Inguinal hernia repair

Inguinal hernia repair

lnguinal Hernia Repair A Comparison of the Shouldice and Cooper Ligament Repair of the Posterior lnguinal Wall Frank Glassow, MA (Cantab), MBB Chir (C...

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lnguinal Hernia Repair A Comparison of the Shouldice and Cooper Ligament Repair of the Posterior lnguinal Wall Frank Glassow, MA (Cantab), MBB Chir (Cantab), FRCS (C), FRCS (Engl), Toronto, Ontario, Canada

Among surgeons there is still no agreement on the best operation for repair of inguinal hernia. Nevertheless, published results of large series in the last two decades have shown a steady decline in recurrence rates and an increasing awareness that recurrence rates from 5 to 20 per cent, commonplace twenty or more years ago, are unacceptable. The greatest remaining challenge in this field is to reduce the recurrence rate in direct inguinal hernia repair. This paper examines the relative merits of two technics now frequently used in repairing the posterior inguinal wall. They are known as the Shouldice repair and the Cooper ligament repair. Bassini [1] in 1890 reported a consecutive series of 251 patients with inguinal hernia who were followed from one to four and a half years, with seven recurrences (2.7 per cent), which as Zimmerman [2] says, is “a record of which any surgeon of today could well be proud.” After dealing with any indirect sac present, Bassini divided the fascial floor of the inguinal canal from internal ring to pubis. He then carefully sutured a triple layer composed of internal oblique, transversus abdominis, and transversalis fascia with interrupted silk sutures to the shelving portion of Poupart’s ligament. The two lowermost sutures included the outer margin of the rectus abdominis muscle. Today many surgeons who, like Bassini, practice the anterior approach to the inguinal canal feel that a more definitive treatment of the transversalis plane or lamina is not only necessary but fundamental to success and that therefore the Bassini repair was unsatisfactory in this respect. They also feel that the Bassini technic of bringing all sutures to the inguinal ligament ignored some of the basic anatomic tenets now prevalent. In more recent times contributions of Anson and McVay [3-51 to our understanding of the normal and pathologic anatomy and of the surgery of the inguinal region during the last thirty-five years have been of outstanding importance. Their basic anatomic conFrom the Department of Surgery, Shouldice Hospital, Toronto, Ontario, Canada. Reprint requests should be addressed to Dr Frank Glassow, Shouldice Hospital, Box 370, Thornhill. Ontario, Canada L3T 127.

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cept, with respect to the transversalis plane, is that the transversus abdominis muscle blends medially by an aponeurotic extension with the rectus sheath, while caudally this extension is attached to Cooper’s ligament inserted on to the superior pubic ramus. A further caudal extension then passes onwards as the anterior portion of the femoral sheath into the thigh. Defects in this all-encompassing sheath are of vital importance in the etiology of indirect, direct, and femoral hernias. Small indirect inguinal hernias will be disregarded from the point of view of the subsequent arguments in this report. Large indirect inguinal hernias and direct inguinal hernias imply, then, a destruction in varying degree of the aponeuroticofascial structure of the posterior inguinal wall. This weakness may be of congenital or acquired origin. Trauma, increasing age, and degenerating musculature are important etiologic factors in patients with acquired weakness. In this regard the studies of Anson, Morgan, and McVay [6] have shown that there is a considerable variation in the number of aponeurotic fibers in the posterior inguinal wall. McVay states that, although occasionally a direct inguinal hernia is diverticular with a narrow neck, the majority occur as diffuse bulges of the posterior inguinal wall. This certainly agrees with my experience during a twenty-one year period with a personal series of 14,982 consecutive inguinal hernia repairs, comprised of 8,490 indirect, 4,741 direct, 1,047 combined indirect and direct, and 704 sliding inguinal hernias. (Tables I and II.) Surgeons who practice the Cooper ligament repair contend that the most logical way to repair this defect-this so-called deficiency of substance of the posterior inguinal wall-is by one of the three following methods, all having the same objective. In the first, the gap is closed by suturing the aponeurosis of the transversus plus its investing fascia, representing the upper margin of the defect, downwards to its insertion on to Cooper’s ligament along the superior ramus of the pubis lateral to the pubic tubercle. This ligament is a strong tough structure and the suturing continues laterally to the femoral vein, so restoring the nor-

