The Lichtenstein technique is being used adequately in inguinal hernia repair: national analysis and review of the surgical technique

Messias, Bruno Amantini; Almeida, Pedro Lustre de; Ichinose, Tania Marcela Sandoval; Mocchetti, Érica Rossi; Barbosa, Cirênio Almeida; Waisberg, Jaques; Roll, Sergio; Ribeiro Junior, Marcelo Fontenelle

doi:10.1590/0100-6991e-20233655-en

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Original article • Rev. Col. Bras. Cir. 50 • 2023 • https://doi.org/10.1590/0100-6991e-20233655-en copy

The Lichtenstein technique is being used adequately in inguinal hernia repair: national analysis and review of the surgical technique

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Introduction:

it is estimated that approximately 20 million people undergo inguinal hernia surgery annually in the world, with the Lichtenstein technique being the most performed surgical procedure. The objective of this study is to analyze the knowledge of the technical principles used in the Lichtenstein technique.

Method:

Survey-type intersectional study approved by the research ethics committee of São Camilo University Center (CAAE: 70036523.1.0000.0062). During the research period, 11,622 e-mails were sent to members of the main national surgical societies with research on the technical principles of Lichtenstein surgery. The survey was carried out using an electronic form with 10 multiple-choice questions. The form was answered anonymously on the SurveyMonkey and Google Forms platforms.

Result:

744 responses were received to the electronic form. Based on this number of respondents, our survey has a confidence level of 95% with a margin of error of 3.5%. It was observed that there is no standardization of the technique among the majority of responders (53.4%). Many surgeons still perform digital dissection of the spermatic cord (47%). A small number of interviewees (15.2%) performed sutures with absorbable thread in the region of the internal oblique aponeurosis, while more than half (55.2%) continued to perform sutures with non-absorbable thread. Most surgeons use a small overlap or fix the mesh juxtaposed to the pubic symphysis (51%).

Conclusion:

Our research identified that a small percentage of respondents adequately know the technical principles of Lichtenstein surgery. The result brings us new insights into the need to review Lichtenstein technique.

Keywords:
Hernia; Abdominal Wall; Herniorrhaphy; Knowledge

	N	%	p-value
1- Is there a technical standardization in the service you operate?
Yes, we follow an established technical standard	347	46.60%	0.01
No, teams members use the technique they are used to with their own modifications	397	53.40%
2- Which anesthetic technique is routinely used in Lichtenstein repairs?
Spinal anesthesia	695	93.40%	Ref.
General anesthesia	30	4%	<0.001
Local anesthesia	19	2.60%	0.001
3- Regarding the use of meshes:
I choose the best mesh for the patient to be operated on, as I have several types of meshes available	216	29%	<0.001
I use the mesh available in the hospital, which is not always the most appropriate for the patient	525	70.60%	Ref.
I do not use mesh in hernia repairs	3	0.40%	<0.001
4- Regarding the size of the mesh:
I use pre-cut, 6 x 12cm meshes	123	16.50%	<0.001
I use 7 x 15cm meshes	418	56.20%	Ref.
I use meshes smaller than 6 x 12cm	34	4.60%	<0.001
I don't worry about the size of the mesh, as long as it is well positioned in the inguinal region	169	22.70%	<0.001
5- Regarding the innervation of the inguinal region:
I identify nerves routinely	552	74.20%	Ref.
I don't identify nerves routinely	167	22.40%	<0.001
The location of the nerves does not interfere with my mesh placement	25	3.40%	<0.001
6- Regarding the release of the spermatic cord:
I use digital release	350	47.00%	Ref.
I use release with atraumatic forceps	266	35.80%	<0.001
I use release with an electric scalpel	128	17.20%	<0.001
7- Mobilization of the spermatic cord is done with:
Gauze	257	34.50%	<0.001
Surgical towel	63	8.50%	<0.001
Penrose drain	375	50.40%	Ref.
Farabeuf retractor	49	6.60%	<0.001
	N	%	p-value
8- Regarding fixation of the mesh in the aponeurosis of the internal oblique muscle/rectus abdominis sheath:
I perform 2 stitches with absorbable suture parallel to the innervation	113	15.20%	<0.001
I perform random simple stitches in the region	144	19.40%	<0.001
I perform stitches with non-absorbable suture	411	55.20%	Ref.
I perform continuous suturing in the region	76	10.20%	<0.001
9- Regarding the mesh overlap in the pubic symphysis region:
I use a 2 cm medial overlap	250	33.60%	0.066
I use a 2 cm inferior overlap	115	15.50%	<0.001
I fix the mesh juxtaposed to the pubic symphysis	284	38.20%	Ref.
I use an overlap of less than 2cm	95	12.80%	<0.001
10- Regarding the mesh fixing overlap:
I use a 2 cm overlap on the aponeurosis of the internal oblique muscle	98	13.20%	<0.001
I use an overlap of 5 to 6cm lateral to the internal inguinal ring	202	27.20%	<0.001
I use an overlap of 2 to 3cm of the internal inguinal ring	265	35.60%	Ref.
I don't worry about overlap as long as the mesh fits in the medial region	179	24.10%	<0.001

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[1] Mailing address: Bruno Amantini Messias E-mail: bruno22med@hotmail.com