Tension-Free Onlay Mesh Hernioplasty

Parviz K. Amid, MD, Esbern Friis, MD, Gunter Horeyseck, MD,
and Matthias Kux, MD

For more than a century, the measure of the success of hernia repair was its recurrence rate. In 1966, for the first time, the importance of the postoperative disability of hernia repair was brought to the attention of surgeons by Lichtenstein. 1 With the goals of decreasing postoperative pain, recovery period, and recurrence rate, the tensionfree hernioplasty project was started at the Lichtenstein Hernia Institute, Los Angeles, CA, in June of 1984. The concept is based on: (1) the degenerative origin of inguinal hernia, which results in the destruction of the inguinal floor2; and (2) the fact that the traditional tissue repair is associated with undue tension at the suture line. Today, understanding the role of protease-antiprotease imbalance in the pathogenesis of groin hernias has lead to a new grasp of the pathology of groin hernias and the causes of their surgical failure. 2 There is morphological and biochemical evidence that adult male inguinal hernias are associated with impaired hydroxilation of proline. These changes lead to the weakening of the fibroconnective tissue of the groin and the development of inguinal hernias. 2 To use this already defective tissue, especially under tension, is a violation of the most basic principles of surgery. Furthermore, the tension resulting from approximation of the transverse tendon to structures, such as the inguinal ligament or iliopubic tract, results in

From the Departments of Surger%, Harbor-UCLA and Cedars-Sinai Medical Centers, Los Angeles, CA. Address reprint requests to Parviz K. Amid, MD, Lichtenstein Hernia Institute, 9201 Sunset Blvd, Suite 505, Los Angeles, CA 90069. Copyright 9 1999 by W.B. Saunders Company 1524-153X/99/0102-0005 $10.00/0

widening of the femoral ring and development of iatrogenic femoral hernias. In the tension-free hernioplasty, instead of suturing anatomical structures that are not in apposition, the entire inguinal floor is reinforced by insertion of a sheet of mesh. The prosthesis, which is placed between the transversalis fascia and the external oblique aponeurosis, extends well beyond the Hesselbach triangle in order to provide sufficient mesh/tissue interface. Upon increased intra-abdominal pressure, the external oblique aponeurosis applies counter pressure on the mesh, thus, using the intra-abdominal pressure in favor of the repair. The procedure is both therapeutic and prophylactic; therefore, it protects the entire susceptible region of the groin to herniation from all future mechanical and metabolic adverse effects. Furthermore, it is suitable for all adult patients regardless of their age, weight, underlying disease, or the hernia size. The procedure is performed under local anesthesia, which is our preferred choice for all reducible adult inguinal hernias) It is safe, simple, effective, economical, and without any side effects such as nausea, vomiting, and urinary retention. Furthermore, local anesthesia administered before making the incision produces a prolonged analgesic effect via inhibition of the build-up of local nociceptive molecules. 3 Epidural anesthesia is preferred for repair of nonreducible inguinal hernias. Sedative drugs given by the surgeon, or preferably by an anesthetist as "conscious sedation" via infusion of rapid, short-acting amnesic and anxiolytic agents such as propofol, reduce the patient's anxiety. This also reduces the amount of local anesthetic agents required, particularly for bilateral inguinal hernia repair in obese patients.

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O p e r a t i v e T e c h n i q u e s i n G e n e r a l Surgery, Vol 1, No 2 (December), 1999: p p 156-168

Tension-Free Onlay Mesh Hernioplasty

15 7

TECHNIQUE OF ANESTHESIA
Several safe and effective anesthetic agents are currently available. Our choice is a 50:50 mixture of 1% lidocaine and 0.5% bupivacaine, with 1/200,000 epinephrine. An average of 45 mL of this mixture is usually sufficient for a unilateral hernia repair and is administered in the following fashion.

1 Subdermal injection. About 5 mL of the mixture is infiltrated along the line of the incision with a ll/2-inch-long 25-gauge needle inserted into the subdermal tissue parallel with the surface of the skin. Infiltration continues as the needle is advanced. Movement of the needle reduces the likelihood of intravascular infusion of the drugs because even if the needle penetrates a blood vessel, the tip will not remain in the vessel long enough to deliver a substantial amount of the anesthetic agent intravenously. This step blocks the subdermal nerve endings and reduces the discomfort of the intradermal infiltration (during the making of the skin wheal), which is the most uncomfortable stage of local anaesthesia.

