INGUINAL

HERNIA

INTRODUCTION Current Problems in Surgery last presented a monograph on inguinal hernia, by Chester B. McVay, Raymond C. Read, and Mark M. Ravitch, in 1967.’ Twenty-four years later, we again are presented with the challenge of reviewing a vast bibliography relating to this common problem and interesting subject. Our effort in a project of this magnitude has a dual purpose. The first, given the wealth of literature on hernias, is to provide an informational resource. Toward this end, we have collected current references that will assist medical students, residents, and general surgeons at all levels of experience. The second purpose is to present a forum for the examination of old and new controversies in hernial surgery. If we have been successful, readers will find that traditional hernia topics are not stale or outmoded but, in light of new observations, are fresh, dynamic, and practical in our everyday approach to the problem of hernias. A classification of groin hernia is presented. In conjunction with an individualized approach to hernial repair, this classification, for the first time, allows for greater precision in operative management. Our entire presentation is dedicated to decreasing the incidence of recurrent hernia, which plagues the surgical world today. The classification of hernias and the matching of specific operative techniques to types of hernia should help each of us to the degree that 25 years from now, less emphasis will be given to the subject of recurrence than is presented herein. The vexing problem of recurrent hernia must be abolished.

ANATOMIC

CONSIDERATIONS

LAh4INAR STRUCTURE

OF THE INGUINAL

REGION

The posterior inguinal wall, a part of the all-encompassing endoabdominal fascia, is the key anatomic layer in which lies the hernial fascial defect. Indeed, the transversalis fascia layer with its analogues

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holds primacy as the tissue readily available for repair during herniorrhaphy. The abdominal wall is composed of musculoaponeurotic layers, and in the inguinal region this arrangement is separated into two laminar structures (Fig 1). Disruption or stretching of one or more of the abdominal laminae gives rise to a groin hernia. The essential goal of the hernial repair, therefore, is to restore the structural integrity of the musculoaponeurotic laminae. In the groin, inguinofemoral hernias specifically result from the breakdown of the transversalis fascia lamina. Other structures and laminae are secondarily displaced. A direct inguinal hernia is a weakening of the transversalis fascia in the Hesselbach triangle (the posterior wall of the inguinal canal). An indirect inguinal hernia is a dilatation of the transversalis fascia lamina at the margins of the internal abdominal ring. It may also progress to involve the posterior wall of the inguinal canal. A femoral hernia is a dilatation of the orifice of the femoral canal that impinges on the transversalis fascia above and medial to the orifice. In every setting of inguinofemoral hernia, then, the basis of repair must be an anatomic restoration of the altered transversalis fascia lamina.

Internal rinq

erna

oblique --- v t Inquinal canal .A

jlliopubic ct

FIG 1. Parasagittal rlor laminar Philadelphia, 408

section through the right midingutnal region illustrating structures. (From Nyhus LM, in Nyhus LM, Condon JB Lipplncott, 1989, p 158. Used by permission.) Curr

the anterior and RE (eds): Hernia,

Probl

Sun-g,

posteed 3.

June 1991

FIG 2. Fascromusculoaponeurotrc components of the lower abdominal wall. The spermatrc cord has been removed and the rliopubic tract IS reflected to demonstrate fascial continuity with the femoral sheath. The posterior inguinal wall (transversus abdominis-transversalis fascia lamina) is firmly “rooted” to the thigh at this point. The crura of the internal abdomrnal ring also are well shown. (From Nyhus LM: Surg Cl/n North Am 1964; 44:1305-1313. Used by permissron.)

The structures often actually used in repairing a hernia are a group of ligamentous and aponeurotic structures closely associated with the transversalis fascia; these structures are termed transversalis fascia analogues. These analogues are capable of retaining sutures and provide the strength required for the reapproximation and restoration of the transversalis fascia (Fig 2). The distinction between transversalis fascia proper and transversalis fascia analogues is made to help clarify the concept of laminar repair.’ TRANSVERSALIS

FASCIA

Transversalis fascia is the investing fascia on the inner surface of the transversus abdominis muscle; it covers that muscle and its aponeurotic tendon of insertion.3-6 The transversalis fascia in the groin is not an isolated structure but is part of the continuous sheet of fascia that surrounds the entire peritoneal cavity, the endoabdominal Curr

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fascia. Therefore, transversalis fascia, which covers the transversus abdominis muscle, is continuous with the iliacus and psoas fascia laterally and quadratus fascia posteriorly. Medially, the transversalis fascia is continuous with the posterior investing fascia of the rectus abdominis muscle. Inferiorly, it inserts into the Cooper ligament; this relationship is particularly clear medially and along the pecten of the pubis. However, the transversalis fascia does not simply end there; it proceeds inferiorly to become continuous with the levator

and obturator

fasciae.

In a direct

months,

hernia

that

the transversalis

the hernial

has been present

defect. Some of the thickening

the aggregation

for more

fascia becomes thickened

of displaced

than

a few

at the margins

is undoubtedly

fascial fibers around

of

caused by

the neck of the

hernial sac. The transversalis fascia frequently assumes a character such that it may be easily sutured with assurance that the repair will hold, as in the plastic closure of the internal abdominal ring. TRANSVERSALIS FASCIA ANALOGUES Fascial condensations

muscular

together

aponeuroses

salis fascia analogues.

strengths.

with

contributions

from

form the group of structures These analogues

Some are more constant

nial repair

than others.

lliopectineal

Ligament

exhibit

a variety of forms and

and thus more important

In the lateral aspect of the groin where transversus cia becomes

thickening

reflected

of the fascia to form a ligament. iliac spine laterally;

of the inguinal

ligament

are attached

portion.

Arching

for the

cremaster

obliquus

internus

more medially

and

and inferiorly,

ligament

the

and transversus

fibers

ligament’s

along the surface of the ilia-

the iliopectineal

muscle

the most inferior

to the iliopectineal

medially

fas-

there is a

This fascial band begins

superior

cus and psoas muscles,

in her-

abdominis

onto the iliacus and psoas muscles,

at the anterior most lateral

adjacent

called transver-

provides

intermingled

abdominis

the ligament

an origin

origins

muscles.

of the

Somewhat

gives rise to the iliopubic

tract and joins on its medial aspect with the lateral crus of the internal abdominal ring. Continuing inferiorly, the iliopectineal ligament contributes to the lateral aspect of the femoral sheath and terminates by inserting into the pubic bone in the region of the ilio-

pectineal

eminence.

The importance

of this ligament

is principally

as an anatomic

landmark.

Iliopubic Tract The iliopubic

tract is a strong fascial band that originates

from the midportion 410

of the iliopectineal

ligament.7 Curr

laterally

It lies immediProbl

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FIG 3. A, The important structures, seen from the preperitoneal groin hernias. (From Nyhus phia, JB Lippincott, 1989, p

transversalis fascia analogues of the posterior inguinal wall as approach. B, The same view demonstrating sites of common LM, in Nyhus LM, Condon RE (eds): Hernia, ed 3. Philadel160. Used by permission.)

ately subadjacent, internal, and cephalad to the inguinal ligament in its midportion. It is, however, easily separated from the inguinal ligament, and its relationship is one of proximity only. From its origin, the iliopubic tract arches over the femoral sheath, firmly attached to the anterior leaf of that sheath. It turns caudally to insert fanwise into the Cooper ligament throughout the midportion of the ligament. The medial border of the femoral canal is the iliopubic tract not the lacunar (or Gimbernat) ligament of classic description. The importance of the iliopubic tract in hernial repair of the groin can be appreciated best when the posterior inguinal wall is visualized by the preperitoneal approach. The iliopubic tract is then noted to be a tough and resilient ligament through which the transitional suture on the medial aspect of the femoral sheath is placed during the Cooper ligament repair of a groin hernia. The iliopubic tract is adjacent to each of the common groin hernias (Fig 3). Direct and indirect inguinal hernial defects are limited on their posterior aspects by the fibers of the iliopubic tract. Femoral hernial defects are similarly limited on their medial and anterior aspects. Curr

