[The modified Lichtenstein technique for complex inguinal hernia repair--how I do it]

The Lichtenstein technique is modified for solving complex groin hernias such as huge hernias with massive transversal fascia destruction associated with the increased intraabdominal pressure or recurrent hernias with the destroyed Poupart's ligament. Whilst these hernias are usually managed by preperitoneal techniques (open or laparoscopic) under general or regional anesthesia, as an "inpatient" procedure, they can be solved applying a modified Lichtenstein technique, most frequently under local anesthesia, as an "out-patient" procedure. The modifications of Lichtenstein technique include the foIlowing: a) lateral movement and fixation of the lower corner of the mesh, caudally to the tubercle, by 20-30 degrees in relation to its lower border, fully protecting the medial triangle (direct inguinal recurrence prevention); b) fixation of the lower border of the mesh by a running "U" suture to both Poupart's and Coopers's ligaments, from the tubercle to the femoral vein, fully protecting the femoral triangle (femoral recurrence prevention); c) the lower mesh border fixation by a running suture, 2-3 cm laterally to the internal inguinal ring, together with the "locking" of the internal inguinal ring by two interrupted sutures, one fixing the superior mesh tail to the inferior one--cranial to the spermatic cord, 1-1,5 cm medially to the Poupart's ligament, and the other fixing the lower border of the superior mesh tail and the lower border of the inferior mesh tail to the inferior part of the Poupart's ligament, 1 cm cranially and laterally to the preceding suture, fully protecting the lateral triangle (indirect inguinal recurrence prevention). One thousand eighteen patients with 1236 (unilateral 800, bilateral 218) inguinal hernias were electively operated on by the modified Lichtenstein technique between January 2003-January 2011. All operations were performed by a single surgeon. One hundred and thirty (10.5%) hernias were recurrent following one or more tension or tension-free repairs, and 203 (16.4%) hernias had a > or = 5 cm hernial defect. In seven hundred and twentyfour (71.1%) patients, the operation was performed under local, in 271 (26.6%) under general, and in 23 (2.3%) under regional anesthesia, while 635 (62.4%) patients were operated on an "out-patient" basis, and 383 (37.6%) on an "in-patient" basis. The ASA score was: 388 ASA I, 450 ASA II, 153 ASA III, and 27 ASA IV. The mean stay at a day surgery unit was 2.5 (2-8) hours, and the mean hospital stay was 1.6 (1-10) days. During the mean follow-up of 37 (1-96) months, the rate of complications was: 23 (1.86%) haematoma, 5 (0.4%) seroma, 5 (0.4%) wound infections, 6 (0.48%) ischaemic orcihitis, 2 (0.16%) testicle atrophy, 1 (0.08%) disejaculation, 3 (0.24%) hydrocoella, 21 (1.7%) pain, and 2 (0.16%) recurrence. There were 6 reoperations due to the complications. The modified Lichtenstein technique performed usually under local anesthesia as "a day-case" procedure is a good solution for challenging groin hernias.