Hernia DOI 10.1007/s10029-014-1218-8
ORIGINAL ARTICLE
Schley’s inguinal hernia repair: a single unit’s experience of a forgotten technique B. S. H. Indrasena • A. L. M. A. Farhan P. J. T. N. S. S. K. Jayasinghe
•
Received: 17 July 2013 / Accepted: 5 January 2014 Ó Springer-Verlag France 2014
Abstract Background This study was done to assess the effectiveness of Schley’s inguinal hernia repair. It is a retrospective study analysing the outcome of patients who received the said technique over a period of 1 year at our institution. The minimum and the maximum follow-up periods were 2 and 3 years. Method The patients who underwent the above technique in 2011 were reviewed retrospectively in December 2013 by going through the hospital records and examining the patients in person. Results 105 patients had undergone surgery in 2011. The majority of them had right-sided hernias and were in 40–59 age group. Two cases of wound infection, one case of haematocele and one hernia recurrence were noted. Operating on the recurrent hernia was straightforward. Conclusion Schley’s inguinal hernia repair is an effective technique with favourable outcome. Keywords Inguinal hernia repair Schley’s inguinal hernia repair Hernioplasty Herniorrhaphy Tissue repair techniques Techniques of inguinal hernia repair Evolving techniques of inguinal hernia repair
B. S. H. Indrasena A. L. M. A. Farhan P. J. T. N. S. S. K. Jayasinghe Department of General Surgery, Teaching Hospital, Batticaloa, Sri Lanka B. S. H. Indrasena (&) No. 529, Balagolla, Kengalla ZIP 20186, Sri Lanka e-mail: [email protected]
Introduction The optimum method of inguinal hernia repair is yet to be determined [1]. Tension-free repair using a synthetic mesh [2], with or without laparoscopic assistance [3], is the standard technique in most developed countries because of low overall recurrence rate, but in developing countries the commonest technique is the modified Bassini because of the financial reasons; as an example, the Sri Lankan government did not fund for synthetic meshes until recently. However, the modified Bassini’s repair is associated with a very high rate of recurrent hernia, which is as high as 7–17 depending on the duration of follow-up [4–7]. In contrary to the common belief, some studies have reported high recurrence rates (5 %) [7] even with Lichtenstein repair. Shouldice repair is said to be associated with very low recurrence rates [5], but it is not popular or widely available and repairing on recurrent hernia after Shouldice repair is no easy task. As a result, it is essential to explore alternative methods. In early 1900s, Winfield S. Schley described four novel techniques by publishing a series of articles in Annals of Surgery from 1913 to 1923 [8–11]. He described four techniques that he had practised in groin hernia repair. They were 1. 2. 3. 4.
Rectus transposition Overlap of external oblique aponeurosis Combined rectus transposition and aponeurotic overlap Combined Bassini repair with aponeurotic overlap
His techniques are a kind of tissue repair. The techniques are not as complicated as Shouldice repair. A synthetic mesh is not required. In that way, Schley’s repair is a
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better alternative to mesh repair. But these techniques have been hardly evaluated by others in terms of rate of recurrence and other complications. Schley’s fourth technique will be described below. This is the technique that was used in this study.
Step 2: Suturing the upper leaf of external oblique aponeurosis to Poupart’s ligament over weak internal oblique and conjoined tendons.
Combined Bassini repair with aponeurotic overlap The emphasis is given in this technique to completely obliterate the inguinal canal and transplant the cord anterior to the external oblique aponeurosis as opposed to strengthening the posterior wall of the inguinal canal alone as emphasized by other methods. The hernial sac and its contents are dealt with in the usual manner. There is no more dissection other than separating the sac from the cord, and the cord from the inguinal canal. Having dealt with the hernia, the posterior wall of the inguinal canal is reinforced first by suturing the internal oblique and conjoined tendons to inguinal ligament (modified Bassini) followed by overlapping the two flaps of the external oblique aponeurosis behind the cord (Schley’s modification). In effect this is akin to reinforcing the modified Bassini’s technique with aponeurotic overlap. The essential steps of the Schley’s technique for a leftsided inguinal hernia are as follows (diagrams are reproduced here from Schley’s original article) [10]: Step 1: Internal oblique and conjoined tendon are sutured to Poupart’s ligament.