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Crura of the Internal Abdominal Ring: Transversalis Fascia Sling and the Znterfoveolar Ligament The internal abdominal ring is ovoid. At its anterior, medial, and posterior borders a condensation of tissue is present within the transversalis fascia, forming a sling (see Fig 2). On the lateral aspect, the fibers of the crura spread far-wise and are quickly lost within the general transversalis fascia. The medial aspect of the sling, in contrast, is a particularly dense, tough band, located immediately subadjacent to the origin and proximal course of the inferior epigastric vessels. The vas deferens turns over this band at an acute angle. Occasionally, fibers from the medial aspect of the sling continue superiorly as a definite band, known as the interfoveolar ligament, as far as the border of the rectus abdominis muscle. In performing a plas-

FIG 4. Posterior inguinal wall depicting relationships between the iliopubic tract, femoral sheath, internal abdominal ring, and transversalis fascia in the Hesselbach triangle. The anterior and posterior crura of the transversalis fascia surrounding the deep ring are clearly seen. 1 = transversus abdominis muscle; 2 and 9 = obliquus internus muscle; 3 and 4 = iliac fascra; 5 = iliopsoas muscle; 6 = fusion of iliac fascia and femoral sheath; 7, 12, 14, 15, and 17 = termination of transversus abdominis aponeurosis; 8 and 18 = femoral vessels; 10 = internal abdominal ring; 11 = iliopubic tract; 13 = transversalis fascia in the Hesselbath triangle; 16 = pecten of the pubis. (From Fruchaud H: Anafomie Chirurgicale des Hernies De L’Aine. Paris, G. Doin, 1956. Used by permission.)

412

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tic closure proximated

of the internal abdominal ring, the anterior to the posterior crus-iliopubic tract.’

crus is ap-

Femoral Sheath The femoral sheath is a tubular fascial structure, wider on the top and tapering on the bottom to closely approximate the adventitia of its contained vessels.’ The ostium of the femoral sheath is continuous with the transversalis fascia. In addition to its relationship with the transversalis fascia, the femoral ostium is reinforced superiorly and medially by the arching fibers of the iliopubic tract; inferiorly, it is in close relation to the Cooper ligament and, laterally, to the iliopectineal ligament. These ligaments are all intimately bound to the uppermost fibers of the sheath, providing strong reinforcement (Fig 4). About 1 cm distal to its internal ostium, the femoral sheath relates anteriorly to the inguinal ligament, which is easily separated from the sheath. It is at this point of narrowing of the femoral canal (insertion of lacunar or Gimbernat ligament) that incarceration of a femoral hernia regularly occurs. THE BIOLOGY

OF GROIN HERNIAS

THE BIOLOGY OF INGUlNAL

HERNLATION

An indirect inguinal hernia is congenital in origin. It requires a preformed or potential hernial sac, namely, the processus vaginalis. The processus vaginalis is the tubular anlage along which the fetal testis moves from its retroperitoneal origin into the scrotum. Normally, the processus vaginalis obliterates to form a fibrous cord, the ligamentum vaginale, which extends from the parietal peritoneum deep to the internal ring through the inguinal canal to the testis. Depending on the length of the patent processus vaginalis, an indirect inguinal hernia may extend into the inguinal canal, through the external ring, or protrude into the scrotum. Anomalies of descent of the processus are frequently related. An undescended testis is always associated with an indirect inguinal hernia, and the occurrence of hydrocele with indirect hernia is likewise well known. Russell’s “saccular theory” of indirect inguinal herniation 11906)‘” was subsequently expanded to include a role for weakening of the transversalis fascia at the internal abdominal ring.‘l In the final analysis, indirect inguinal hernias are a result of a combination of two factors: the presence of a potential space within the processus vaginalis, which may open into an indirect hernial sac at any time from birth to death; and the concomitant weakening of the transversalis fascia crura surrounding the spermatic cord structures at the internal abdominal ring. These two factors play an imCorr

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413

portant role in the etiology of indirect hernias in both men and women. Direct inguinal hernias are not congenital but are acquired. The shutter mechanism of the aponeurotic arch of the transversus abdominis muscle when properly functioning protects the floor of the inguinal canal from incursions of intraabdominal pressure?’ When the shutter mechanism is defective, the transversalis fascia of the posterior inguinal wall is directly exposed to intraabdominal pressure. Acquired tissue deficiencies predispose to weakening of the inguinal floor and subsequent direct hen-nation. The pivotal role of changes within the transversalis fascia lamina was corroborated by studies of collagen biochemistry. Peacock and colleagues attributed transversalis fascia weakening to a cellular metabolic collagen defect .13,I4 Read and colleagues reported on a series of chronic smokers who had primary direct inguinal herniation. In these patients with “metastatic emphysema,” circulating proteases of pulmonary origin increased serum elastolytic activity. This observation correlated with a qualitative defect in the inhibitory capacity of alpha,-antitrypsin, a predominant circulating antiprotease.15-17 PHYSIOLOGY OF THE STRUCTURES

OF THE INGUINAL

CANAL

Two mechanisms act to preserve the structural integrity of the inguinal canal and to prevent herniation of abdominal contents through the transversalis fascia of the Hesselbach triangle (floor of inguinal canal) and the internal abdominal ring. The shutter mechanism is produced by movement of the transversus aponeurotic arch. This arch, which is normally convex at rest, straightens and flattens when the transversus abdominis and obliquus internus muscles are tensed. This tensing action moves the arch toward or in apposition to the iliopubic tract, thereby reinforcing the floor of the inguinal canal (Fig 5). In theory, the appearance of a direct inguinal hernia may be explained by a defective transversus aponeurotic arch because if the arch is in an abnormal position, it cannot effectively reinforce the Hesselbach triangle when the abdominal muscles are tensed. This exposes a single layer of transversalis fascia in the Hesselbach triangle to the strong forces of intraabdominal pressure, eventuating in a direct inguinal hernia. The internal abdominal ring is attached to the transversus abdominis muscle by the transversalis fascia sling. In the sphincter mechanism, when the transversus abdominis contracts, the transversalis fascia sling is pulled superiorly and laterally to close the internal ring around the cord structures? For the coordinated actions of the sphincter and shutter to occur, the transversalis fascia and related structures must be free to move in their respective laminar planes. 414

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FIG 5. Schematically illustrated posterior view of the lower right anterior abdominal wall. The drawings show how the two most important factors that protect against inguinal hernia operate. A, The abdominal muscles are in the relaxed position. B, What happens when the oblrquus internus and transversus abdominis muscles contract. Shutter mechanism: When the obliquus internus and transversus abdominis muscles contract, they cover the posterior wall of the inguinal canal. Sphincter mechanism: Contraction of the transversus abdominis muscle results in the cranial-lateral displacement and narrowing of the deep inguinal ring. 1 = femoral vessels; 2 = spermatic cord; 3 = superior ramus of the pubic bone; 4 = lacunar ligament: 5 = iliopubic tract; 6 = posterior wall of inguinal canal; 7 = transversus abdominis arch; 8 = inferior epigastric artery; 9 = deep inguinal ring; 10 = inguinal ligament; 11 = lateral edge of the rectus abdominis muscle. (From Spangen L, Anderson R, Ohlsson, LM in Nyhus LM, Condon RE (eds): Hernia, ed 3. Philadelphia, JB Lippincott, 1989, p 76. Used by permission.)

