1. Comparison of open Lichtenstein hernioplasty under local anesthesia and laparoscopic extra peritoneal hernioplasty under general anesthesia
Dr. Sunil Pudale P.G. (BVDU Medical College & Hospital, Sangli)
Dr.Chinmay Gandhi . Associate professor.
Dr.Ashok Dhonde (consultant laparoscopic surgeon) conflict of interest none

2. Material and methods
This is prospective comparison of 25 Lichtenstein hernioplasty under local and 25 laparoscopic extra peritoneal inguinal hernioplasty under general anesthesia.
This is comparison of intra and post operative complications with 3 month post operative result for chronic pain and recurrence.

3. Surgical method for Lichtenstein repair
Open Lichtenstein hernioplasty were done under step by step local anesthesia technique as described by P.K.Amid.
10 ml 2% Xylocain and 10 ml 0.5% sensorcain mixture was diluted in 20 ml water for injection. This 40 ml solution was used by step by step local anesthesia technique.
For anxiety of the patient propofol was used for 4 patients

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. ilihypogastric iliinguinal nerves were seen
ilihypogastric iliinguinal nerves were seen. Pre hernia cord lipoma excised to prevent hernia recurrence.
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.

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. Mesh should form a loose dome over the posterior inguinal wall
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.
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.

11. Intra operative findings in open Lichtenstein hernioplasty
All 25 patients had reducible inguinal hernia. All patients operated were male, in the range of 18 to 75 years of age.
Nyhus distribution of type of hernia is as follows- Nyhus 1 in 10 patients, Nyhus 2 in 4 patients, Nyhus 3 in11 patients.
Intraoperative results: Duration of surgery was 30 to
45 minutes in all cases.
3 patients in younger age of 18 to 40 year had anxiety requiring Intraoperative sedation with propofol, where as 1 patient in older age between 40 to 75 year required sedation with propofol.
No patient complained of Intraoperative pain.

12. Post operative 48 hrs results after Lichtenstein hernioplasty under local anesthesia
All patients required 2 injections of analgesics like tramadol or diclofenac in the first 24 hrs.
All patients were ambulated after 24 hrs.
All patients were comfortable on oral analgesics from day 2.
Not a single patient complained of headache or hypotension in postoperative period.( which is complication of spinal anesthesia)
Only one patient required catheterization for postoperative
retention of urine due to anxiety and pain at local site due to delayed analgesic injection.
Otherwise all other patient were ambulated and passed urine
without catheterization.

13. post operative 7 day results
2 patients had scrotal edema which resolved over 2 weeks.
1 patient had superficial wound infection.
2 patients were prescribed mild oral analgesics on day 7 for mild local pain.

14. 3 month post operative results
There was no case of recurrence.
2 patients required intermittent oral analgesics for mild local pain.

15. Laparoscopic extra peritoneal hernioplasty under general anesthesia
This is a prospective observational study of 25 laparoscopic extra peritoneal inguinal hernia repair done with selective fixation of large size lightweight polypropylene mesh (12 by 15 cm).
All patients with unilateral or bilateral reducible inguinal hernia primary or recurrent, which were fit for general anaesthesia.

16. LAP. TEP REPAIR
All surgeries were done under general anaesthesia with self retaining bladder catheter in place.
Standard totally extra peritoneal dissection to expose critical view of myopectineal orifices before inserting 12 by 15 cm mesh was done in all cases.
All patients were male.

17. Surgical procedure TEP
Entry in preperitoneal space, dissection of retro retzius space.
Identification of landmarks like pubic symphysis, cooper ligament and iliac vein.

18. Critical view 1,2,3,4, of Daes Jones
Hassel bachs triangle dissected for possible direct sac and removal of fat in the area.
Dissection between cooper and bladder for 2 cm. and retro pubic area for medial lower end mesh placement.
Dissection between cooper and iliac vein for femoral and Obturatore hernia.

19. Critical view 5,6,7,8
Identification of inferior epigastric, entering space of bogros, extending dissection to ASIS and laterally and backwards.
Expose psos muscle with
preserving transversalis fascia layer over it to protect nerves.

20. Critical view 5,6,7,8
Parietalization of cord structures with reduction of indirect sac

21. Critical view 5,6,7,8
Parietalization of cord with exposure of triangle of doom.
Removal of cord lipoma.
Ensure there is no tethering of peritoneum to cord structures after Parietalization

22. Selective mesh fixation
After achieving critical view of myopectineal orifices spreading adequate size mesh (12 by 15 cm.).
Fixation in large direct and indirect sac at three points above line joining ASIS and hernia defect with one fixation at coopers ligament.