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Step 3: The upper leaf of external oblique aponeurosis may be notched for cord or sutured over the cord.
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Step 4: Completion of suture of the upper leaf of external oblique aponeurosis to Poupart’s ligament.
Step 5: The lower leaf of the external oblique aponeurosis lapping suture line and folded over upper half secured by interrupted sutures.
Step 7: Completion of overlapping.
Study design Objective
Step 6: The lower leaf may also be notched to surround transplanted cord or may be sutured only to site of cord.
We have been practising Schley’s fourth technique of inguinal hernia repair described above for quite sometime especially on patients who were not able to afford to spend on synthetic meshes and patients who underwent emergency surgery for strangulated hernias.
123
Hernia Table 1 The distribution of cases according to the age
Table 3 Complications developing during the follow-up period
Age in years
Complication
Number of cases
%
Wound infection
2
39
Haematocele
1
Recurrence of hernia
1
Number of cases (Total 105) Number
20–39
41
40–59
43
41
60–79
20
19
1
1
80 and above
Table 2 The distribution of cases according to the side operated Side
Number of cases (Total 105) Number
%
Left
34
32
Right
66
63
5
5
Bilateral
Later we offered this technique to all patients unless the patient insisted on mesh repair. The aim of this study was to assess the outcome of the procedure on that patient population.
The number of days the patients stayed in hospital after surgery ranged from 1 to 5 days. One patient developed urinary retention, and two patients developed haematoma that was managed conservatively. Only 24 patients turned up at the clinic in January 2013 and December 2013 for the follow-up and this accounted for 23 % of the operated cases. The duration of time they stayed at home before joining work after surgery ranged from 1 to 2 months. The following complications were noted in the followed up cases (Table 3). No patients complained of chronic pain at the operated site after 2–3 years of follow-up. All of them were quite satisfied with the operation.
Discussion Methodology This is a retrospective descriptive study of the cohort of patients who underwent Schley’s inguinal hernia repair in the year 2011, over a period of 1 year. The patients were reviewed in clinic in January and December 2013 after sending request letters to attend the clinic for a review. The necessary information related to the operation was collected by taking history, doing physical examination and reviewing the clinic records and hospital records. All adult patients who underwent Schley’s repair during the said period were evaluated. This included the patients who underwent emergency surgery for strangulated hernia. This study does not include patients who underwent surgery for recurrent inguinal hernia to whom we offered Lichtenstein mesh repair. Children and women were obviously not included in the study because repairing the posterior wall was not an issue to these two categories. The main outcome measures evaluated were the postoperative complications, recurrence of hernia and the quality of life.
Results The total number of cases operated in 2011 was 105 (Tables 1, 2).
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Our study revealed that most of the patients with hernia were above the age of 40 years (61 %) and right side hernia is twice as common as left side hernia. The minimum follow-up period of the sample was 2 years and the longest follow-up period was 3 years. Although this does not seem to be an adequate period of follow-up, this is a quite reasonable period of follow-up because when hernias recur, more than 50 % of hernias recur within 3 years of surgery [6]. The best post-operative period of follow-up to detect recurrent hernias is yet to be ascertained. Despite the best efforts, it was not possible to review more than 24 patients because the addresses that the patients had provided were inaccurate or incomplete. But we did not find any other patient attending to the clinic with a complication associated with this technique during the post-discharge period. As a result, we can conclude that the post-operative chronic pain following this technique is quite rare. Otherwise we must have seen such patients attending to the clinic with pain. Post-operative chronic pain is a significant complication following Lichtenstein repair. However, the same cannot be assumed in regard to recurrences because the recurrences can remain asymptomatic or small and ignored by the patients. Anyway the high dropout rate is a drawback in this study to prove statistically the efficacy of Schley’s inguinal hernia repair technique.