Therefore, any operative repair that sutures the posterior lamina to a superficial fixed structure such as the inguinal ligament disrupts the shutter and sphincter mechanisms. Direct injury to either mechanism increases the risk of herniation. For example, the McBurney incision for appendectomy may injure the nerve supply to the musculature of the internal abdominal ring.1g Laparoscopic views of the internal abdominal ring after an appendectomy have demonstrated poor to absent contractions during coughing or straining. Arnbjornsson reported a threefold increase in the incidence of right inguinal hernia in men who had UIIdergone appendectomy.” Women are less susceptible to direct inguinal herniation because several factors contribute to make the shutter and sphincter mechanisms more efficient. The Hesselbach triangle is regularly covered by transversus abdominis aponeurosis, and the smaller configuration of the internal abdominal ring (produced by the exit of the round ligament) makes the sphincter mechanism more resistant to indirect inguinal herrnation.” THE

BIOLOGY

OF FEMORAL

HERNIA

The cause of femoral herniation is poorly understood.‘“, ” Etiologic factors are less detailed than those of inguinal herniation and usually contain a mixture of epidemiologic observation, folklore, and theoretic license. Does enlargement of the femoral ring predispose to the development of an acquired femoral hernia? An abnormal insertion of the posterior inguinal wall or iliopubic tract onto the Cooper ligament has been implicated as a cause of the femoral ring enlargement. As seen from the preperitoneal approach during an operation, an enlarged ring is frequently present without an accompanying hernia. Thus we question the idea that the size of the femoral ring represents a major factor of importance in the formation of a femoral hernia. There is little doubt that a femoral hernia can occur in response to high intraabdominal pressures when a bolus of preperitoneal fat enters the femoral canal and drags along sufficient pelvic peritoneum through the femoral ring orifice. The peritoneal sac then moves down the femoral canal to encounter the narrowing at the level of the insertion of the lacunar ligament, finally becoming visible and palpable in the anterior part of the upper thigh. Why femoral hernias develop in elderly people, particularly women, is a mystery. An attractive concept involves the muscle bulk adjacent to the distal femoral canaLz4 Normally, the iliopsoas and pectineus muscle bundles encroach on the canal and thus act as a barrier to the development of a femoral hernia. With the natural atrophy of muscle tissue that occurs with senescence, the actual vol416

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ume of muscle within the canal decreases, allowing positive intraabdominal pressure to push the peritoneum into the canal. This would explain the high rate of femoral hernia among elderly women as well as men. In women of all ages, the muscle mass is not as great as it is in men. Thus women are predisposed to femoral hernias as the result of any condition that increases intraabdominal pressure, such as pregnancy or morbid obesity. THE

CLASSIFICATION

OF GROIN

HERNL4

OLD AND NEW A classification of hernia is expected to facilitate the objective evaluation of repair techniques and permit the verification of results. A classification can serve as the basis for a technical guide when it is linked to or matched with satisfactory repair options. With these goals in mind, Casten,” Chapp and McVay,‘” Gilbertz7 and Harkins’” introduced classifications of their own. In spite of individual strengths, none of these classifications has gained wide acceptance. This is somewhat unfortunate because the classification by Casten, in particular, is highly innovative and practical. Gilbert’s classification has several drawbacks that limit its use.z7 The exclusion of femoral hernia severely restricts the classification of a major category of groin hernia. Further, the classification falls short of providing a framework for individualization of operative technique because repairs of all five types of primary hernial defects, as classified, require prosthetic mesh. The routine use of mesh for all primary hernias is inappropriate. When classification of hernia type is matched with individualization of operative technique, mesh may be advantageous in about 20% of primary hernia repairs. AN INDIVIDUALIZED

APPROACH

The classification of groin hernia (Table 1) includes primary inguinal and femoral hernias (types I, II, and III), as well as recurrent groin hernias (type IV). Primary inguinal hernias are classified according to the severity of damage to the underlying internal abdominal ring or the defect in the Hesselbach triangle. Small to massive (for example, scrotal or sliding) indirect hernias may be viewed as a continuum of disease. Initially they are confined to the internal abdominal ring (type I); then they enlarge medially (type II). In the final stages, they alter the posterior inguinal wall (type III). All direct hernias (small and large without involvement of the internal abdominal ring) are in the transversalis fascia layer and therefore are considered type III. CurrProblSurg,

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417

TABLE 1. Classification

of Groin

Hernias

T&e I--Indirect inguinal hernia Internal inguinal ring normal (e.g., pediatric hernial Type II-Indirect inguinal hernia Internal inguinal ring dilated but posterior inguinal wall intact; inferior vessels not displaced Type III-posterior wall defects A. Direct inguinal hernia B. Indirect inguinal hernia Internal inguinal ring dilated, medially encroaching on or destroying transversalis fascia of the Hesselbach triangle le.g., massive scrotal, pantaloon hernias1 C. Femoral hernia Type IV- Recurrent hernias

deep

the sliding,

epigastric

or

The proposed classification of groin hernias is based on anatomic criteria. The challenge in devising a classification of this nature lies in formulating descriptions that are clear and specific.

Type I hernias are indirect inguinal hernias (usually in infants, children, or young adults) in which the internal abdominal ring is of normal size, configuration, and structure. The boundaries are well delineated and the Hesselbach triangle is normal. There is an indirect hernial sac, which extends variably from just distal to the internal abdominal ring to the midinguinal canal.

Type II hernias are indirect inguinal hernias in patients in whom the internal ring is enlarged and distorted without impinging on the floor of the inguinal canal. The Hesselbach triangle (floor of the canal) is normal as palpated through the opened peritoneal sac. The hernial sac is not scrotal but may occupy the entire inguinal canal.

Type 111classifies defects in the posterior inguinal wall (floor1 into three subtypes: direct, indirect, and femoral. In direct inguinal hernias (type IIIA), the protrusion does not herniate through the internal abdominal (inguinal) ring. The weakened transversalis fascia (posterior inguinal wall medial to the inferior epigastric vessels) bulges outward in front of the hernial mass. As previously stated, all direct hernias, small or large, are type III% Type IIIB hernias are indirect inguinal hernias with a large dilated ring that has expanded medially and encroaches on the posterior inguinal wall (floor) to a greater or lesser degree. Type IIIB hernias 418

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frequently have a scrotal position. Occasionally, the cecum on the right or the sigmoid colon on the left makes up a portion of the sac wall. These sliding hernias always destroy a portion of the inguinal floor (type BIB). The internal abdominal ring may be dilated without displacement of the inferior epigastric vessels. Direct and indirect components of the hernial sac may straddle those vessels to form a pantaloon hernia (type IIIBl. Type IIIC hernias are femoral hernias, a specialized form of posterior wall defect.

Type IV hernias agement problems nias. OPERATIONS

are recurrent hernias. They cause intricate manand carry a higher morbidity than do other her-

FOR HERNIA

It is the purpose of this section to provide a state-of-the-art examination of the operations used today to treat inguinofemoral hernias. It is not our intention to provide detailed technical descriptions of each repair. Operative techniques are considered, however, in terms of what is currently known about the theoretic aspects of hernial disease. We present a critique of the factors believed to be responsible for the recalcitrant problem of hernial recurrence. We are concerned that the routine use of a single operative technique for all types of hernias contributes to hernia recurrence. To destroy a normal inguinal floor (type I and II hernias) as a part of a routine technique chosen by many surgeons is misguided. We hope that attention to matters of anatomic importance as described herein will allow for proper selection of operative methods. The key to all successful hernial repairs is reestablishment of the posterior lamina of the transversalis fascia layer. RASSINI

REPAIR:

TECHNICAL

CONSIDERATIONS

The most widely performed procedure for indirect and direct inguinal hernias was introduced by Eduardo Bassini in 1887.” The operation incorporates novel techniques such as dissection and skeletonization of the spermatic cord and the use of interrupted permanent suture. There is little disagreement about these aspects of the procedure. However, the issue of opening the floor of the inguinal canal before placing sutures in the “triple layer” (the obliquus internus muscle, the aponeurotic arch of the transversus abdominis muscle, and the transversalis fascia) is unresolved. curr

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In his original description,30 Bassini did not mention opening inguinal floor, although one of his illustrations (Fig 6) shows floor (transversalis fascia) incised:

the the

I dissect the external oblique aponeurosis up to the external margin of the rectus sheath to join without difficulty the triple layer formed by the internal oblique, transverse muscle, and fascia verticalis of Cooper (transversalis) to the posterior border of Poupart ligament. Then I suture these two parts together for a total length of 5-7 centimeters from the pubic tubercle until the spermatic cord is displaced one centimeter laterally toward the anterosuperior iliac spine. In this way the internal inguinal ring and the posterior wall of the inguinal canal are reconstructed.

