cassai (Guidi), Tommaso di ser Giovanni di Guidi; December 21, 1401,...
Jewish code of conduct "Shulchan Aruch" about Christianity and attitude towards the goyim

(Published in Tel Aviv in 1958. Transmitted with minor abbreviations). Jews! Love each other, help each other...
Step-by-step recipe for making caramel cream for a cake Technology for making caramel cream

Take a ladle or saucepan and pour milk and cream into it. Add vanilla sugar (sugar with vanilla seeds). In a separate...

2024-01-20 01:35:12

Recipes for making sausages in dough

Hello everyone! Today we have a very tasty and simple recipe in front of us - sausages in dough in the oven. Do you feel...
2024-01-20 01:35:12

How to Make Avocado Sauce Making Avocado Sauce Without Vinegar

Avocado is one of the healthiest fruits. This is a real storehouse of vitamins and nutrients. And him...

2024-01-20 01:35:12

Homemade roast pork and potatoes, recipe with photo

Roast pork is an ideal tasty and satisfying dish that can feed the whole family. Mistresses...
2024-01-20 01:35:12

No-bake cake Napoleon from cookies “Ears”

This cake is very easy to make and tastes like the classic Napoleon. When preparing the cake there is...

2024-01-19 01:20:59

Compatibility: Libra woman and Leo man

Representatives of these zodiac signs do not always become close people, but they are pleasant and interesting to each other....
2024-01-19 01:20:59

Compatibility of a rooster and a pig in a relationship

Compatibility between a Rooster man and a Pig woman is based on mutual understanding between the partners. They have different personalities and...

2024-01-19 01:20:59

Collection of basic formulas for a school chemistry course

several basic concepts and formulas. All substances have different mass, density and volume. A piece of metal...
2024-01-19 01:20:59

Characteristics of an Aries woman in love

If we’re going to talk about gender equality, then it’s with someone like an Aries woman. This emancipated lady is a bright...

2024-01-18 01:22:01
Philosophical vision of the problem

The meaning of life is related to the question “What to live for”, and not to the question of how to maintain life. Attitude...
2024-01-18 01:22:01
What mushrooms grow in a pine forest? Porcini mushrooms in moss

A mushroom is a living organism that forms a separate kingdom of the same name. For a long time they were classified as a kingdom...
2024-01-18 01:22:01
White mushroom - where they grow, description, photo

For lovers of “quiet” hunting, mushroom season begins in early summer and lasts until late autumn. And rarely when...
2024-01-18 01:22:00
Reputation consulting (special seminar), List of recommended literature Management consulting list of references

Aleshnikova, V.I. Use of professional consultants. - M.: Infra-M, 1999. - 240 p. 2. Beich,...
2024-01-17 01:13:45
The most complete interpretation of sleep orange

Orange juice. The symbolic meaning of orange juice in dream books is pleasure and temptation. Enough...
2024-01-17 01:13:45
The meaning of the Nautiz rune in love and relationships

We most often overcome all kinds of difficulties encountered along the path of life. Of course, for this we...
2024-01-22 01:24:11
Composite order Tools and materials

Tuscan order. Tuscan order, one of the five Roman architectural orders. The name is associated with...

2024-01-22 01:24:11

What is a libretto: history of the term What is a libretto in brief

LIBRETTO. If you love music (which you undoubtedly do, since you needed this book), then you'll probably...
2024-01-22 01:24:11

Events during the reign of Svyatoslav Igorevich

Religion: paganism Birth: 942 (0942) Death: March on the Dnieper Family: Rurikovich Father:...

The essence of the operation

Stages of implementation

Indications and contraindications for surgery

Rehabilitation period after surgery

Positive sides

Disadvantages of plastic surgery according to Liechtenstein

Liechtenstein plastic surgery cost

Lichtenstein operation for inguinal hernia

When to resort to the Lichtenstein technique

Restrictions and contraindications

Pros and cons of the method

Advantages of Liechtenstein plastic surgery

Cons of the operation

How is the operation performed?

Stages of intervention

What happens after surgery

Operation Liechtenstein

Video: Indirect inguinal hernia, hernia repair operation

Video: Operation Liechtenstein

Video: TAPP for recurrent inguinal hernia

Operation Liechtenstein

Hernialloplasty technique according to Lichtenstein

Plastic surgery according to Lichtenstein for inguinal hernia

How is hernioplasty performed?

Contraindications for surgery

Advantages of plastic surgery according to Liechtenstein

Disadvantages of the method

Possible complications

Rehabilitation

Methods of surgical removal of a hernia: tension and non-tension hernioplasty

Hernioplasty using the Lichtenstein technique

Types of hernia repair for the treatment of inguinal hernia

Other types of hernioplasty

Recovery after hernia repair

How is hernioplasty performed?

Contraindications for surgery

Advantages of plastic surgery according to Liechtenstein

Disadvantages of the method

Possible complications

Rehabilitation

Inguinal hernia: definition, description

Surgical methods for treating inguinal hernia

Lichtenstein method: the essence of the operation

Indications and contraindications

How is hernia repair performed according to Liechtenstein?

Stages of hernioplasty

Rehabilitation

Complications

Advantages and disadvantages of the method

Types of operations for hernias

When is hernioplasty performed and to whom is it contraindicated?

Preoperative preparation

Options for hernia repair operations and methods of hernia repair

Lichtenstein method

Video: hernioplasty according to Liechtenstein

Tension hernioplasty according to Bassini

Mayo method

Laparoscopic hernioplasty

Postoperative period and complications

Video: umbilical hernia repair

Random articles

Advertising

Low hemoglobin

ALT and AST

Lymphocytes

Leukocytes

New

Popular