The American Journal of Surgery

lnguinal Hernia Repair

ma1 anatomic configuration. If the lower borders of the transversus and the internal oblique aponeurosis cannot be brought down to Cooper’s ligament without tension, due either to congenital deficiency or to attenuation by a protruding hernial sac, the second method of closure is employed. This utilizes a relaxing incision [7,8] made in the medial part of the anterior rectus sheath. The sheath is then separated from the rectus muscle to the latter’s lateral margin, when it slides into position as the new posterior inguinal wall. In the third method, comprising only a very small percentage of cases, a mesh has to be used for adequate closure of the gap by anchoring it to the margins described. The Shouldice repair for inguinal hernia has two main facets. The first deals with the technic used at the internal ring for the cure of indirect hernia, including sliding hernia. The second deals with the technic used in the repair of the posterior inguinal wall for the cure of direct inguinal hernia, although it is also frequently used prophylactically when the posterior inguinal wall is weak. The Cooper ligament repair can obviously only be compared with the second of these. The full Shouldice repair has been described in detail elsewhere [914] and only the principles of the repair of the posterior inguinal wall will be discussed here. The Shouldice repair of the posterior inguinal wall, like the Cooper ligament repair, recognizes the basic importance of first reconstructing the innermost of the three musculoaponeurotic layers of the anterior abdominal wall, the transversalis lamina. However, in dealing with this transversalis plane, the Shouldice concept is basically different in one particular respect, which will be amplified after the following brief description of the essential part of the repair. The strength of the posterior inguinal wall is routinely assessed first by inspection and then by palpation with a finger in the preperitoneal plane inserted just medial to the internal ring through an opening made in the transversalis facia, whether a direct inguinal hernia is present or not. The posterior inguinal wall is then divided partially or completely, depending upon the strength of the medial part. The division begins laterally where the opening in this layer has already been made. In a typical patient, in which this division is complete, two segments or flaps of transversalis result. If a protruding diffuse direct inguinal hernia has stretched or attenuated the overlying aponeuroticofascial transversalis layer some of the latter may be excised from each flap. The upper or medial flap is usually somewhat narrower than the voluma131,March

1976

TABLE

I

Personal Series of Primary lnguinal Herniorrhaphies from 1954 to 1974

Typeot

Primary Hernia Indirect Direct Indirect direct

and

Sliding Total

TABLE

II

Sliding Total

Number of Recurrences

7,863 3,814 798

43 (0.6%) 27 (0.7%) 3 (0.4%)

633 13,108

0 (0) 73 (0.6%)

Personal Series of Recurrent lnguinal Herniorrhaphies from 1954 to 1974

Type of Recurrent Hernia Indirect Direct Indirect direct

_. Number of Repairs

and

Number of Repairs

Number of Recurrences

627 927 249

4 (0.6%) 10 (1.1%) 4 (1.6%)

71 1,874

0 (0) 18 (1.0%)