Despite the significant technical innovation of Bassini, his operation as performed today carries a recurrence rate of 3% to 23%.31 Could the restriction of natural inguinal musculoaponeurotic movement account for the high recurrence rates so frequently reported

FIG 6. DissectIon of lnguinal region by Basslni as publlshed in 1889. The inguinal floor appears to have been opened, but nowhere in the descriptive text does Bassini mention such a maneuver. The point probably is moot since today most surgeons performing a “Bassini” operation open the transversalis fascia of the inguinal floor. (From Bassini E: Nuovo metodo operativa per la cura de//a ernia inguinale. Plate I. Padua, R. Stabllimento Prosperini, 1889.) 4!m

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after all hernial repairs that use the inguinal ligament as their primary anchor? As an integral part of the transversus abdoministransversalis fascia crural sling sphincter mechanism at the internal abdominal ring, free motion must be maintained.32 It is our contention that placing sutures between the posterior inguinal wall (the portion relating to the sphincter mechanism) and the inguinal ligament destroys the sphincter. Placing sutures between the resilient posterior wall and the fixed inguinal ligament restricts the natural movement of the individual layers and disrupts the suture line.

COOPER LIGAMENT

REPAIR

The use of the Cooper ligament in the repair of inguinal hernias was first mentioned by Lotheissen in 1898.33 McVay, most closely associated with the repair in our own time, urged the use of the Cooper ligament as an alternative to the inguinal ligament in the repair of large direct and indirect inguinal hernias34 (Fig 7). The Cooper ligament repair begins at the pubic tubercle, where successive interrupted nonabsorbable sutures are used to anchor the edge of the transversus abdominis aponeurosis to the Cooper ligament. As one proceeds laterally and the femoral vein is approached, a transition suture is placed. The suture picks up the Cooper ligament, the pectineus fascia and then the medial extent of the anterior femoral sheath. This closes the angle between the Cooper ligament and the anterior femoral sheath and prevents future herniation through this area. Lateral to the transition stitch, sutures are placed between the transversus abdominis aponeurosis and the anterior femoral sheath (iliopubic tract). An important principle of the repair is the need for a relaxing incision, which allows the edges of the repair to be sutured without excessive tension. Residual movement of the sphincter must be preserved at the deep ring. Sutures placed between the aponeurosis of the transversus abdominis muscle and the Cooper ligament have the same restrictive properties as sutures in the inguinal ligament. However, if careful attention is given to the placement of the iliopubic tract sutures lateral to the transition suture, sphincter movement at the deep ring is preserved. The Cooper ligament repair is satisfactory for large direct and indirect hernias in which the posterior wall is destroyed. In patients with small- to medium-size indirect hernias in which the posterior wall is intact, it is inappropriate to perform a Cooper ligament repair. In these type I and type II hernias, two or three sutures to tighten a patulous internal ring are sufficient. McVay also subscribed Curr

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FIG 7. Cooper ligament repair. Arch of the transversus abdominis and the transversalis fascia are brought to the Cooper ligament medially (I), the transition suture (2) which moves the repair to a superficial plane, and (3) lateral continuation of the posterior inguinal wall reparr with sutures between the transversus abdominis aponeurosis and iliopubic tract. These latter sutures are complete when the deep ring has been closed about the spermatic cord using the same fascia of the posterior inguinal wall. Note the relaxing incision placed over the rectus abdominis muscle. (From McVay CB, Chapp JD: Ann Surg 1958; 148:499-510. Used by permission.)

to this repair of the internal abdominal ring (plastic closure) for these smaller hernias.35 Halverson and McVay published the results of 442 Cooper ligament repairs. Their reported rate of hernial recurrence over a 22year period was 3.5%.36

Rutledge

reported

on a 2.5year experience

with the exclusive

use

of the Cooper ligament repair for all inguinal and femoral hernias. After 1,142 repairs with an average follow-up time of 9 years, the reported recurrence rate was 2% .37,38 The Cooper ligament repair has been proposed for the treatment of femoral hernias. Since it is not necessary to tear down the normal 422

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posterior inguinal wall to reach the hernia and close the femoral orifice, we believe that the Cooper ligament approach is contraindicated. There are other operations better suited to repair femoral hernias .

ANTERIOR

ZLIOPUBIC TRACT REPAIR (CONDON)

Alexander Thomson first described the iliopubic tract in 1836,3s but it was not until after the second world war that interest in the iliopubic tract was revitalized.40-42 The application to hernial surgery grew from recognition of the iliopubic tract’s unique anatomic position adjacent to direct and indirect inguinal as well as femoral hernial defects (see Fig 3B). A detailed description of the preperitoneal approach and iliopubic tract repair WTR) is found in a subsequent section. However, the IPTR can also be performed by the anterior approach and, in certain respects, it is similar to the Cooper ligament repair (Fig 8, top). First the medial stitches of an anterior IPTR are placed into the Cooper ligament since the Cooper ligament and iliopubic tract insert together into the superior ramus of the pubis. Proceeding laterally, successive sutures are then placed from the transversus abdominis aponeurotic arch to the iliopubic tract below. The repair is not complete without a relaxing incision. Although the iliopubic tract is not as readily apparent by the anterior approach because it is covered by the more superficial overlying edge of the inguinal ligament, we believe there are several advantages over the Cooper ligament repair: 1. The distance that must be traversed in pulling down the “curtain” of the transversus abdominis aponeurosis to the iliopubic tract is not as great as the distance in bringing the aponeurosis to the Cooper ligament. Hence, there is less tension on the suture line. 2. An integral part of the Cooper ligament repair, the transition suture into the anterior femoral sheath-iliopubic tract, is not necessary since all the sutures are placed into the length of the iliopubic tract from medial to lateral. 3. In small indirect hernias (types I and II) best treated by a plastic closure of the internal ring, there is no need to incise the intact posterior inguinal wall. The crura of the transversalis fascia are seen directly and easily sutured (Fig 8, bottom). 4. The IFTR, both the anterior and posterior approaches, restores the laminar structure, maintaining synchronous movement at the deep ring to preserve the sphincter mechanism.

curr

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423

FIG 8. Anterior ilropubic tract repair (Condon). Top, The reparr of a complete Indirect inguinal hernia in which the posterior wall of the inguinal canal is weakened requires suture reconstruction of the entire inguinal floor (type 1118). The medial sutures are placed, begrnning at the pubic tubercle, through the transversus abdominis arch above and the iliopubic tract below. Bottom, In the repair of a type II indirect inguinal hernia, only a few sutures on the medial side of the spermatic cord are needed (plastic closure of the internal abdominal ring). (From Condon RE, in Nyhus LM, Condon RE (eds): Hernia, ed 3. Philadelphia, JB Lippincott, 1989, p 145. Used by permission.)

THE

SHOULDZCE

(CANADIANI

REPAIR

The Canadian repair of inguinal hernia, as originated by the surgeons of the Shouldice Clinic in Toronto, has enjoyed increasing popularity.43 This is a factor of both high patient satisfaction with the procedure and verification by other surgeons of the previously reported low recurrence rate.44-46 The Shouldice repair of inguinal hernias incorporates a number of techniques, most of which have historical precedent43’47:

424

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1. Skeletonization of spermatic cord contents. Complete division of the cremaster muscle allows for better visualization of the posterior inguinal wall. In addition, detailed dissection of the contents of the spermatic cord helps to prevent overlooking the presence of an indirect inguinal hernia, a common source of recurrent hernia. 2. Continuous running suture technique. The continuous running suture prevents gaps (a possible source of recurrence) and distributes tension uniformly along the entire length of the repair, thereby making a relaxing incision unnecessary. 3. Imbrication of the suture fine. Once the initial dissection is complete, the posterior wall of the inguinal canal, which has been opened, is reconstructed by superimposed running suture lines with progression from deeper to more superficial layers. In theory, each successive suture line reinforces and takes tension off the former, thereby adding strength to the repair. The first suture line anchors the transversus abdominis aponeurotic arch to the iliopubic tract. This suture is run back and forth with a vest-over-pants technique similar to the Andrews method of imbrication4’ When complete, the obliquus internus and transversus abdominis muscles and aponeuroses (the triple layer of Bassini) are sutured to the inguinal ligament (Fig 91. In the final analysis, the Shouldice repair can be conceptualized as an anterior IPIR with a superimposed BassiniAndrews technique. 4. Local anesthesia. Local anesthesia decreases the complication rate associated with regional or general anesthesia and shortens the recovery time. Local technique also allows the surgeon to check the repair intraoperatively by asking the patient to voluntarily perform maneuvers inclined to stress the suture line. Reported recurrence rates are extremely low for the Canadian repair. The largest series from the Shouldice Clinic reports a recurrence rate that is consistently less than 1% .43 Other independent reports by surgeons using the Canadian repair have confirmed these figures ? 45 Of interest is the observation that recurrence rates increased to as high as 8.1% when surgeons deviated from using stainless-steel wire in the repair?5 Like other hernial repairs, the Canadian repair is not immune to the more traditional complications of wound infection, hematoma, hemorrhage, and even pulmonary embolus. Because of the number of continuous running suture lines that pass by or near the internal abdominal ring, compromise of the testicular artery and vein has been reported.4g Fortunately, given the excellent collateral blood supply, ischemic orchitis and testicular atrophy are rare complications of primary hernial repair. It is of interest that the Shouldice repair contains key parts of Curr

