How to avoid recurrence in Lichtenstein tension-free hernioplasty.

The following key principles of the Lichtenstein tension-free hernioplasty can help avoid recurrence and decrease postoperative pain: (1) Use a large sheet of mesh that will extend approximately 2 cm medial to the pubic tubercle, 3 to 4 cm above Hesselbach's triangle, and 5 to 6 cm lateral to the internal ring. (2) Cross the tails of the mesh behind the spermatic cord to avoid recurrence lateral to the internal ring. (3) Secure the mesh with two interrupted sutures on the upper edge and one continuous suture with no more than 3 to 4 passes on the lower edge of the mesh to prevent folding and movement of the mesh in the groin. (4) Position the mesh in a slightly relaxed dome shape configuration to counteract the forward protrusion of the transversalis fascia when the patient stands up from the intraoperative supine position. (5) Identify and protect the ilioinguinal, iliohypogastric, and genital nerves throughout the operation.