lower or lateral one. It is this lower or lateral flap, measuring usually approximately 1 to 2 cm in width, that is vital to the Shouldice repair. It is also vital to an understanding of the difference between the Shouldice repair and the Cooper ligament repair. Those surgeons who perform the latter repair, which in essence brings down the upper edge of the transversus defect to the ligament, largely ignore the existence of this lower flap. McVay in his earlier writings states: “The attenuated aponeurosis and fascia [is] excised down to Cooper’s ligament . . .” 1151. Later he states: “. . . the inguinal ligament and the residual posterior wall attachment to Cooper’s ligament [the iliopubic tract] are not suitable for the reattachment of the new posterior inguinal wall. . .” [16]. In my experience this lower transversalis flap is usually quite substantial and occasionally very strong. Even in the presence of a large direct inguinal hernia or a recurrent inguinal hernia, it is surprising how it can eventually be defined by careful dissection and ultimately completely freed and then demonstrated as being perfectly suitable for the subsequent reconstruction of the normal anatomic planes. The free upper edge of this lower flap, whose base Anson and McVay’s anatomic studies have demonstrated to be firmly anchored to the superior pubic ramus by Cooper’s ligament, is carried upwards and medially underneath its fellow upper flap, which therefore overlaps it. This attachment is effected by a continuous line of nonabsorbable suture inserted without tension using small bites. Monofilament gauge number 34 stain-

Glassow

less steel wire has so far been the suture material of choice. The first suture line begins medially at the pubic bone and ends laterally medial to the internal ring. Medially, underneath the medial flap, the lateral edge of the rectus is seen as it inserts on to the pubic bone. The suture commences here joining the upper edge of the flap to the posterior aspect of the lateral edge of the rectus at this critical medial point where it is inserted in a manner to prevent subsequent weakness here. After two or three small bites into the lateral edge of the rectus the suture line then picks up the deep surface of the arching transversus as it passes laterally. Problems associated with extreme proximity of the femoral vein are rarely encountered. The “transition” stitch described by McVay to overcome this problem in the Cooper ligament repair has no counterpart in the Shouldice repair. In the latter the cremaster muscle is excised early in the operation. Hence, laterally, the upper lateral cremasteric stump, itself attached to the transversalis fascia, is eminently suitable for inclusion in this reconstruction of the normal anatomic plane. When this first line is completed, it can be seen that in most patients a firm barrier has been reestablished. The general direction of attachment of this lower flap is upwards and medially with the continuous sutures placed closely together and inserted firmly although without tension. This contrasts with the Cooper ligament repair in which the sutures are individually tied and frequently deeply placed because of the direction of the pubic ramus so that tension is not uncommon and a relaxing incision often needed and in which the general pull and direction of the repair is downwards. The experience I have gained in a twenty-one year period with some 15,000 inguinal hernia repairs utilizing the Shouldice technic leaves no doubt in my mind that, except for a small number of patients, the completion of the first line can be seen to have eliminated the posterior inguinal wall defect. However, the Shouldice repair employs a total of four lines of continuous nonabsorbable sutures in the reconstruction of the posterior inguinal wall. The second line of sutures, a continuation of the original suture’which is reversed at the internal ring, commences laterally and travels medially attaching the free edge of the upper divided aponeuroticofascial transversalis fibers (the same edge utilized in the Cooper ligament repair) to the shelving surface of Poupart’s ligament, until it reaches the pubic bone where it is tied to its fellow. This second line is particularly effective in patients in whom there were doubts about the quali-

