1. OBJECTIVES OF THIS LESSON To prepare surgeons to perform a proper surgical repair of an inguinal hernia using the Lichtenstein technique: – by describing the operative technique General plan of our lesson -anaesthetic options/ application of local anaesthesia -optimum surgical approach -how to handle the nerves -the indirect sac -the direct sac -mesh placement -closure -common pitfalls -further reading

2. ANAESTHETIC OPTIONS Anaesthetic options – general anaesthetic – spinal anaesthetic – local anaesthetic Local anaesthetic -patient must be prepared to be awake -there are few contraindications -particularly useful in older patients and those with co-morbidity -caution with younger, anxious patients and those with irreducible or partially reducible hernias

3. LOCAL ANAESTHESIA – NON CLINICAL SKILLS

4. LOCAL ANAESTHESIA – PREPERATION AND AMOUNT

5. LOCAL ANAESTHESIA – INFILTRATION 1

6. LOCAL ANAESTHESIA – INFILTRATION 2

7. LOCAL ANAESTHESIA – INFILTRATION 3

8. OPERATIVE TECHNIQUE - INCISION

9. OPERATIVE TECHNIQUE – APPROACH TO EXTERNAL OBLIQUE APONEUROSIS

10. OPERATIVE TECHNIQUE – OPENING THE INGUINAL CANAL

11. OPERATIVE TECHNIQUE – OPENING THE INGUINAL CANAL 2

12. OPERATIVE TECHNIQUE – ELEVATION OF THE CORD

13. OPERATIVE TECHIQUE - HOW TO HANDLE THE NERVES Visualise and protect the ilio-inguinal, ilio-hypogastric and genital branch of the genito-femoral nerves throughout the operation

14. OPERATIVE TECHIQUE – INDIRECT SAC A B C D

15. OPERATIVE TECHIQUE – DIRCET SAC BA

16. OPERATIVE TECHIQUE – MESH PLACEMENT 1

17. OPERATIVE TECHIQUE – MESH PLACEMENT 2

18. OPERATIVE TECHIQUE – MESH PLACEMENT 3 AB C

19. OPERATIVE TECHIQUE – CLOSURE

20. OPERATIVE TECHIQUE – COMMON PITFALLS Opening external oblique aponeurosis -Care should be taken to avoid opening the aponeurosis too close to the rolled edge of the inguinal ligament Dissection of the sac -Ensure that the dissection is carried out on the sac itself to avoid damaging adherent cord structures -Transect a fixed scrotal sac Mesh fixation -Ensure adequate medial overlap of the mesh -Avoid the ilio-hypogastric nerve when securing the lateral edge of the mesh

21. OPERATIVE TECHIQUE – FURTHER READING Monographs and papers – Lichtenstein, I.L., Hernia repair without disability. 2nd ed. ed. 1987, St. Louis, Mo.: Ishiyaku EuroAmerica. – Amid, P.K., Lichtenstein tension-free hernioplasty: its inception, evolution, and principles. Hernia, 2004. 8(1): p. 1-7. – Amid, P.K., How to avoid recurrence in Lichtenstein tension-free hernioplasty. Am J Surg, 2002. 184(3): p. 259-60. – Amid, P.K. and I.L. Lichtenstein, The Lichtenstein open "tension-free" mesh repair of inguinal hernias. Rozhl Chir, 1995. 74(6): p. 296-301. Books – Bendavid, R., Abdominal wall hernias : principles and management. 2001, New York ; London: Springer. – Kingsnorth, A.N. and K.A. LeBlanc, Management of abdominal hernias. Fourth Edition. ed. 2013, New York ; London: Springer.

22. Dr David L Sanders and Prof Andrew N Kingsnorth Derriford Hospital, Plymouth, UK Performed by: