1. OUTCOME OF LICHTENSTEIN HERNIOPLASTY
NO CONFLICT OF INTEREST
DR. VENKATESH kamepalli (Pg)
bharati deemed university medical college & hospital, sangli DR.CHINMAY GANDHI ASSOCIATE PROFESSOR

2. INTRODUCTION Inguinal hernia is the commonest surgical disease.
Altered ratio of collagen 1 and 3 causes weakness of fascia.
Weakness in fascia transversalis causes hernia at inguinal region, so we strengthen fascia transversalis with mesh in Lichtenstein hernioplasty.

3. STUDY DESIGN
This is the retrospective observational study of 150 inguinal hernia operated by Lichtenstein tension free hernioplasty at our institute from 2012 to Surgeries were done by residents and faculties. All patients were above 18 years having unilateral non strangulated inguinal hernia . Patients were followed for 2 years postoperatively for recurrence and chronic groin pain. .

4. SURGICAL METHOD
Inguinal incision was given to expose external oblique aponeurosis and superficial ring

5. Types of hernia sac we encountered after opening inguinal canal.
direct sac in Hasselbachs triangle was invaginated most of times

6. After Invagination of direct sac we can see ilioinguinal nerve with cord.

7. Indirect sac dissection from cord structures up to retro peritoneum, reduction of its content, inversion of small indirect sac ,ligation of the neck of the large indirect sac, cutting across the body and keeping rest of sac open.
ilihypogastric iliinguinal nerves were seen. Pre hernia cord lipoma excised to prevent hernia recurrence.

8. Strengthening of posterior wall of inguinal canal with 6 X 4 inch polypropylene mesh was done in all cases. 2cm Overlap on medial side of pubic tubercle was given . Lower edge of mesh was sutured with polypropylene 2-0 suture to shelving part of inguinal ligament from pubic tubercle to internal ring level.

9. Lateral edge of mesh was cut approximately 1/3 from lower edge to make two tails of mesh this is done to accommodate cord structures at internal ring. Anuloplasty done to make new internal ring from mesh. 5 cm overlap of mesh lateral to internal ring was given.

10. Medial fixation of mesh on to anterior rectus sheath
Medial fixation of mesh on to anterior rectus sheath. Superiorly 3 cm overlap was given above Hasselbachs triangle.
Fixation is also done at medial and superior to internal ring through internal oblique muscle.
Mesh should form a loose dome over the posterior inguinal wall. Incised external oblique aponeurosis was sutured with 2-0 polypropylene suture with creation of new lax external ring.

11. Study follow up
Follow up was done in out patient department and by telephonic conversation. All patients received prophylactic cefotaxim 1 gm. 2 hrs prior to surgery

12. Out of 150 operated patients 141 were male and 9 female.

13. Nyhus distribution of type of hernia
Nyhus type 1: Indirect hernia with normal internal ring (54 PATIENTS)
Nyhus type 2: Indirect hernia with dilated internal ring, posterior wall intact(15 PATIENTS)
Nyhus type 3 A: posterior wall defect direct inguinal hernia (66 PATIENTS)
Nyhus type 3 B: Indirect inguinal hernia ring dilated with posterior wall defect (11 PATIENTS)
Nyhus type 3 C: Femoral hernia ( NO PATIENTS)
. Nyhus type 4: Recurrent hernia(4 PATIENTS)

14. Results for recurrence of hernia
149 patients had no recurrence on 2 years follow-up.
One patient had recurrence of hernia within 1 year of surgery.
We had used polypropylene mesh, with wide overlap expecting 20 to 40% mesh contracture in future. This had given only 0.66% recurrence in our study.

15. POST OPERATIVE CHRONIC GROIN PAIN
Results at 3 month for chronic groin pain .
Results of chronic groin pain at 2 years
Out of 150 patients 16 had mild pain on 3 month follow-up.
10.6% patients had mild pain at 3 month follow-up.(four point verbal rating scale used for measuring groin pain)
There was not a single case of severe or moderate groin pain requiring emergency or late surgical intervention.
Out of 150 patients 3 had mild pain at 2 years.
2 % mild pain after 2 year follow up.
One patient complained of heaviness and hyperesthesia in inguinal region. (Neuropathic mild pain )
Two had intermittent mild groin pain(somatic pain) relived with mild anti-inflammatory analgesics.

16. Patients with chronic pain

17. TECHNIQUES WE FOLLOWED TO PREVENT CHRONIC GROIN PAIN
Nerves ilioinguinal, ileohypogastric and genital branch of genitofemoral nerve were identified with meticulous dissection, preserving investing layer of fascia over it.
Not lifting ilioinguinal nerve from bed.
Genital branch of the genitofemoral nerve is located in the cord along with external spermatic vein, covered and protected from direct contact with mesh by the deep cremastric fascia. It should be kept with the cord, while the cord is separated from inguinal floor using blunt peanut dissection, grasping the cord with thumb and index finger should be avoided.
Creating lax external inguinal opening to prevent compression of ilioinguinal nerve.

18. TECHNIQUES WE FOLLOWED TO PREVENT CHRONIC GROIN PAIN
Iliohypogastric is easily visible after superior anatomical dissection between external and internal oblique muscle. It has to be safeguarded by splitting mesh and preserving fascia over it.
Should wait more than 6 months before surgically treating chronic groin pain disturbing daily activity.
Severe pain should be treated immediate postoperative.

19. Take home message
. Meticulous technique can reduce chronic groin pain up to 0.5% after Lichtenstein hernioplasty .Use of Light weight mesh( between 35 to 70gm/m2) recommended in Lichtenstein hernioplasty. .Lichtenstein hernioplasty can bring recurrence below 1%. Lichtenstein hernioplasty has short learning curve for residents, results can be reproduced. Lichtenstein hernioplasty gives satisfactory long term results to community

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