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426

FIG 9. The Shouldice repair. This technique reconstructs the floor of the ingurnal canal by an rmbrication technique (Andrews) utilizing several layers for greater strength, beginning with closure of the transversalis fascia of the posterior lamina. Bottom, A second suture approximates the aponeurosis of the obliquus internus muscle and the underlying muscle to the rnguinal ligament. The number of imbrrcated suture lines can range from three to five. The suturing of the obliquus rnternus muscle over the inguinal ligament is reminiscent of the triple-layer repair of Bassrni. (From Wantz GE, in Nyhus LM, Condon RE (eds): Hernra, ed 3. Phrladelphra, JB Lippincott, 1989, p 241. Used by permrssion.)

other operative procedures, such as IFTR of the posterior inguinal wall, the imbrication modification of Andrews, and the use of the triple layer of Bassini. The results of combining these several techniques have been very good. The Canadian repair is used for all types of hernial defects. Is it necessary to take this “belt-and-suspender” approach? When properly performed, several other techniques give similar satisfaction to the patient. Certainly, the Shouldice repair should not be used in type I and type II hernial defects, nor for femoral (type IIIC) hernias. The role of the multilayer method appears to be that of creating a solid barrier to recurrence in the inguinal floor repair of type IIIA (direct) and type RIB (large indirect) hernias. Since most recurrent hernias (type IV) are direct hernias, they could conceivably be ap426

Curr

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1991

proached pair.

by the multiple

TENSION-FREE

layering

method

of the

Shouldice

re-

HERNIOPLASTY

A newly proposed hernial repair, tension-free hernioplasty, uses prosthetic material to reinforce the entire posterior wall without using endogenous tissue.” This approach is based on the theory that hernias are the result of abnormal collagen metabolism and the subsequent breakdown of tissue. A formal repair of the posterior inguinal wall is not performed; a prosthetic patch is used instead. The patch is sutured between the rectus sheath and the transversus abdominis muscle above and the inguinal ligament below. A small slit is made laterally in the patch for the spermatic cord to emerge from the internal ring. No hernias recurred in patients followed from 1 to 5 years. Surgeons will be attracted to this technique. Although the new prosthetic materials are seldom rejected, each is a foreign body, which always carries the threat of rejection. To routinely place foreign prosthetic materials in hernial wounds is contraindicated. Primary repairs of type I, II, and IIIC (femoral) hernias do not need prosthetic mesh. GIANT

PROSTHETIC

REINFORCEMENT

OF THE

VISCERAL

SAC

Giant prosthetic reinforcement of the visceral sac (GPRVS) attempts a surgical cure of all lower abdominal hernias by inserting a large piece of polyester mesh beneath the abdominal wall in the preperitoneal space.51’ 52 The Mersilene mesh that serves as a nonabsorbable buttress of the endoabdominal fascia of the entire lower abdomen is held in place without sutures by the force of intraabdominal pressure. As adhesions form between the transversalis fascia and the mesh, the mesh becomes permanently incoporated into the body (Fig 10). This technique is not used routinely. Indications for the use of the GPRVS are: 1. Complex hernias such as bilateral groin defects or unilateral groin hernias associated with lower abdominal eventrations 2. Complicated hernias such as sliding inguinal and recurrent hernias 3. Hernias in patients with intrinsic tissue collagen defects The recurrence rate in reported sults are especially encouraging Curr

Probl

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1991

series is less than 1% .52 These rebecause many of the patients 427

FIG 10. Giant prosthetic reinforcement of the visceral sac (Stoppa). Schematic anteroposterior view of the large Dacron mesh prosthesis surrounding the visceral sac as an artificial endoabdominal fascia. This view shows the relations between the prosthesis and the visceral sac. The spermatic cord may either pass through the prosthesis (right) or be parietalized (left). (From lstoppa RE, Warlaumont CR, in Nyhus LM, Condon RE (eds): Hernia, ed 3. Philadelphia, JB Lippincott, 1989, p 212. Used by permission.)

treated had difficult hernias, and the GPRVS provided an excellent alternative in specific instances. We again plead that this technique be applied selectively. THE PREPERITONEAL (POSTERIOR) APPROACH TO AND ILIOPUBIC TRACT REPAIR OF GROIN HERNIAS Recognition of the importance of the posterior structural lamina stimulated interest in an alternative approach to hernial repair from inside the inguinal abdominal floor.53J 54 The preperitoneal approach directly exposes the posterior inguinal wall, transversalis fascia analogues, the iliopubic tract, and the adjacent inguinal or femoral hernia. Introduced by Annandale,55 the concept of a posterior method was then used by others in a variety of clinical circumstances.56-58 Sliding hernias, so frequently the cause of consternation, are readily 428

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ISSI

recognized and handled. All incarcerated and strangulated hernias of the groin can be released with relative ease (Fig 11). The constricting ring can be cut with minimal danger to vital blood vessels and nerves. If it is necessary to resect strangulated intestine, the peritoneum may be opened and the appropriate resection and anastomosis undertaken.5g After more than 1,200 hernial repairs in which the posterior inguinal wall was visualized and dissected, new techniques for the preperitoneal approach to hernial repair were developed.6’ These were then integrated with an understanding of the role of the iliopubic tract as the principal structural anchor for repairing a defect. As the techniques evolved, the approach was used for all complicated groin hernias. This alternative to the conventional (anterior) approach is an ideal method for circumventing the scar tissue in operations for recurrent hernias. The posterior approach has a definite advantage in these patients. Contraindications to the preperitoneal (posterior) IPTR are few. In obese patients, the anterior flap of the abdominal wall may be difficult to handle during exposure of the posterior inguinal wall. We do

/b

External

r

oblique

m. and fascia

Internal oblique m. and Transversus abdominis , Transversalis fascia

fascia m. and

fascia

FIG 11. The posterior approach to strangulated groin hernia facilitates reduction, repair. At times, bimanual reduction of the hernia may be necessary. (From Condon RE: Surg Gynecol Obstet 1989; 162:65-67. Used by permission.) CurrProblSurg,

June1991

resection, Malangoni

and MA,

429

not consider a direct hernia a contraindication to the preperitoneal approach. Recognition that a relaxing incision is just as important in repairs by the posterior approach as in repairs by the anterior approach and the judicious use of an inlay mesh to buttress the repair of large defects regularly give good long-term results. General Approach to the Preperitoneal Space A preperitoneal operation begins with a transverse incision slightly above the usual incision made for a standard anterior approach to an inguinal hernia. This incision should be made two fingerbreadths above the symphysis pubis and slightly above the level of the internal inguinal ring (Fig 12). Dissection is carried down to the anterior rectus sheath, which is opened transversely, and the rectus muscle is retracted medially (Fig 13). At this point, the incision is extended laterally approximately 2.5 cm. through the full thickness of the musculoaponeurotic layers formed by the obliquus externus, obliquus internus, and transversus abdominis muscles. The transversalis (endoabdominal) fascia is ex-

posed and opened

transversely.

It is important

that peritoneum

un-

derlying the transversalis fascia not be opened. The preperitoneal fat can be swept cephalad with sponge sticks to gain access to the posterior inguinal wall and the area of herniation (Fig 14). The inferior

epigastric

artery and its two accompanying

veins are encountered

in

the preperitoneal space. It may be necessary to ligate these blood vessels to improve visualization of the posterior inguinal wall.

