Anterior / Lichtenstein Inguinal Hernia Repair

You are having anterior hernia repair with mesh, also called a Lichtenstein hernia repair. This is the most commonly performed approach to inguinal hernia repair in this country. 

 

The procedure:

This repair is performed by making an incision in the groin and coming down on top of the bulging hernia. The bulging tissue is pushed back into the abdomen where it belongs and the hole through which it is passing is sutured tighter. In men, it cannot be completely closed as this is also the hole through which the spermatic cord passes. Next, a mesh patch is placed over this area to add support to the repair. 

One important difference in this approach is that the mesh is being placed on the outside of the hernia. This is also the area where three nerves are present. Without careful attention paid to identifying and avoiding inadvertent injury to these nerves, the chance of having pain in the area that extends beyond what is normal in recovery is 5-15%. Because of this, we are very careful to find these three nerves and either ensure they are out of the area where they could be injured, move them out of the area where they could be injured or if needed, remove a portion of the nerve to prevent it from being caught in a stitch. Removing a segment of nerve results in a small area of numbness of the skin- a far better outcome than the possibility of developing chronic pain. Removing a segment of the nerve does not affect any physical or sexual function. Many people worry about cutting any nerves, but in reality this leaves only a feeling of mild numbness on the skin of the lower abdomen for a few months or more. 

 

Anesthesia:

This surgery is typically done under IV sedation (similar to the anesthesia for a colonoscopy) with local numbing medication, but sometimes, depending on the patient’s individual medical and surgical history, more anesthesia support is needed. We try to minimize anesthesia for every patient while making sure they are kept safe during surgery.

 

Why we recommend this repair:

We recommend this type of repair to patients who have certain medical problems that make other approaches more risky and those who have had other pelvic surgery or trauma in the past, including certain prostate surgeries and some previous inguinal hernia surgery. Patients who have had a laparoscopic or robotic prostatectomy, or previous laparoscopic inguinal hernia repair on the same side are good candidates for this repair.

 

A note on mesh:

Patients often ask us “Is mesh safe?” The mesh we use has been used millions of times and is well tolerated by patients. There are lawsuits related to a specific type of mesh that was taken off the market several years back. We do not use this mesh. There are other concerns related to where mesh is placed in the groin. In the case of inguinal hernia repair, this usually relates to stitching and placing mesh over the area of the three nerves in the groin. When one of these nerves is inadvertently injured, patients can develop chronic pain. In the case of open preperitoneal inguinal hernia repair, we are placing the mesh on the inside of the hernia hole- this allows us to stay away from the area where most of the nerves course. This is one of the major benefits of repairing a hernia from the inside. Additionally, when using a foreign material like mesh, there is a chance that material becomes infected. Your body can’t defend infection in a foreign material as well as it can in our own bodies. Fortunately, this is very rare (about 1 in 10,000) but can result in the need for the mesh to be removed.

 

Risks of surgery:

During your appointment, you discussed the risks of surgery. Unfortunately, there is no way to have a risk-free surgery but we do everything we can to minimize the chance that you have a complication related to one of these risks. 

  1. Hernia recurrence – 3/100 – Hernias can come back after repair. After Lichtenstein inguinal hernia repair, the risk of recurrence is likely about 3-5%. 
  2. Infection risk – 1/200 – If an infection occurs after surgery, this is usually a skin infection and is well treated with antibiotics. If the mesh becomes infected, it can require removal.
  3. Chronic pain risk – 1/50 – This can occur through stitching or placing mesh over the nerves in the area. The rate of this occurring in this country is 5-15%. We minimize this risk by identifying and managing the nerves as described above and this significantly reduces the risk of chronic pain after this type of repair. 
  4. Bleeding – 1/400 – The risk of any significant bleeding after inguinal hernia repair is less than 1/400 and this is kept very low risk when patients adhere to activity restrictions in the first couple weeks after surgery. 
  5. Complication requiring additional surgery – about 1/400 patients require a second operation after their first operation to fix bleeding or an intestinal issue. While this is not common, we take a very proactive approach in order to speed up the healing process.

 

Preparing for surgery: 

  • Please continue to be as active as you normally are. It is safe to exercise as long as you do not have pain with your activities. 
  • Make sure you have acetaminophen (tylenol) and ibuprofen (motrin, advil) at home as these medications are typically all that is needed to treat post-operative pain.
  • No bowel prep is needed before surgery. 
  • You will likely need to have a Covid test within 72 hours before surgery. Our medical assistants give you instructions on how best to arrange this at the time of your consultation. 
  • Depending on what facility you are having surgery in, another step is required prior to surgery: 
    • Newton-Wellesley Hospital – Our medical assistants will schedule you a pretesting phone appointment and we will contact you regarding the scheduling of this appointment. 
    • BOSS – You were given a sheet detailing what you need to do to register prior to surgery. 
    • Surgical Center of NH at Derry – You will receive an email or text from the surgery center itself to register as a new patient. 

The day of surgery: 

  • Please arrive promptly at the time you are given as a lot has to happen before you are wheeled into the operating room.
  • You will get an IV, meet the team (including the preoperative nurses, the OR nurse, the anesthesiologist or nurse anesthetist), and see your surgeon and physician assistant in preparation for surgery. 
  • After surgery, you will spend about 1-2 hours in the recovery room before you go home. 

 

After surgery: 

  • Take acetaminophen and ibuprofen together every 6 hours for the first 2-5 days for pain control. 
  • Avoid any activity more strenuous than casual walking for two weeks after surgery.
  • Remove bandage (if present) 48 hours after surgery. 
  • A note on resuming exercise after the 4 week recovery period: Once you are two weeks out from surgery, you can start testing different activities. Approach activities slowly until you are sure they don’t cause you sharp pain. Any activity that causes sharp pain at the incision should be avoided. If you feel well and are active throughout one day, it is normal to feel more sore the next day while you continue to recover. You didn’t hurt yourself so long as you don’t push through an activity that’s causing you pain while doing it. Ultimately, the goal after you are fully recovered is to get you back to all of your activities without restriction. For most of our patients who have this type of surgery, they are back to most of their pre-op activities about 1 month after surgery.  

 

We hope this information has helped you prepare for your upcoming hernia surgery. If you have any questions about the above information, please call our office to set up a follow up appointment so that we can ensure all of your questions are adequately answered and you feel comfortable prior to your surgery.