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ty of the lower flap after the insertion of the first suture line. Two further reinforcing suture lines are used bringing internal oblique and transversus on the medial aspect to Poupart’s ligament on the lateral aspect, making a total of four lines of sutures in the repair of the posterior inguinal wall. Results The Shouldice repair for inguinal hernia performed under local anesthesia lends itself well to a short hospital stay, usually of 72 hours or less, and to an early return to work. In this report, however, the main criteria used for comparing the two technics will be their respective recurrence rates. During the period from 1945 to 1973, a total of 84,500 inguinal hernia repairs were performed at Shouldice Hospital. However, during the initial six or seven years of this period the repair had not become standardized. Despite this, in the entire period there were 650 (0.8 per cent) recurrences [17]. Approximately 50,500 of the repairs were for indirect inguinal hernia, with 335 (0.7 per cent) recurrences. Of these, some 4,300 were recurrent indirect inguinal hernias and 32 (0.8 per cent) recurred. Approximately 25,000 direct inguinal hernia repairs were performed, with 218 (0.9 per cent) recurrences. Of these, 4,700 were recurrent direct inguinal hernias and 65 (1.4 per cent) recurred. Tables I, II, and III summarize the results of my personal series of 14,982 consecutive inguinal herniorrhaphies, 91 (0.6 per cent) of which recurred. They are more suitable for analysis in greater detail because throughout the entire twenty-one year period from 1954 to 1974 I used only the Shouldice technic for the inguinal repair. Of a total of 73 personal recurrences occurring subsequent to the 13,108 primary inguinal hernia repairs (Table I), 46 underwent a seco.id repair at which 15 direct recurrences and 31 femoral recurrences were dealt with. No instance of indirect mguinal recurrence occurred in these 46 patients. Of the remaining 27 recurrences in this group, consisting of 13 clinically inguinal recurrences and 14 clinically femoral recurrences, no further repair has been performed. Of a total of 18 personal (‘re-recurrences” occurring subsequent to the 1,874 recurrent inguinal hernia repairs (Table II), 12 underwent a further (second) operation in this hospital at which time 1 indirect re-recurrence, 7 direct re-recurrences, and 4 femoral re-recurrences were encountered and dealt with. In the remaining group of 6 personal re-recurrences, consisting of 4 clinically inguinal and 2 clinically femoral re-recurrences, no further

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lnguinal Hernia Repair

TABLE III

Personal Repairs of 2,792 Direct lnguinal Hernias from 1954 to 1964 with Recurrence Rates in 1974 (minimum follow-up, 10 years; maximum follow-up, 20 years) 1954 1955 1957 1956 1959 1958 1960 1961 1962 1963 1964 Total

Primary direct hernia repairs Recurrences by 1974 Recurrence rate (%)

71

Primary direct and indirect repairs Recurrences by 1974 Recurrence rate (%)

12

Recurrent direct hernia repairs Recurrences by 1974 Recurrence rate (%)

0

11

19

0

0

1

)

0

2

1

0

1

0

0

5

c

0

5.3

d

0

4.4

2.5

0

1.9

0

0

1.4

Recurrent direct and indirect hernia repairs Recurrences by 1974 Recurrence rate (%)

0

3

6

10

5

22

0

0

0

0

0

0

0

0

0

0

Total direct hernia repairs Total recurrences by 1974 Total recurrence rate

118

206

254

247

172

209

178

174

123

108

1,860

2

2

6

1

0

3

2

1

2

2

0

2.8

1.7

2.4

0.5

0

1.4

1.2

0.6

1.2

1.6

0

24

61

55

37

54

30

55

36

53

21 1.1

33

450

0

1

0

0

0

0

1

1

0

0

0

3

0

4.2

0

0

0

0

3.3

1.8

0

0

0

0.7

83

28

318

334

156

41

45

40

15

49

52

43

18

18

14

1

0

0

0

0

0

1

6.7

0

0

0

0

0

0.8

251

280

185

239

3

7

1

0

6

4

2

3

2

2.4

1.9

2.1

0.3

0

2.0

1.6

1.1

1.1

0.8

repair has been performed. Of this overall personal total of 91 recurrences after inguinal herniorrhaphy, therefore, 40 were inguinal and 51 femoral in type. This somewhat unexpectedly high proportion of femoral “recurrences,” [18] constituting more than one half of all my recurrences, nevertheless represents only 0.3 per cent of the entire series. It may represent some missed hernias, or some technical error in dealing with the lower transversalis flap, or the use of too much tension. It should be noted in this regard that bilateral repairs are associated with a slightly higher recurrence rate. It is also noteworthy that the number of femoral recurrences in my personal series is di-