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Amid et al

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2 Intradermic injection (making of the skin wheal). (Left) The needle in the subdermal plane is withdrawn slowly until the tip of the needle reaches the intradermic level. Without extracting the needle completely, the dermis is infiltrated by slow injection of about 3 mL of the mixture along the line of the incision. Deep subcutaneous injection. (Right) A total of 10 mL of the mixture is injected deep into the subcutaneous adipose tissue through vertical insertions of the needle (perpendicular to the skin surface) 2 cm apart. Again, injections are continued as the needle is kept moving to reduce the risk of intravascular infusion.

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3 Subaponeurotic injection. About 10 mL of the anesthetic mixture is injected immediately underneath the aponeurosis of the external oblique muscle through a window created in the subcutaneous fat at the lateral corner of the incision. This injection floods the enclosed inguinal canal and anesthetizes all three major nerves in the region (iliohypogastric, ilioinguinal, and genital branch of genitofemoral) while the remaining subcutaneous fat is incised. It also separates the external oblique aponeurosis from the underlying ilioinguinal nerve, reducing the likelihood of injuring the nerve when the external oblique aponeurosis is incised.

Occasionally, it is necessary to infiltrate a few milliliters of the mixture at the level of the pubic tubercle, at the internal ring, or inside the indirect hernia sac. The local anesthesia can be further prolonged by splashing 10 mL of the mixture into the inguinal canal before closure of the external oblique aponeurosis and in the subcutaneous space before skin closure. 3 A, indirect hernia bulge.

4

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SURGICAL

TECHNIQUE

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5 A 5- to 6-cm skin incision, which starts from the pubic tubercle and extends laterally within the Langer's line, gives excellent exposure of the pubic tubercle and the internal ring. It is important to start the incision exactly from the pubic tubercle in order to achieve adequate medial exposure. After skin incision, the external oblique aponeurosis is opened and its lower leaf is freed from the spermatic cord. The upper leaf of the external oblique is then freed from the underlying internal oblique muscle and aponeurosis for a distance of 3 cm above the inguinal floor. The anatomical cleavage between these two layers is avascular and the dissection can be done rapidly and nontraumatically. High separation of these layers has a dual benefit, because it allows for visualization of the iliohypogastric nerve, and creates ample space for insertion of a sufficiently wide sheet of mesh that can overlap the internal oblique by at least 3 cm above the upper margin of the inguinal floor. The cord with its cremaster covering is separated from the floor of the inguinal canal and the pubic bone for a distance of about 2 cm beyond the pubic tubercle. The anatomical plane between the cremasteric sheath and the aponeurotic tissue attached to the pubic bone is avascular, therefore, there is no risk of damaging the testicular blood flow. When lifting the cord, care should be taken to include the flioinguinal nerve, external spermatic vessels, and the genital branch of the genitofemoral nerve with the cord. This assures that the genital branch, which is always in juxtaposition to the external spermatic vessels, is preserved. The principal author found this method of preserving the genital branch safer and easier than the originally described "lesser cord" method (a method in which the genital nerve and external spermatic vessels are separated from the cord in the form of a bundle, referred to as the "lesser cord," and passed through a gap along the mesh-inguinal ligament sutureline)# Cutting or ligating the genital branch can cause long-term incapacitating neuralgia. The iliohypogastric nerve should also be preserved. (Reprinted with permission. 4a)

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D A B

6 Indirect hernia sac isolated from the cord. To explore the internal ring for indirect hernia sacs, the cremasteric sheath is incised transversely (if overly thick) or longitudinally at the level of the deep ring. The latter prevents the testicle from hanging low and dysfunction of the cremasteric muscles, which may lead to dysejaculation. Complete stripping and excision of the cremasteric fibers is unnecessary, and can result in injury to the nerves, small blood vessels, and vas deferens. Indirect hernial sacs are freed from the cord to a point beyond the neck of the sac and inverted into the abdomen without ligation. Because of mechanical pressure and ischemic changes, ligation of the highly innervated peritoneal sac is a major cause of postoperative pain. 6 It has been shown that nonligation of the indirect hernia sac does not increase the chance of recurrence. 6 To minimize the risk of postoperative ischemic orchitis, complete nonsliding scrotal hernia sacs are transacted at the midpoint of the canal, leaving the distal section in place. However, the anterior wall of the distal sac is incised to prevent postoperative hydrocele formation. A, preperitoneal fat; B, indirect hernia sac; C, ilioinguinal nerve; D, cremasteric muscle: E, deep epigastric vessels.