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One patient presented with recurrent hernia. Because only 24 patients were followed up at clinic, the rate of recurrence comes as 4 %. Assuming that the patients who did not present had no recurrence, the rate of recurrence is as low as 1 %. Certainly, both these figures are much better than the reported recurrence rate following modified Bassini’s repair which is as high as 17 % in some studies. The duration of post-operative hospital stay ranged from 1 to 5 days. Apart from two patients developing haematoma and one patient developing urinary retention, there were no major complications. The post-operative morbidity associated with this technique is comparable with other techniques. The patient who developed wound infection responded to antibiotics and laid opening of the wound. Further surgery was required to close the wound by secondary suturing. There is no issue of infection of prosthetic materials requiring removal of the mesh. Since there is no use of prosthetic materials, this technique can be employed in strangulated hernias that need emergency surgery. The single recurrence that occurred was observed at 7 months of surgery. It was painless and small about 2 cm of diameter occurring at the site of the new superficial inguinal ring. On exploration, it was found that the neoopening had become widened by giving away of sutures put between the upper flap of the external oblique aponeurosis and inguinal ligament close to the cord. It can be considered as surgeon’s failure to follow the technique properly rather than a failure of the technique. Repeat surgery was not difficult. It required only minor dissection around the cord and leaving a piece of synthetic mesh around the cord behind the external oblique aponeurosis. There were no complications from the repeat surgery. This contrasts drastically with the main drawback of Shouldice repair viz. difficulty of reoperation in case of recurrence. One patient presented with haematoma in the distal segment of the hernial sac. This was managed expectantly.
Conclusion Due to higher recurrence rate associated with modified Bassini’s repair and the cost of mesh associated with Lichtenstein’s repair, Schley’s Repair is worth exploring as
an alternative tissue repair technique for inguinal hernia surgery. Unlike in Shouldice repair, repairing a recurrent hernia after Schley’s repair is simple. Schley’s repair avoids the complications associated with laparoscopic techniques which include long operating time and higher probability of potentially life-threatening complications. Schley’s repair has surely got a prominent place among nearly 75 techniques already published. However, further studies aiming for long-term follow-up of larger samples is necessary and worth embarking on. Conflict of interest BSHI declares no conflict of interest, MAFAL declares no conflict of interest, PJTNSSK declares no conflict of interest.
References 1. Udwadia TE (2006) Inguinal hernia repair: the total picture. J Minimal Access Surg 2(3):144–146 2. The EU Hernia Trialists Collaboration (2002) Repair of groin hernia with synthetic mesh. Meta analysis of randomised controlled trials. Ann Surg 235(3):322–332 3. Bittner R, Schwarz J (2012) Inguinal hernia repair: current surgical techniques. Langenbecks Arch Surg 397:271–282 4. Vrijland WW et al (2002) Randomized clinical trial of non-mesh versus mesh repair of primary inguinal hernia. Br J Surg 89:293–297 5. Paul A, Troidl H, Williams JI, Rixen D, Langen R (1994) Randomized trial of modified Bassini versus Shouldice inguinal hernia repair. The Cologne hernia study group. Br J Surg 81(10):1531–1534 6. Van Veen RN et al (2007) Long-term follow-up of a randomized clinical trial of non-mesh versus mesh repair of primary inguinal hernia. Br J Surg 94:506–510 7. Harjai MM et al (2007) A Prospective Randomized Controlled Study of Lichtenstein’s tension free versus modified bassini repair in the management of Groin Hernias. MJAFI 63(1):40–43 8. Schley WS (1913) Rectus transplantation for deficiency of internal oblique muscle, in certain cases of inguinal hernia. Ann Surg 58(4):473–478 9. Schley WS (1918) Rectus muscle transposition in certain cases of inguinal hernia. Ann Surg 67(4):465–467 10. Schley WS (1920) The utilization of the external oblique aponeurosis in inguinal hernia with muscle deficiency. Ann Surg 71(6):753–754.4 11. Schley WS (1923) Transposition of the rectus muscle and the utilization of the external oblique aponeurosis in the radical cure of the inguinal hernia. Ann Surg 77(5):605–611
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ORIGINAL ARTICLE
