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 tension-
free 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 her-
nias are associated with impaired hydroxilation of proline.
These changes lead to the weakening of the fibroconnec-
tive 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
156 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
widening of the femoral ring and development of iatro-
genic 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 aponeuro-
sis applies counter pressure on the mesh, thus, using the
intra-abdominal pressure in favor of the repair. The
procedure is both therapeutic and prophylactic; there-
fore, 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 dis-
ease, 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 propo-
fol, reduce the patient's anxiety. This also reduces the
amount of local anesthetic agents required, particularly
for bilateral inguinal hernia repair in obese patients.
Tension-Free Onlay Mesh Hernioplasty 15 7

TECHNIQUE OF ANESTHESIA

Several safe and effective anesthetic agents are cur-

rently available. Our choice is a 50:50 mixture of 1%
lidocaine and 0.5% bupivacaine, with 1/200,000 epineph-
rine.
An average of 45 mL of this mixture is usually
sufficient for a unilateral hernia repair and is adminis-
tered 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.
158 Amid et al

,', ; ;
,,--:'---~:==2-

termal
l

Subcutaneous

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.
Tension-Free Onlay Mesh Hernioplasty 159

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 (iliohypogas-
tric, 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 aponeu-
rosis is incised.

4 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.
160 Amid et a|

SURGICAL TECHNIQUE

Ilic

Externa
apon(

Internal c
muscle
aponeu

luinal
~e

anch

al nerve

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)
Tension-Free Onlay Mesh Hernioplasty 161

D A

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.
162 Amid et al

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 sur-
face texture promotes fibroplasia and the monofila-
mented structure does not perpetuate or harbor infec-
tion. 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, overlap-
ping 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 permis-
sion. s)
Tension-Free Onlay Mesh Hernioplasty 163

~: A

--E

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.
164 Amid et al

FX
spe
ve

Genital
o
genitof~
ner

.......

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)
Tension-Free Onlay Mesh Hernioplasty 165

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 be-
cause 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 unneces-
sary and could result in entrapment of the ilioinguinal
nerve with the fixation suture.
166
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 anatomi-
cal space and may lead to major bladder and neurovascu-
lar 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 addi-
tion, 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 shrink-
age. 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 compen-
sate 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 um-
brella 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, inser-
tion 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 ves-
sels, 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 includ-
ing 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 laparo-
scopic 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, fol-
lowed in order by Lichtenstein under general, laparo-
scopic 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 associ-
ated 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-
Tension-Free Onlay Mesh Hernioplasty
Table 1. Authors' Results of the Lichtenstein Tension-Free Hernioplasty
Return
toWork
Authors Pain Control (days) Recurrence
Amid 0-20 tabs (mean, 8), hydrocodone 2-14 1/1,000
Horyseck 0-20 tabs (mean, 4), diclofenan 3-36 0.25%
Kux 0-20 tabs metamizol 2-24 0.9%
Friis 6 tabs, naproxen not recorded 0%-1%*
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 overlap-
ping 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 recur-
rences .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 frac-
tion of 1%.
Table 1 summarizes the authors' results from two
universities and two private practice settings.
Conclusion
Since the introduction of the open tension-free hernio-
plasty in 1984, the operation has been evaluated and
compared with other types of hernia repairs in several
studies with regard to postoperative pain, postoperative
167
Hematoma Seroma Infection Testicular Mesh
(%) (%) Neuralgia (%) Atrophy Infection
<1 <1 1/4,000 <1 1/4,000 0
2 4 1.2% 2 1% 0
2 4 1.4% 2 0 0
2 2 0.5% 2 0.9% 0
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, pub-
lished recurrence rates are uniformly low, 1% or less, after
the tension-free operation performed as described previ-
ously,
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 her-
nia 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 opera-
tion, 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
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