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7 In the event of direct hernias, if large, the direct sacs are inverted with an absorbable suture (see also "F" in 9). A thorough exploration of the groin is necessary to rule out the coexisting intraparietal (interstitial), low-lying Spigelian or femoral hernias. The femoral ring is routinely evaluated via the space of Bogros through a small opening in the canal floor.

8 A sheet of 8 X 16-cm mesh is used. We prefer monofilament polypropylene mesh because the surface texture promotes fibroplasia and the monofilamented structure does not perpetuate or harbor infection. r The medial end of the mesh is rounded to the shape of the medial corner of the inguinal canal. With the cord retracted upward, the rounded corner is sutured with a nonabsorbable monofilament suture to the aponeurotic tissue over the pubic bone, overlapping the bone by 1 to 1.5 cm. This is a crucial step in the repair because failure to cover this bone with the mesh can result in recurrence. The periosteum of the bone is avoided. This suture is continued (as a continuous suture with up to four passages) to attach the lower edge of the patch to the inguinal ligament up to a point just lateral to the internal ring. Suturing the mesh beyond this point is unnecessary and could injure the femoral nerve. (Reprinted with permission. s)

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9 If there is a concurrent femoral hernia, the mesh is also sutured to Cooper's ligament 1 to 2 cm below its suture line with the inguinal ligament (along the dotted line) to close the femoral ring. The same technique is used for the repair of isolated femoral hernias. A, external oblique aponeurosis; B, internal oblique muscle; C, transversus aponeurosis; D, transversalis fascia; E, peritoneum; F, inverted direct sac; G, Cooper's ligament; H, pubis; I, inguinal ligament; J, sperrnatic cord; K, mesh patch bridging defect; dotted line; fixation of the mesh to the ligament of Cooper for closure of the femoral ring.

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l 0 A slit is made at the lateral end of the mesh creating two tails, a wide one (two-thirds) above and a narrower one (one-third) below. The upper wide tail is grasped with a hemostat and passed toward the head of the patient from underneath the spermatic cord; this positions the cord between the two tails of the mesh. The wider upper tail is crossed and placed over the narrower one and held with a hemostat. (Reprinted with permission, z)

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11 With the cord retracted downward and the upper leaf of the external oblique aponeurosis retracted upward, the upper edge of the patch is sutured in place with two interrupted absorbable sutures, one to the rectus sheath and the other to the internal oblique aponeurosis, just lateral to the internal ring. Occasionally, the iliohypogastric nerve has an abnormal course and stands against the upper edge of the mesh. In those instances, a slit in the mesh will accommodate the nerve. Sharp retraction of the upper leaf of the external oblique during this phase of the repair is important because it achieves the appropriate amount of laxity for the patch. When the retraction is released, the mesh buckles slightly, and this laxity assures a true tension-free repair and is taken up when the patient strains on command during the operation or resumes an upright position. More importantly, it compensates for the future contraction of the mesh. ~ (Reprinted with permission. 5)

12 Using a single nonabsorbable monofilamented suture, the lower edges of each of the two tails are fixed to the inguinal ligament just lateral to the completion knot of the lower running suture. This creates a new internal ring made of mesh. The crossing of the two tails produces a configuration similar to that of the normal transversalis fascia sling, which is assumed to be largely responsible for the normal integrity of the internal ring. In addition, it results in buckling or sagitattion of the mesh in this area and assures a tension-free repair of the internal ring area. The excess patch on the lateral side is trimmed, leaving at least 5 cm of mesh beyond the internal ring. This is tucked underneath the external oblique aponeurosis, which is then closed over the cord with an absorbable suture. Fixation of the tails of the mesh to the internal oblique muscle, lateral to the internal ring, is unnecessary and could result in entrapment of the ilioinguinal nerve with the fixation suture.

