Inguinal Hernia Repair (Lichtenstein / Laparoscopic)
What the Examiner Expects
Surgical repair of inguinal hernia using mesh reinforcement, either through an open (Lichtenstein) or laparoscopic (TEP/TAPP) approach. The examiner expects you to know the anatomy of the inguinal canal (internal ring, external ring, inguinal ligament, transversalis fascia, conjoint tendon), differentiate indirect (through the internal ring, lateral to the inferior epigastric vessels) from direct (through Hesselbach's triangle, medial to the vessels), and describe the repair. Lichtenstein involves placing a polypropylene mesh over the inguinal floor, securing it to the inguinal ligament, pubic tubercle, and conjoint tendon. Laparoscopic repair places mesh in the preperitoneal space covering all potential hernia sites (myopectineal orifice of Fruchaud).
Key Examiner Focus Points
- Lichtenstein (open tension-free mesh): most common open technique; mesh placed over the floor of the inguinal canal
- TEP (totally extraperitoneal): laparoscopic preperitoneal approach; no peritoneal entry
- TAPP (transabdominal preperitoneal): laparoscopic transperitoneal approach; peritoneum closed over mesh
- Indirect: hernia sac through internal ring lateral to epigastric vessels
- Direct: hernia through Hesselbach's triangle (floor of inguinal canal) medial to epigastric vessels
Common Curveballs
During open repair, you find an indirect hernia sac that extends into the scrotum and is densely adherent to cord structures
Do not attempt to completely excise a long, adherent sac — risk of testicular vessel or vas deferens injury. Divide the sac at the internal ring, ligate the proximal sac, and leave the distal sac open in the scrotum (to prevent hydrocele, open the distal sac anteriorly). This is safe and reduces cord complications.
Patient develops testicular pain and swelling 1 week after open inguinal hernia repair
Ischemic orchitis from thrombosis of the pampiniform plexus (not from direct ligation of testicular artery). This is more common with large indirect hernias requiring extensive dissection. Supportive care with NSAIDs, scrotal elevation. Usually self-limited but can progress to testicular atrophy in some cases.
Recurrent inguinal hernia after prior open Lichtenstein repair
For recurrence after open repair, a laparoscopic approach (TEP or TAPP) is preferred — it avoids the scarred anterior tissue planes and approaches from the preperitoneal space. Conversely, for recurrence after laparoscopic repair, an open approach is preferred.
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