Vohma 131, Yarch 1976

120

206

2

w

362

9

306

334

34

2,792

30

1.1

-

minishing. From 1954 to 1960, during which I performed 5,236 inguinal repairs, there were altogether 47 recurrences, 10 of which were inguinal and 37 femoral. Yet from 1960 to 1974, during which I performed 9,746 inguinal repairs, there were 44 recurrences, 30 of which were inguinal and 14 femoral. It appears then, perhaps with increasing experience, that the proportion of femoral “pseudorecurrences” after inguinal herniorrhaphy in a large series decreases with time, although this recurrence is rare in the first place. Table III analyzes the group of 2,792 direct inguinal herniorrhaphies that I-performed between 1954 and 1964, that is, all my personal direct in-

Glassow

guinal hernia repairs performed not less than ten years ago and not more than twenty years ago and followed up to 1974. The table specifically records the long-term recurrence rates obtained (1.1 per cent) in a large series of primary and recurrent direct inguinal hernia repairs using the Shouldice technic for the repair of the posterior inguinal wall throughout the entire period. Of all well documented series representing the Cooper ligament repair for inguinal hernia the figures of Halverson and McVay [19] are most pertinent for comparison. In a twenty-two year period from 1946 to 1968 they reported a series of 1,211 herniorrhaphies, 96 of which were femoral or had a femoral component. The remaining 1,115 repairs were entirely inguinal and were subdivided into three groups. The first group of 646 represented abdominal ring repairs only; of these, 583 were small hernias and the only repair performed was located close to the internal ring. Twenty-one (3.1 per cent) recurred, 8 being indirect, 7 direct, 5 femoral, and 1 combined in type. However, since no Cooper ligament repair was performed, they are not relevant to this discussion. Nevertheless, if the comparisons undertaken had included the first facet of the Shouldice repair (technic used at internal ring for indirect hernia), this group would have been most interesting. The remaining 63 repairs in this group were performed for medium sized indirect inguinal hernias so that only a.very modified (lateral) Cooper type repair was performed. Likewise, the 3 (4.8 per cent) recurrences in this group cannot be included in any true comparison of the relative merits of the two types of repair of posterior inguinal wall under discussion. Only in the second group of 442 repairs for hernias, listed as large indirect, direct, or combined, are comparisons valid, for in this group the posterior wall was demonstrably involved and a Cooper ligament repair performed. In this second group there were 16 (3.6 per cent) recurrences altogether. Of these 442 patients, 179 had repair of large indirect inguinal hernia with 3 (1.7 per cent) recurrences, 180 had repair of direct inguinal hernia with 9 (5.0 per cent) recurrences, and 83 had repairs of combined indirect and direct inguinal hernias with 4 (4.8 per cent) recurrences. Therefore, in a total of 263 repairs for primary direct inguinal hernia in which the posterior inguinal wall was undoubtedly primarily involved, as Halverson and McVay pointed out, there were 13 recurrences, giving a recurrence rate of 4.9 per cent for the Cooper ligament repair in this group. In my corresponding personal series of 4,812 repairs for