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Technical Considerations The following are technical considerations in relation to other approaches such as preperitoneal repair (open and laparoscopic), sutureless, and mesh plug repairs: (1) Using a wide piece of mesh to overlap tissues beyond the boundary of Hesselbach's triangle for 3 to 4 cm is important in reducing the chance of recurrence. After incorporation is complete, this overlap results in uniform distribution of intra-abdominal pressure over the much wider surface of the overlapped area, rather than just the line where the mesh is joined to the tissue. More importantly, it compensates for future shrinkage of the mesh. 7 (2) Because the mesh is placed behind the external oblique aponeurosis, the intra-abd0minal pressure works in favor of the repair. The external oblique aponeurosis keeps the mesh tightly in place by acting as an external support when intra-abdominal pressure rises. Although a sound concept, placement of the mesh underneath the transversalis fascia, in the preperitoneal space, requires unnecessary dissection of this highly complex anatomical space and may lead to major bladder and neurovascular injuries. In fact, a recent prospective and randomized study comparing the Lichtenstein repair with repair by placement of the mesh behind the transversalis fascia indicated no difference in the recurrence rate. 8 In addition, the study concluded that Lichtenstein's repair was easier to perform, teach, and Iearn. a (3) Proper fixation of the margins of the mesh to the groin tissue is another important step in the prevention of recurrence. In mobile areas such as the groin, there is a tendency for the prosthesis to fold, wrinkle, or curl around the cord. More importantly, according to our laboratory and clinical studies, in vivo, mesh prostheses lose approximately 20% of their size because of shrinkage. 7 Even the slightest movement of the mesh from the pubic tubercle, the inguinal ligament, and the area of the internal ring is a leading cause of failure of mesh repair of inguinal hernias. (4) Adequate laxity of the mesh must be allowed during fixation to totally eliminate tension, to compensate for increased intra-abdominal pressure when the patient stands or strains, and for future shrinkage of the mesh. 7 A mesh that is completely fiat with no ripple in a patient under sedation and in a recumbent position, will be subject to tension when the patient strains or is in a standing position. (5) Creation of a new internal ring by crossing the tails of the mesh is another important part of the mesh hernioplasty. Making a new internal ring by edge-to-edge suturing of the two tails of the mesh laterally to the ring results in recurrences of indirect hernias behind the cord. 9 Furthermore, based on 25 years of experience with the mesh plug repair at the Lichtenstein Hernia Institute, insertion of a plug into the internal ring to secure the ring

A m i d et al

and to safeguard the repair by placement of the prosthesis in the preperitoneal space is not as effective as crossing the tails of the mesh because: (a) plugs cannot act as an adequate preperitoneal prothesis because they are far smaller than 10 • 15 cm, which is the minimum requirement of an adequate preperitoneal prosthesis; and (b) after implantation, depending on their looseness, mesh plugs (Lichtenstein's cigarette plug, Gilbert's umbrella plug, and Robin-Rutkow's Perfix plug) lose up to 75% of their diameter and convert to an abrasive and hard foreign body 10,11 As a result of shrinkage, anchoring sutures of the plug pull through the margin of the hernia defect, leading to recurrence of the hernia and the occasional migration of the plug. 10-13Furthermore, insertion of a plug behind the transversalis fascia and into the internal ring and small space of Bogros, places the plug in close proximity with the geniofemoral nerve, iliac vessels, and the bladder. In fact, migration into the inguinal canal, 13 scrotum 1~ and deep into the pelvis, 11 and neuralgia 14 from Perfix plug repair have been observed by us and reported by other authors. In addition, erosion of the Lichtenstein cigarette plug and Gilbert umbrella plug into the bladder7 and the intestines15,16 has been reported. Outcome Measures Reported by more than 100 authors from Europe and the US, the results of the open tension-free hernioplasty are as follows: P o s t o p e r a t i v e pain. Regardless of the approach (open or laparoscopic), tension-free mesh repair of inguinal hernias results in minimal postoperative pain, requiring only moderate oral analgesic for a period of 1 to 4 days. Several prospective, randomized studies including those by one of u s ( G . H . ) 17 and by Filipi et aI is show no statistical difference in postoperative pain after open tension-free hernia repair compared with the laparoscopic tension-free technique. In fact, a five-armed study by Kawji et a119 comparing Lichtenstein repair under local and general laparoscopic repair, Shouldice repair, and open preperitoneal repair showed that postoperative pain, as well as the postoperative analgesic requirement, were lowest after Lichtenstein repair under local, followed in order by Lichtenstein under general, laparoscopic repair, Shouldice repair, and open preperitoneal repair. This is not to say that one approach is less painful than the other; instead, it is only to conclude that tension-free repair (regardless of the approach) is associated with minimal discomfort, which results in a faster recovery and return to normal activities. R e t u r n to W o r k Returning to work after hernia operation is a complex socioeconomic issue that largely depends on preopera-