Indirect

lnguinal

Hernias

An indirect hernia is easily identified as passing through the internal ring with the cord and its contents. As with an anterior approach, the first maneuver is to encompass the spermatic cord and hernial sac. When encompassing the cord contents, one must beware of the iliac vessels that lie directly posteriorly. At this point, the sac must be removed from the inguinal canal and separated from the cord structure. This maneuver is easily done by opening the sac and invaginating a finger into the sac to its distal extent. A wet 4 x 4-in. gauze pad can be used to gently tease the sac from the cord

contents

and to reduce it. After high ligation

defect is repaired. For small hernias

(types I and II) a few sutures

lateral to the cord, approximately the internal

abdominal

of the sac, the hernial

ring to the iliopubic

ring), should

placed

medial

the fibers of the anterior tract (plastic closure

or

crus of

of the internal

suffice (Fig 15).

Larger indirect hernias (type IIIB) expand medially and destroy the posterior inguinal wall. These hernias should be repaired as direct inguinal hernias (type IRA) are repaired, and buttressed with an

inlay of polypropylene 430

mesh (Marlex, CR. Bard, Billerica, Mass.). Cur-r

Probl

surg,

June

1931

FIG 12. Posterior approach and iliopubic tract repair. The operative approach to the preperitoneal space. The skin incision for the preperitoneal approach is placed approximately two fingerbreadths above the symphysis pubis in a transverse direction. Inset, After the skin and subcutaneous tissues have been incised and the rectus sheath has been exposed, the level of the internal ring may be estimated by the insertion of the left index finger into the external ring. This simple maneuver allows the surgeon to visualize in his or her mind the location of the internal ring, which is hidden from view. The incision in the anterior rectus fascia should be placed so that it passes just superior (cephalad) to the internal ring. This maneuver prevents the incision from being placed too high or too low. (From Nyhus LM, Pollak R, Bombeck CT, et al: Ann Surg 1988; 208:733-737. Used by permission.)

Results with the posterior approach and IFIR for recurrent direct inguinal hernias routinely employing a prosthetic inlay buttress have been very favorable.61 Because of this positive experience in repair of recurrent hernias, it seems reasonable to apply the same technique to massive direct and indirect inguinal hernias alike. This is one of our few exceptions to the rule of avoiding prosthetic material in repair of primary hernias. Cur-r

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1991

431

FIG 13. Posterior approach and iliopubic tract repair. The surgeon enlarges the incision by separating and cutting fascia and muscle fibers of the obliquus externus, obliquus internus, and transversus abdominis muscles. The transversalis fascia is seen in the depth of the wound. (From Nyhus LM, in Nyhus LM, Condon RE (eds): Hernia, ed 3. Philadelphia, JB Lrppincott, 1989, p 163. Used by permission,)

Subcutaneous tissue -- se@/-& 2 Trayfyrdis

ry _-G

FIG 14. Posterior approach and iliopubic tract repair. Diagram of the operative approach to the preperitoneal space highlighting layers of the abdominal wall. When the transversalis fascia IS cut, the preperitoneal space is entered and the proper plane of dissection IS achreved. (From Nyhus LM, in Nyhus LM, Condon RE (eds): Hernia, ed 3. Philadelphia, JB Lippincott, 1989, p 164. Used by permission.) 432

Cur-r

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1991

FIG 15. Posterior approach and iliopubic tract repair of a small indirect hernia. The indirect hernia sac has been ligated and removed, and sutures are in place in the anterior and posterior crura of the internal ring. The posterior crus blends into the iliopubic tract at varying distances from the medial margin of the internal ring. The sutures at this point are placed into the iliopubic tract. (From Nyhus LM, Baker RJ: Mastery of Surgery. Boston, Little, Brown, 1984, p 1287. Used by permission.)

Direct Znguinal Hernias The direct hernial sac is easily identified in a defect medial to the epigastric vessels in the Hesselbach triangle. It is reduced by gentle traction and dissection. The sac, once reduced, need not be excised because it is broad-based. However, when the sac is excessively large and cumbersome, it may be inverted with a running suture. When one deals with the medial portion of a direct sac, care must be taken to avoid damage to the bladder. Once reduced, the defect is repaired with interrupted no. 0 polypropylene sutures placed between the transversus abdominis arch and the thickened transversalis fascia above and the iliopubic tract below (Fig 16). The iliopubic tract is easily identified as a thick bandlike structure arching over the iliac vessels. The two most medial sutures may encompass the Cooper ligament and iliopubic tract where the two transversalis fascia analogues tend to converge near the pecten of the pubis. After the defect is closed, we reinforce the anatomic repair with an inlay buttress of polypropylene mesh (Marlex). There is no question that a relaxing incision is important for the satisfactory repair of direct inguinal hernias by the anterior method. The classic relaxing incision also must be made in the posterior approach. The de facto relaxing incision made by dividing the rectus sheath when entering the preperitoneal space gives the surgeon a false impression that there is no tension on the suture line. But Cut-r Probl

Surg,

June

1991

433

FIG 16. Posterior approach and iliopubic tract repair of a direct hernia. The peritoneal sac is removed from the direct defect. The superior edge of the direct defect is the fused transversalis fascia-transversus abdominis aponeurosis layer. A suture is placed into this upper edge and the iliopubic tract below. One may delineate these structures by placlng a finger into the direct defect and placing lateral traction on the tissues. (From Nyhus LM, in Nyhus LM, Condon RE (eds): Hernia, ed 3. Philadelphia, JB Lippincott, 1989, p 165. Used by permission.)

when these layers of the anterior abdominal mated at the end of the operation, there may sion on the repair suture line. Recognizing this, ily make a classic relaxing incision in the layers before closing the anterior abdominal wall.

wall are reapproxibe considerable tenthe surgeon can easof the rectus sheath

Results of Repair of Znguinal Hernias We published the results of primary hernial repairs that were done without a relaxing incision or prosthetic material?’ Although the recurrence rates were 3% for indirect hernias and 6% for direct hernias, these results were not achieved by others.62,63 The disappointing results with the posterior approach to repair of inguinal hernias apply to the old and outmoded Cheatle-Henry method (vertical midline) and repair (use of inappropriate anatomic 434

CurrProblSurg,

June

1991

fascia structures). Greenburg and associates confirmed the good results that can be obtained when proper techniques for the posterior approach and repair are used.64, 65 Femoral

Hernias

The technical details of the approach to the preperitoneal space are the same as for inguinal hernias. Several helpful points are in order, however. A femoral hernial sac is gently reduced by traction and blunt dissection. If the hernia is incarcerated, the sac is released by carefully incising the insertion of the iliopubic tract into the Cooper ligament at the medial margin of the femoral ring. If the restraining fascia is present at the distal aspect of the orifice of the femoral canal (Gimbernat or lacunar ligament), it can usually be released from

FIG 17. Posterior approach and iliopubic tract repair of a femoral hernia. Completion of the iliopubit tract repair of a femoral hernia. The femoral canal is narrowed by placing sutures between the iliopubic tract above and the Cooper ligament below. Note that the femoral vessels well vrsualized by this approach are easily protected. The inferior epigastric vessels have been ligated for better exposure. (From Nyhus LM, in Nyhus LM, Condon RE (eds): Hernia, ed 3. Philadelphia, JB Lippincott, 1989, p 194. Used by permission.) Cur-r

Probl

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June

1991

435

above. Only in rare circumstances is a counterincision in the upper thigh over a femoral hernial mass necessary. After the sac is opened to remove its contents, excess peritoneum is removed and the sac is ligated. The hernial repair is completed by suturing the anterior margin of the hernial defect (the iliopubic tract) to the posterior margin or Cooper ligament (Fig 17). This maneuver obliterates the femoral canal medial to the femoral vein. This vein is well exposed by the posterior approach, allowing for effective closure of the canal without danger of compression or direct injury to the vessels. An aberrant obturator artery (corona morns) may cross the Cooper ligament and, if present, should be avoided. Use of a relaxing incision is unusual. An incarcerated or strangulated femoral hernia is readily managed by the same posterior approach. Proximal control of the normal-appearing intestine is obtained first. Release of constricting insertions of the posterior inguinal wall into the Cooper ligament at the femoral ring, or of the Gimbemat ligament at the distal femoral orifice, or both, allows for easy withdrawal of the strangulated intestine, resection, and anastomosis. A classic IIYTR is then performed. A recurrence rate of less than 1% has been confirmed by Mikkelesen and Berne,66 McNaught,67 Keynes and Withycombe,“’ and Lindholm and colleagues.70 In view of these excepLjungdahl,“’ tional results, we strongly recommend the preperitoneal approach and IPTR as the method of choice for the treatment of femoral hernia.