23. INTR OPERATIVE FINDINGS IN LAP.TEP.
All 25 patients were male. Intraoperative hernia was classified according to European hernia society classification. Out of these 25 patients one had recurrence and four had bilateral inguinal hernia repair.
PM1: 9 Patients, Primary medial hernia about 1.5 cm defect.
PM2: 1 Patient, Primary medial hernia about 3 cm defect.
RM1: 1 Patient, Recurrent medial hernia with 1.5 cm defect..
PL1: 13 Patients, Primary lateral hernia with 1.5 cm defect.
PL2: 1 Patients, Primary lateral hernia with 3 cm defect.

24. Selective fixation of mesh in TEP
We had used non absorbable tackers selectively. In small ( <1.5 cm) direct sac a single tacker was used to fix mesh at cooper ligament or at least 4 cm medial cover of mesh over direct defect. In large direct hernia sac (>1.5 cm) we did two to three point fixation of the mesh. One over cooper ligament, other just above pubic bone to anterior abdominal wall or last fixation at medial superior edge of mesh to anterior abdominal wall. We had not done any fixation for small indirect inguinal hernia (<1.5cm)as mesh could cover 5 to 6 cm all round the defect, for large indirect inguinal hernia we had done two or three point fixation ,one over cooper ligament, other medial superior edge of mesh to anterior abdominal wall or last over superior lateral edge of mesh to anterior abdominal wall.

25. INTRA OPERATIVE FINDINGS
Duration was 45 to 60 minutes for unilateral hernias and up to 90 minutes for bilateral cases.
Intraoperative complications like vascular, intestinal or bladder injuries were not observed in our series.
There were no cases of surgical emphysema in these series.
Intraoperative peritoneal tear was observed in 5 cases. endo loop catgut suture for closer of peritoneal tear used. (20% cases)
There were no anesthesia related complications like hypercarbia and hypotension.

26. Post operative 48 hrs
postoperatively catheter was removed on first postoperative day.
All patients required one or two injections of tramadol on first day.
All patients were mobilized next day.
Patients were on mild oral analgesics from day two.
Patients were discharged on 2nd postoperative day. On day two NRS (numerical rating score) pain score of all patients was between 2&3/10.

27. Post operative 7 days.
Patients were followed on 7th postoperative day.
23 patients were pain free on 7th postoperative day.
2 patients had persistent NRS pain score of 3/10.It was found that these patients were having inguinal or scrotal seroma.
On postoperative day 14 seroma disappeared and they were pain free.

28. Post operative results for TEP.
Post operative results for TEP
None of our patient had wound infection, mesh infection or groin hematoma.
Two of our patients had seroma. These patients were having either large direct hernia or complete indirect inguinal hernia. The seroma disappeared 2 weeks postoperatively on its own with mild oral analgesic and anti-inflammatory drugs.
There were no patients with testicular swelling due to Orchitis.
post operatively all patients were able to do routine normal activity from day seven and they were advised routine normal physical activity afterwards.
There were no recurrence of hernia at the end of 3month postoperative and no patient with chronic pain

29. Discussion
inguinal hernioplasty under local anesthesia provided with increased safety for the patient.
Better postoperative pain control.
no anesthesia related complications like spinal headache, perioperative hypotension, postoperative nausea and vomiting .
reduced postoperative retention of urine requiring catheterization
Patients had short recovery time.
There is overall reduction of the cost of surgery.
At 3 months there were no patients with recurrence and
only 8% patients had mild chronic pain.

30. Discussion
Since the introduction of tension free Lichtenstein hernioplasty in 1989 the recurrence of inguinal hernia has drastically reduced below 1%. Chronic groin pain a remained the major concern after open inguinal mesh repair.
First total extra peritoneal laparoscopic inguinal mesh repair was described by McKernan and Law in 1993.

31. discussion
Main principle of laparoscopic inguinal hernia is to keep large size mesh in extra peritoneal space covering myopectineal orifices.
Pascal's hydrostatic force which causes the hernia also keeps the mesh in place after TEP.
Most of the inguinal hernia recurrences with TEP will be prevented by mesh in extra peritoneal space as per Pascal's hydrostatic law.

32. Lap. TEP
We found laparoscopic TEP had advantage in recurrence of inguinal hernia after anterior repair, In bilateral inguinal hernia.
Less post operative chronic inguinal pain, early return to work, less postoperative medical care requirement( less wound infection) were advantages for laparoscopic repair.

33. Conclusion BOTH THE PROCEDURES ARE DAY CARE,
OPEN LICHTENSTEINE REPAIR IS EASY TO LEARN. EXPERIANCED LAPAROSCOPIC SURGEON CAN REDUCE THE LEARNING CURVE
IN LAPAROSCOPIC TEP.
BOTH CAN GIVE LESS POSTOPERATIVE <1% RECURRENCE.
OVER ALL COST OF SURGERY IS LESS IN OPEN LICHTENSTEINE REPAIR.

34. Conclusion
Early return to work and less loss of productive days are advantage of laparoscopic totally extra peritoneal hernia repair.
For a given patient surgeon should be the master of both the procedures to improve his results of inguinal hernia surgery.

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