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Authors' Results of the Lichtenstein Tension-Free Hernioplasty Return toWork (days) 2-14 3-36 2-24 not recorded Hematoma (%) <1 2 2 2 Seroma (%) <1 4 4 2 Infection (%) <1 2 2 2 Testicular Atrophy 1/4,000 1% 0 0.9% Mesh Infection 0 0 0 0

Table 1.

Authors Amid Horyseck Kux Friis

Pain Control 0-20 tabs (mean, 8), hydrocodone 0-20 tabs (mean, 4), diclofenan 0-20 tabs metamizol 6 tabs, naproxen

Recurrence 1/1,000 0.25% 0.9% 0%-1%*

Neuralgia 1/4,000 1.2% 1.4% 0.5%

Abbreviations: tabs, tablets. *0% for indirect, and 1% for direct hernias.

tive patient education and patient motivation. In general, return to work after tension-free hernioplasty (regardless of the approach) is between 2 to 14 days depending on the patient's occupation. According to several major series, return to work after open tension-free repair for bilateral inguinal hernia is a maximum of 2 days longer than unilateral repair. 2~ This is comparable with return to work after laparoscopic repair of bilateral inguinal hernias.

Recurrence Rate
The reported recurrence rate of the procedure is less than 1%. Early in the evolution of tension-free hernioplasty, several patients operated on at the Lichtenstein Hernia Institute developed recurrences as a result of technical errors. Three hernias reoccurred at the pubic tubercle because of a failure to overlap the bone with the mesh. One resulted from total disruption of the mesh from the inguinal ligament because the mesh was too narrow. Lessons learned from these recurrences led to overlapping the mesh with the pubic bone, increasing the width of the mesh to approximately 7.5 cm, and keeping the mesh slightly wrinkled. These refinements, adopted by the principal author in late 1980s, 4 served to further decrease the postoperative pain and compensate for the future shrinkage of the mesh in order to avoid recurrences .4,7 Complications Complications such as infection, hematoma, and seroma occur in approximately 1% of the cases. The most serious complications associated with the technique are chronic neuralgia and testicular atrophy, which occur in a fraction of 1%. Table 1 summarizes the authors' results from two universities and two private practice settings.

time off work, complications, costs, and recurrence rate. Comparison of data from different institutions studying the same conventional herniorrhaphies are characterized by a considerable variation in results from institution to institution, whereas studies of the open tension-free hernioplasty report remarkably uniform results, a fact that increases the validity of the individual studies. Published series, many from European universities, show that the open tension-free hernioplasty can safely be performed under local anesthesia and allows patients immediate mobilization, keeping hospital stay, cost, and patient discomfort at a minimum. Furthermore, published recurrence rates are uniformly low, 1% or less, after the tension-free operation performed as described previously, Fifteen years after the beginning of the tension-free hernioplasty in 198"$ and 10 years after the publication of the first series of open tension-free hernioplasty in 1989, the operation has been thoroughly evaluated in large series and has been gaining increasing acceptance with surgeons around the globe. In fact, a recent survey in England showed that 70% of British surgeons are now employing the Lichtenstein tension-free method of hernia repair. 23 From a surgical point of view, the operation is simple, and safe. Randomized studies indicate that excellent results from the open tension-free operation are less dependent on the experience of the surgeon than results from conventional tissue repair or laparoscopic operation, an indication of the simplicity of the operation and short learning curve. 1z,22 The same technique can safely be applied to all inguinal hernias, as well as recurrent hernias.10,24

REFERENCES
1. Lichtenstein IL: Immediate ambulation and return to work following herniorrhaphy. Indust Med Surg 35:754-759, 1996 2. Read RC: A review: The role ofprotease-antiprotease imbalance in the pathogenesis of herniation and abdominal aortic aneurism in certain smokers. Postgrad Gen Surg 4:161-165, 1992 3. Amid PK, Shulman AG, Lichtenstein IL: Local anesthesia for inguinal hernia repair step-by-step procedure. Ann Surg 220: 735737, 1994 3a.Lichtenstein I (ed): Hernia Repair Without Disability (ed 1). St Louis, MO, CV Mosby, 1970