INDMDUALIZATION

OF REPAIR

TO

TYPE

OF HERNIA

Individualization of the approach to hernial repair should be based on complete assessment of the internal inguinal ring, the condition of the posterior inguinal wall (floor), and inspection of the femoral ring to exclude an associated subclinical defect (Table 2). Digital exploration of the internal ring is most effectively performed according to the method of Griffith7* (Fig 18). The hernial sac should be opened and the index finger inserted through its neck to draw up the internal ring. With the finger inside the sac, the ring margin can be defined, the strength of the posterior wall of the inguinal canal can be assessed, and a direct hernial weakness can be detected. Digital exploration is the most effective maneuver in this regard, and the examination must be carried out before the sac is tied off. In the absence of manometric or other measurements of internal ring function, the evaluation is somewhat subjective because of the tactile impression of sphincter tone at the internal ring. More definitive measurements of internal ring function can be expected during hernial repairs under local anesthesia. 436

Curr

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June

19%

TABLE I&pair Type

2. Individualized

to Tvpe

of Hernia

of Hernia

Repair

Type I-Indirect with normal internal abdominal ring Type II-Indirect with internal abdominal ring dilated, posterior abdominal wall intact Type III-Posterior wall defects A. Direct B. Large indirect

C. Femoral T&e IV-Recurrent ‘Excision

usualIy forcement

TYPES

and ligation

of hernial

not opened,

excised,

of the visceral

I AND

sac are performed

High

ligation

of sac*;

no repair

High ligation of sac; transversalis repair of internal abdominal mpairl

fascia ring (plastic

Anterior approach-IFTR without mesh ICondon); Shouldice repair; Cooper ligament repair Posterior appmach-IPTR with inlay buttress of polypropylene mesh; Stoppa CPRVS with Mersilene Posterior approach-IFTR without mesh Posterior approach-IPTR with inlay buttress of polypropylene mesh for all indirect

or ligated. IFI’R = &pubic

and femoral

hernias.

A direct

tract repair; GPRVS = giant pmsthetic

sac is

rein-

sac.

II

A small indirect inguinal hernia in which there is a slightly dilated internal ring but no weakening of the posterior inguinal wall (type II) is best treated from the anterior approach by high ligation of the sac and plastic closure of the transversalis fascia at the internal ring. After high ligation and resection of the hernial sac, the margins of the dilated internal abdominal ring should be defined by sharp dissection to identify the transversalis fascia above (anterior crus) and the femoral sheath below (iliopubic tract-posterior crus). The cord is drawn laterally and the closure is accomplished by approximating the anterior crus to the posterior crus with a series of interrupted nonabsorbable sutures (we prefer no. 0 polypropylene) (Fig 19). Ponka described a “triangulation technique” for approximating the transversalis fascia at the internal ring.7z Type II represents a large group of overtreated hernias because repair of the inguinal floor is unnecessary. Although commonly performed, a posterior wall repair is made at the expense of disrupting a normal inguinal floor and increases the risk of hernial recurrence. We are perplexed at the reluctance to accept these small to medium-size hernias (types I and II) as simply a problem of the internal abdominal ring. Many surgeons tend to overtreat these patients who have no posterior wall defect. There is no evidence to suggest that a posterior wall repair may be “prophylactic” treatment.73 On the con437

iliopubic

tract”

FIG 18. Palpation of the inguinal floor (Griffith). The hole in the transversalis fascia. The sac has been ligated and removed. A finger inserted through the internal ring, behind the transversalis fascia preperitoneally down to the pubic spine, palpates the inguinal floor. A section of the inguinal ligament has been removed from the illustration to show the transversalis fascra composing the inguinal floor. This illustration demonstrates that the iliopubic tract continues with that fascia adjacent to the ligated external spermatic artery. This fascia is also continuous with the femoral sheath. The stump of the external spermatic artery is therefore a landmark for the fascia composing the inferior edge of the internal ring. Superrorly, the transversalis fascia continues beneath the transversus abdominis aponeurosis. (From Griffith CA, in Nyhus LM, Condon RE (eds): Hernia, ed 3. Philadelphia, JB Lipprncott. 1989, p 116 Used by permission.)

trary, in type I and II hernias, incision of a strong posterior layer (the first step in a Bassini, Shouldice, or McVay repair) is inappropriate. Simple closures of the abdominal ring comprised more than 50% of 646 operations for hernias reported on by Halverson and McVay in 1970.36 They found that only 3.3% of these hernias recurred. This procedure has become almost vestigial since that time. Patients with type I and II hernias simply do not need a big operation or prosthetic mesh. 438

Curr

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1991

Direct inguinal (type IRA) and large indirect inguinal (type IIIB) hernias are satisfactorily repaired by anterior or posterior approaches. Although in the past we eschewed prosthetic mesh for the repair of primary groin hernias, we now recognize that the posterior approach and IPIR for types IRA or IIIB hernias should include an inlay buttress to support the anatomic repair. This is also Stoppa’s recommendation for GPRVS, which uses a Mersilene polyester mesh.52 Relaxing incisions are indispensable. We prefer to repair type IIIC (femoral) hernias using the posterior approach and IPTR.

FIG 19. Marcy plastic closure of the internal ring. A, Sutures are placed through the transversalis fascia. The cord structures are displaced laterally. The reconstructed ring admits only the trp of a hemostat. This repair has been made possible by the removal of the cremaster muscle and retraction as illustrated. B, Retractors have been removed to allow the inguinal ligament and the obliquus internus and transversus abdominis muscles to assume their normal positions at rest. The internal ring is buttressed by overlying muscle. If at this stage under local anesthesia the patient coughs on request, the sutures snap upward and laterally (drsplacement of the internal ring), and the arcuate fibers move against the inguinal ligament (inguinal sphincter). (From Griffith CA, in Nyhus LM, Condon RE (eds): Hernia, ed 3. Philadelphia, JB Lippincott, 1989, p 117. Used by permission.) Curr

Probl

Surg,

June

1991

439

Type IV recurrent hernias routinely are treated by the posterior approach and IPTR with an inlay buttress of Marlex mesh. RECtJlUWNT

HERNIAS

Recurrent hernia is the most common complication following repair of groin hernias. Reported recurrence rates vary from 1.1% to 20.7% for indirect inguinal hernias, 3.5% to 20.9% for direct inguinal hernias, 0% to 31.3% for femoral hernias, and 1.2% to 33.1% for recurrent

hernias

(Table 3).

In reviewing the literature on this subject, one discovers epidemiologic data, case studies of a personal or anecdotal nature, and new developments in technical knowledge.74-78 Unfortunately, the experience is constrained

by the lack of an endorsed

classification

of her-

nias, which could have more objectively structured the comparison of repair techniques for a given defect. However, principles that are essential to our method of treatment and time-honored guidelines for improving operative results are contained herein. CAUSE OF RECURZWVCE Technical

quently,

failure

systemic

Poor surgical

causes

most

hernial

or wound-healing

judgment

recurrences.7g’8”

problems

Infre-

may be implicated.

is a serious but understated

factor. The rou-

tine use of one operative method is to be discouraged because it frequently results in a suboptimal repair. We emphasize the importance of an individualized approach as the prime component of any successful

operation

to treat a hernia.

Missed Hernias If certain rules of intraoperative conduct are broken, a hernia may be missed at the time of the primary operation. Careful palpation of the internal inguinal (abdominal) ring, the femoral canal, and the Hesselbach

triangle

is required

ing the repair of an indirect guinal

hernia

missed. During

may be quite

repair

hernia or a femoral

to avoid “hernia trap” scenarios.

inguinal obvious,

of a direct

hernia

hernia, an associated but a femoral

inguinal

hernia,

hernia

Dur-

direct inmay be

a small indirect

also may be easily missed.