Schley’s inguinal hernia repair: a single unit’s experience of a forgotten technique B. S. H. Indrasena • A. L. M. A. Farhan P. J. T. N. S. S. K. Jayasinghe
•
Received: 17 July 2013 / Accepted: 5 January 2014 Ó Springer-Verlag France 2014
Abstract Background This study was done to assess the effectiveness of Schley’s inguinal hernia repair. It is a retrospective study analysing the outcome of patients who received the said technique over a period of 1 year at our institution. The minimum and the maximum follow-up periods were 2 and 3 years. Method The patients who underwent the above technique in 2011 were reviewed retrospectively in December 2013 by going through the hospital records and examining the patients in person. Results 105 patients had undergone surgery in 2011. The majority of them had right-sided hernias and were in 40–59 age group. Two cases of wound infection, one case of haematocele and one hernia recurrence were noted. Operating on the recurrent hernia was straightforward. Conclusion Schley’s inguinal hernia repair is an effective technique with favourable outcome. Keywords Inguinal hernia repair Schley’s inguinal hernia repair Hernioplasty Herniorrhaphy Tissue repair techniques Techniques of inguinal hernia repair Evolving techniques of inguinal hernia repair
B. S. H. Indrasena A. L. M. A. Farhan P. J. T. N. S. S. K. Jayasinghe Department of General Surgery, Teaching Hospital, Batticaloa, Sri Lanka B. S. H. Indrasena (&) No. 529, Balagolla, Kengalla ZIP 20186, Sri Lanka e-mail: [email protected]
Introduction The optimum method of inguinal hernia repair is yet to be determined [1]. Tension-free repair using a synthetic mesh [2], with or without laparoscopic assistance [3], is the standard technique in most developed countries because of low overall recurrence rate, but in developing countries the commonest technique is the modified Bassini because of the financial reasons; as an example, the Sri Lankan government did not fund for synthetic meshes until recently. However, the modified Bassini’s repair is associated with a very high rate of recurrent hernia, which is as high as 7–17 depending on the duration of follow-up [4–7]. In contrary to the common belief, some studies have reported high recurrence rates (5 %) [7] even with Lichtenstein repair. Shouldice repair is said to be associated with very low recurrence rates [5], but it is not popular or widely available and repairing on recurrent hernia after Shouldice repair is no easy task. As a result, it is essential to explore alternative methods. In early 1900s, Winfield S. Schley described four novel techniques by publishing a series of articles in Annals of Surgery from 1913 to 1923 [8–11]. He described four techniques that he had practised in groin hernia repair. They were 1. 2. 3. 4.
Rectus transposition Overlap of external oblique aponeurosis Combined rectus transposition and aponeurotic overlap Combined Bassini repair with aponeurotic overlap
His techniques are a kind of tissue repair. The techniques are not as complicated as Shouldice repair. A synthetic mesh is not required. In that way, Schley’s repair is a
123
Hernia
better alternative to mesh repair. But these techniques have been hardly evaluated by others in terms of rate of recurrence and other complications. Schley’s fourth technique will be described below. This is the technique that was used in this study.
Step 2: Suturing the upper leaf of external oblique aponeurosis to Poupart’s ligament over weak internal oblique and conjoined tendons.
Combined Bassini repair with aponeurotic overlap The emphasis is given in this technique to completely obliterate the inguinal canal and transplant the cord anterior to the external oblique aponeurosis as opposed to strengthening the posterior wall of the inguinal canal alone as emphasized by other methods. The hernial sac and its contents are dealt with in the usual manner. There is no more dissection other than separating the sac from the cord, and the cord from the inguinal canal. Having dealt with the hernia, the posterior wall of the inguinal canal is reinforced first by suturing the internal oblique and conjoined tendons to inguinal ligament (modified Bassini) followed by overlapping the two flaps of the external oblique aponeurosis behind the cord (Schley’s modification). In effect this is akin to reinforcing the modified Bassini’s technique with aponeurotic overlap. The essential steps of the Schley’s technique for a leftsided inguinal hernia are as follows (diagrams are reproduced here from Schley’s original article) [10]: Step 1: Internal oblique and conjoined tendon are sutured to Poupart’s ligament.