Conclusion
Since the introduction of the open tension-free hernioplasty in 1984, the operation has been evaluated and compared with other types of hernia repairs in several studies with regard to postoperative pain, postoperative

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4. Amid PK, Shulman AG, Lichtenstein IL: Critical scrutiny of the open tension-free hernioplasty. AmJ Surg 165:369-371, 1993 4a. Amid PK, Shulman AG, Lichtenstein IL: The Lichtenstein open "tension-free" mesh repair of inguinal hernias. Surg Today 25:619625, 1995 5. Smedgerg SGG, Broome AEA, Gullmo A: Ligation of the hernia sac? Surg Clin North Am 64:299-306, 1984 6. Amid PK: Classification of biomaterials and their related complications in abdominal wall hernia surgery. Hernia i:12-19, 1997 7. Bonwich JP, Johnson DD, Read RC, et al: Randomized trial of superficial and preperitoneal prosthetic mesh placement in inguinal hernia repair. Hernia 1:$3, 1998 (abstr) 8. Celdran A: Objetivos del uso de los biomateriales, su clasificacion e interaccion con el tejido conjunctivo, in Auspiciado por la Sociedad Espanola de Cirujanos: Fundamentos y tecnicas de la hernioplastia sin tension. Madrid, Spain, Curso Internacional, Universidad Autonoma de Madrid, 1998 9. Amid PK, Lichtenstein IL: Long-term result and current status of the Lichtenstein open tension-free hernioplasty. Hernia 2:89-94, i998 10. Gai H: Hernienoperation mach Lichtenstein. Chir Praxis 54:183195, 1998 1 I. Dieter RAJr: Mesh plug migration into scrotum: A new complication of hernia repair. Int Surg 84:57-59, 1999 12. Flament JP: Experience with the mesh umbrella repair on recurrent inguinal hernia, in Schumpelick V, Kingsnorth AN (eds): Incisional Hernia. New York, NY, Springer-Verlag, 1999, pp 396-401 13. Palot JP, Avisse C, Cailliez-TomasiJR et al: The mesh plug repair of groin hernias: A three year experience. Hernia 2:31-34, 1998

Amid et al 14. Gilbert AI, Graham MF: The internal inguinal ring is nature's window into the preperitoneal space--Why not use it?, in Chevrel JP (ed): Hernias and Surgery of the Abdominal Wall (ed 2). New York, NY, Springer-Verlag, 1997, pp 210-214 15. Danielfi PG, Kurihara H, Montecamozzo G, et al: Le complicanze dei plugs: Infezioni e recidive. Hernia i:55, 1997 i6. Horeyseck G, Roland F, Rolfes N: Die "spannungsfreie" reparation der Leistenhernie: Laparoskopisch (TAPP) versus often (Lichtenstein) Chirurg 67:1036-1040, 1996 17. Filipi CJ, Gaston-Johansson F, McBride PJ, et al: An assessment of pain and return to normal activity: Laparoscopic herniorrhaphy versus open tension-free Lichtenstein repair. Surg Endosc 10:983986, 1996 18. Kawji R, Feichter A, Fuchsjager N, et al: Postoperative pain and return to activity after five different types of inguinal herniorrhaphy. Hernia 3:31-35, 1999 I9. Kark AE, Kurzer MN, Belsham PA: Three thousand one hundred seventy-five primary inguinal hernia repairs: Advantages of ambulatory open mesh repair using local anesthesia. J Am Coll Surg 186:447-456, 1998 20. Amid PK, Shulman AG, Lichtenstein IL: Simultaneous repair of bilateral inguinal hernias under local anesthesia. Ann Surg 223:249-252, 1996 2i. Wantz GE: Experience with tension-free hernioplassty for primary inguinal hernias in men. J Am Coll Surg 193:351-360, 1996 22. O'Riordan DC, Morgan M, Kmgsnorth AN, et al: The surgical management of inguinal hernias in England. Hernia 2:S17, i998 (abstr) 23. Horeyseck G, Pohl C: Lichtenstein-patch repair of recurrent inguinal hernia. Hernia 2:$6-$7, 1998

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