Recurrence of an Indirect Znguinal Hernia Resulting from Failure to Close a Patulous Internal Abdominal Ring The condition of the internal abdominal ring should be carefully assessed.

should

If the ring

be performed.

is abnormal,

large cord before closing the internal 440

a direct

It is also important

repair

(plastic

to reduce

closure)

the size of a

ring. Curr

Probl

Surg,

June

19%

Chevalley et a131 Rignault” Rutledge3’ Nyhus= IPTR = iliopubic tract repair.

1986 1986 1988 1989

1983

Asmussen

& Jensen73

1970 1971 1983 1983

1963 1970

Rydellal Halverson

Glassed’ Thurston Thieme75 Magnusson & Isaksson83 Ingimarsson & Spakw

Year

of Recurrence

Study

Reports

& McVap

3.

Representative

TABLE

Rates

Repair

of Inguinal

Bassini Inlay buttress Cooper ligament IPTR inlay buttress

various Plastic closure; Cooper ligament Shouldice Various Bassini Bassini; Cooper ligament Cooper ligament; plastic closure

Technique

i% J after

7.4 3.7 5.6 20.7 0 3.3 1.1 10.3 3.5

9.7 10.8 20.9 7.5

5.0 -

7.1

-

Direct

7.6 3.2

Hernias

Indirect

and Femoral of Hernia

22.9 -

-

-

4.8 0.7

Combined

Type

0

31.3

-

7.3

Femoral

10.0 1.2 2.4 1.7

-

-

33.1

-

-

Recurrent

The musculoaponeurotic component (posterior inguinal canal) of the repair indirectly strengthens the internal abdominal ring. However, this result is secondary and does not restore the structural integrity of an abnormal internal abdominal ring. The reconstruction of the posterior inguinal wall must include repair of the transversalis fascia at the level of the internal abdominal ring.

Likely Breakdown

of Repair under

Tension

A hernia repaired under tension does not heal normally but is subject to disruption during the postoperative period. Tension on the repair line may be effectively reduced by a relaxing incision. Relaxing incisions should be used routinely to repair all groin hernias, with two exceptions-small femoral and small indirect inguinal hernias. When a hernia is repaired with strong fascial margins and a relaxing incision is used to eliminate tension, the two most important technical requirements are satisfied.

TREATMENT

The repair of recurrent hernias is technically intricate and is associated with a high incidence of secondary recurrence. One of us (L. M. N.) adopted the preperitoneal approach to the inguinal region for all recurrent hernias repaired since 19i‘8.86 Evidence that recurrence may result from a localized collagen metabolic defect has confirmed our theory that more than direct reapproximation of the weakened posterior lamina is necessary if further recurrences are to be avoided.““-88 In this context, therefore, incorporation of the prosthetic mesh buttress to strengthen the repair is an important addition to the preperitoneal approach in the management of all recurrent groin hernias. The posterior approach is expected to serve the following purposes: 1. Avoid dissection through nuisance scar tissue 2. Allow thorough assessment of indirect, direct or femoral defects 3. Allow confident exclusion of multiple hernial defects 4. Facilitate the approach to repair by easy visualization of the Cooper ligament, iliopubic tract, and femoral sheath 5. Apply the principle of intraabdominal pressure to the inlay buttress (the Pascal law), evenly fortifying its protection.86 Onlay prosthetic mesh fails to protect the suture line of the repair, and dangerous incarceration of tissue under the mesh may occur (Fig 20). 442

Curr

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June

1991

FIG 20. Onlay prosthetic mesh. The line of hernia repair has broken down and the intestine has incarcerated between the recurrent defect in the abdominal wall and the onlay prosthetic mesh. (From Nyhus LM: World J Surg 1989; 13541. Used by permission.)

Our lo-year experience suggests that this approach to the management of recurrent groin hernias is associated with minimal morbidity and few secondary recurrences.

Technique The steps for gaining access to the proper planes of dissection are described on the preceding pages. Fascial margins of the defect are approximated without excessive tension before the polypropylene mesh is applied to the posterior wall. Anatomic repair of a direct hernia with endogenous fascia, if feasible, approximates transversalis fascia to the iliopubic tract or Cooper ligament. Direct defects are Cur-r

Probl

Surg,

June

1991

443

FIG 21. A polypropylene mesh buttress IS attached posteriorly to the Cooper ligament (after repair of the recurrent defect in the wall) with no. 0 polypropylene suture material. If there is concern about closure of the internal abdominal ring (indirect recurrence), the mesh may be folded around the spermatic cord (insert). (From Nyhus LM, in Nyhus LM, Condon RE (eds): Hernia, ed 3. Philadelphia, JB Lippincott, 1989, p 171. Used by permission.)

closed with no. 0 polypropylene suture (our standard suture material for herniorrhaphy), incorporating healthy fascia. Indirect hernial defects are closed medial to the spermatic cord by two or three sutures between the anterior crus of transversalis fascia at the internal abdominal ring and iliopubic tract posteriorly. Occasionally one or two sutures may be placed lateral to the cord. Femoral hernial defects are closed with two or three sutures between the Cooper ligament below and the iliopubic tract above. A relaxing incision is made in the anterior rectus sheath as part of the anatomic repair. 444

C’urr

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June

1991

After the recurrent hernial defect is closed, a piece of polypropylene mesh (Marlex) is cut. Ordinarily, the size of the mesh is 10 X 4 cm. The Cooper ligament is visualized, and the mesh is sutured to it (Fig 21). When a recurrent indirect hernia is being repaired, the spermatic cord should be incorporated into the mesh. The mesh is simply folded over the fascial repair and tacked to the posterior inguinal wall with no. 000 polypropylene. The polypropylene mesh may be tailored to fit the area that is to be covered. Finally, the mesh is sutured beneath the abdominal wound of entry to buttress the closure. This inlay repair is an effective buttress against positive intraabdominal pressure (Fig 22).

FIG 22. Inlay prosthetic mesh. Arrows depict the Pascal principle of even pressure prosthetic mesh. The suture line of the hernial defect remains intact and (From Nyhus LM: World J Surg 1989; 13541 Used by permission.) Cur-r Probl

Sorg,

June

1991

apl Ilied to the well protec ted.

445

Results Over 102 patients with 115 hernias treated by IPTR and inlay buttress were followed for 6 months to 10 years. The re-recurrence rate was 1.7% !l The complications were minor, including five superficial wound infections.

FUTURE

SHOCK AND HERNIA

SURGERY

Must we specialize in herniorrhaphy to achieve better results? One hundred years after the modern concept of repair of hernias was introduced, mastery of the operation remains an elusive goal. Despite advances in the understanding of hernia and improvements in operative technique, recurrent hernias continue to plague patients. According to several studies, hernial recurrence rates are subject to even greater dichotomy between hernia experts (herniologists) and “nonspecialized” general surgeons. This led Deysine and SoroffBg to reflect on the potential advantages of a certification process for specialization in hernial surgery: If we intend to improve the results of inguinal herniorrhaphy we must consider whether the time has come for specialization. Other fields of general surgery have proceeded toward the hands of specialists with undeniably improved results. The need for such a decision seems statistically clear, but the question is: are we ready? How are we as general surgeons to interpret this distress call for another surgical specialty? Are improved outcomes only within reach of specialists in hernia, or are we failing to provide residents with adequate training in hernial surgery? There are clinics, hospitals, and institutes that advertise a special expertise in the treatment of hernias, particularly groin hernias. There is nothing wrong with this approach, but to escalate the practice of hernial surgery to a unique branch of general surgery is unnecessary, if not wrong. General surgical residents can be taught the fundamentals of surgical anatomy of groin hernias. The correct surgical techniques for various types of hernias regularly found in our patients can be taught during supervised training. Continuing problems, such as recurrence, are caused not by deficiencies in training programs but by incorrect application of the various hernial operations. If attention is given to the preservation of sphincter and shutter mechanisms, to selective use of prosthetic materials, and to insistence on the time-honored repair (fascia to fascia without tension), all of us will perform superior repairs of groin hernias. At the same time, we can remain true general surgeons, fulfilling ourselves intellectually and creatively by performing a variety of operations for a variety of surgical diseases. 446

Curr

Probl

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June 19%

REFERENCES

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447

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AmJSurg

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74:697-

707.

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75263-266. 77.

78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89.

450

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Curr ProbZ Suq, June

1991