123
Step 3: The upper leaf of external oblique aponeurosis may be notched for cord or sutured over the cord.
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Step 4: Completion of suture of the upper leaf of external oblique aponeurosis to Poupart’s ligament.
Step 5: The lower leaf of the external oblique aponeurosis lapping suture line and folded over upper half secured by interrupted sutures.
Step 7: Completion of overlapping.
Study design Objective
Step 6: The lower leaf may also be notched to surround transplanted cord or may be sutured only to site of cord.
We have been practising Schley’s fourth technique of inguinal hernia repair described above for quite sometime especially on patients who were not able to afford to spend on synthetic meshes and patients who underwent emergency surgery for strangulated hernias.
123
Hernia Table 1 The distribution of cases according to the age
Table 3 Complications developing during the follow-up period
Age in years
Complication
Number of cases
%
Wound infection
2
39
Haematocele
1
Recurrence of hernia
1
Number of cases (Total 105) Number
20–39
41
40–59
43
41
60–79
20
19
1
1
80 and above
Table 2 The distribution of cases according to the side operated Side
Number of cases (Total 105) Number
%
Left
34
32
Right
66
63
5
5
Bilateral
Later we offered this technique to all patients unless the patient insisted on mesh repair. The aim of this study was to assess the outcome of the procedure on that patient population.
The number of days the patients stayed in hospital after surgery ranged from 1 to 5 days. One patient developed urinary retention, and two patients developed haematoma that was managed conservatively. Only 24 patients turned up at the clinic in January 2013 and December 2013 for the follow-up and this accounted for 23 % of the operated cases. The duration of time they stayed at home before joining work after surgery ranged from 1 to 2 months. The following complications were noted in the followed up cases (Table 3). No patients complained of chronic pain at the operated site after 2–3 years of follow-up. All of them were quite satisfied with the operation.
Discussion Methodology This is a retrospective descriptive study of the cohort of patients who underwent Schley’s inguinal hernia repair in the year 2011, over a period of 1 year. The patients were reviewed in clinic in January and December 2013 after sending request letters to attend the clinic for a review. The necessary information related to the operation was collected by taking history, doing physical examination and reviewing the clinic records and hospital records. All adult patients who underwent Schley’s repair during the said period were evaluated. This included the patients who underwent emergency surgery for strangulated hernia. This study does not include patients who underwent surgery for recurrent inguinal hernia to whom we offered Lichtenstein mesh repair. Children and women were obviously not included in the study because repairing the posterior wall was not an issue to these two categories. The main outcome measures evaluated were the postoperative complications, recurrence of hernia and the quality of life.
Results The total number of cases operated in 2011 was 105 (Tables 1, 2).
123
Our study revealed that most of the patients with hernia were above the age of 40 years (61 %) and right side hernia is twice as common as left side hernia. The minimum follow-up period of the sample was 2 years and the longest follow-up period was 3 years. Although this does not seem to be an adequate period of follow-up, this is a quite reasonable period of follow-up because when hernias recur, more than 50 % of hernias recur within 3 years of surgery [6]. The best post-operative period of follow-up to detect recurrent hernias is yet to be ascertained. Despite the best efforts, it was not possible to review more than 24 patients because the addresses that the patients had provided were inaccurate or incomplete. But we did not find any other patient attending to the clinic with a complication associated with this technique during the post-discharge period. As a result, we can conclude that the post-operative chronic pain following this technique is quite rare. Otherwise we must have seen such patients attending to the clinic with pain. Post-operative chronic pain is a significant complication following Lichtenstein repair. However, the same cannot be assumed in regard to recurrences because the recurrences can remain asymptomatic or small and ignored by the patients. Anyway the high dropout rate is a drawback in this study to prove statistically the efficacy of Schley’s inguinal hernia repair technique.
Hernia
One patient presented with recurrent hernia. Because only 24 patients were followed up at clinic, the rate of recurrence comes as 4 %. Assuming that the patients who did not present had no recurrence, the rate of recurrence is as low as 1 %. Certainly, both these figures are much better than the reported recurrence rate following modified Bassini’s repair which is as high as 17 % in some studies. The duration of post-operative hospital stay ranged from 1 to 5 days. Apart from two patients developing haematoma and one patient developing urinary retention, there were no major complications. The post-operative morbidity associated with this technique is comparable with other techniques. The patient who developed wound infection responded to antibiotics and laid opening of the wound. Further surgery was required to close the wound by secondary suturing. There is no issue of infection of prosthetic materials requiring removal of the mesh. Since there is no use of prosthetic materials, this technique can be employed in strangulated hernias that need emergency surgery. The single recurrence that occurred was observed at 7 months of surgery. It was painless and small about 2 cm of diameter occurring at the site of the new superficial inguinal ring. On exploration, it was found that the neoopening had become widened by giving away of sutures put between the upper flap of the external oblique aponeurosis and inguinal ligament close to the cord. It can be considered as surgeon’s failure to follow the technique properly rather than a failure of the technique. Repeat surgery was not difficult. It required only minor dissection around the cord and leaving a piece of synthetic mesh around the cord behind the external oblique aponeurosis. There were no complications from the repeat surgery. This contrasts drastically with the main drawback of Shouldice repair viz. difficulty of reoperation in case of recurrence. One patient presented with haematoma in the distal segment of the hernial sac. This was managed expectantly.
Conclusion Due to higher recurrence rate associated with modified Bassini’s repair and the cost of mesh associated with Lichtenstein’s repair, Schley’s Repair is worth exploring as
an alternative tissue repair technique for inguinal hernia surgery. Unlike in Shouldice repair, repairing a recurrent hernia after Schley’s repair is simple. Schley’s repair avoids the complications associated with laparoscopic techniques which include long operating time and higher probability of potentially life-threatening complications. Schley’s repair has surely got a prominent place among nearly 75 techniques already published. However, further studies aiming for long-term follow-up of larger samples is necessary and worth embarking on. Conflict of interest BSHI declares no conflict of interest, MAFAL declares no conflict of interest, PJTNSSK declares no conflict of interest.
References 1. Udwadia TE (2006) Inguinal hernia repair: the total picture. J Minimal Access Surg 2(3):144–146 2. The EU Hernia Trialists Collaboration (2002) Repair of groin hernia with synthetic mesh. Meta analysis of randomised controlled trials. Ann Surg 235(3):322–332 3. Bittner R, Schwarz J (2012) Inguinal hernia repair: current surgical techniques. Langenbecks Arch Surg 397:271–282 4. Vrijland WW et al (2002) Randomized clinical trial of non-mesh versus mesh repair of primary inguinal hernia. Br J Surg 89:293–297 5. Paul A, Troidl H, Williams JI, Rixen D, Langen R (1994) Randomized trial of modified Bassini versus Shouldice inguinal hernia repair. The Cologne hernia study group. Br J Surg 81(10):1531–1534 6. Van Veen RN et al (2007) Long-term follow-up of a randomized clinical trial of non-mesh versus mesh repair of primary inguinal hernia. Br J Surg 94:506–510 7. Harjai MM et al (2007) A Prospective Randomized Controlled Study of Lichtenstein’s tension free versus modified bassini repair in the management of Groin Hernias. MJAFI 63(1):40–43 8. Schley WS (1913) Rectus transplantation for deficiency of internal oblique muscle, in certain cases of inguinal hernia. Ann Surg 58(4):473–478 9. Schley WS (1918) Rectus muscle transposition in certain cases of inguinal hernia. Ann Surg 67(4):465–467 10. Schley WS (1920) The utilization of the external oblique aponeurosis in inguinal hernia with muscle deficiency. Ann Surg 71(6):753–754.4 11. Schley WS (1923) Transposition of the rectus muscle and the utilization of the external oblique aponeurosis in the radical cure of the inguinal hernia. Ann Surg 77(5):605–611
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