310

primary direct inguinal hernia, using the Shouldice technic, there were 30 (0.7 per cent) recurrences during the twenty-one year period from 1954 to 1974. Of these, 2,310 with 24 (1.0 per cent) recurrences were performed from 1954 to 1964 and have been followed up to 1974. In Halverson and McVay’s third group of 135 recurrent hernias there were 4 (3.0 per cent) recurrences. In my personal corresponding series of 1,874 recurrent inguinal hernia repairs there were 18 (1.0 per cent) recurrences. Halverson and McVay rightly emphasize the extreme importance of the follow-up. They justify their concern by the care with which the patients in their series were traced. The same continuing conscientious effort is a constant feature of the massive figures I have quoted. The technics used in this effort have been described in detail elsewhere [10,20,21]. Making every allowance for the statistical flaws inevitably introduced by the inadequacies and inaccuracies of a follow-up system which has to take into account these large numbers, the vagaries of a moving population, a continued depletion from deaths (more than 10 per cent of patients in our, series were older than 70 years), indifference to inquiries, and infrequency of reporting for examination, it is nevertheless genuinely felt that the figures quoted are reasonably accurate. Valuable supporting evidence for the recurrence rates quoted comes from the reports of other surgeons now also using the Shouldice technic for inguinal repair. They quote almost identical figures. In particular, Shearburn and Myers [14] in a thirteen year series of 953 consecutive inguinal repairs report a recurrence rate of 0.7 per cent, and Burson [22] in a four year series of 600 inguinal repairs reports a recurrence rate of 0.4 per cent. I have purposely left to the end a detailed “critique” of the Cooper ligament repair, as described and performed by McVay, as a method of repair of the posterior inguinal wall. Zimmerman [23] reviewed the salient points in an editorial in 1948. He questioned McVay’s hypothesis that it was a fundamental error to use the inguinal ligament in the repair of inguinal hernia. He drew attention to the technical difficulties inherent in the Cooper ligament repair for surgeons not familiar with the anatomy of the region. The pubic ramus is a deeply placed structure, often poorly seen, and the necessary proximity of the repair to the femoral vein an ever present hazard to the unwary and inexperienced surgeon. He discussed the basic principle of the Cooper ligament repair and cast some theo-

The Amerlcsn Journal of Surgery

lnguinal Hernia Repair

retical doubt upon the efficiency of an operation predicated upon the need of “. . . a firm and unyielding bastion to resist the pull of muscular structures” [23] which he felt must be wrong in its conception. Although he acknowledged the good results obtainable by surgeons familiar with this area, he remarked in conclusion that “. . . it appears scarcely credible that the superior pubic ligament will replace the inguinal ligament in the routine repair of inguinal hernias” [23]. I am in complete agreement with these arguments and opinions. The Shouldice repair of the posterior inguinal wall, with use of nonabsorbable sutures, restores the continuity of the transversalis lamina without utilizing Cooper’s ligament. It then strengthens the posterior inguinal wall by an overlapping technic of the divided transversalis lamina utilizing the inguinal ligament and then further strengthens the whole area by an approximation of internal oblique and transversus to the inguinal ligament. It is associated with a low recurrence rate of 1 per cent or less. Many thousands of cases have been followed and documented for periods of between ten and twenty years. The figures quoted appear to establish the fact that the Shouldice repair of the posterior inguinal wall has produced results superior to those resulting from the Cooper ligament repair.

In two large well-documented series, each using one of these technics exclusively, the recurrence rates are used to compare these two methods of repair. In Halverson and McVay’s twenty-two year series of 263 repairs for primary direct inguinal hernia, using the Cooper ligament method throughout, this rate was 4.9 per cent. In my personal twenty-one year series of 4,812 primary direct inguinal hernia repairs using the Shouldice method exclusively, a recurrence rate of 0.7 per cent was achieved. These results suggest that the Shouldice repair is superior.

References

5.

6.

7.

6.

Summary The basic principle of the Cooper ligament repair is the closure of the deficiency in the posterior inguinal wall effected by suturing the upper margin of the defect, represented by the aponeurosis of the transversus plus its investing fascia, downwards to its insertion on to Cooper’s ligament along the superior ramus of the pubis lateral to the pubic tubercle. Because of tension, a relaxing incision in the anterior rectus sheath is frequently necessary. The basic principle of the Shouldice repair of the posterior inguinal wall is an overlapping repair utilizing the transversalis fascia, previously divided from internal ring to pubic tubercle. The lateral (or lower) transversalis flap is anchored upwards, underneath the medial (or upper) flap, being attached medially to the edge of the rectus and laterally to the arching fibers of transversus and internal oblique. The medial flap is then attached to the deepest part of the shelving surface of the inguinal ligament. Tension is a less significant factor and a relaxing incision is not used.

Vodumo131, March 1876

9. 10. 11. 12. 13. 14. 15. 16.

17. 18. 19.

20. 21. 22. 23.

Bassini E: bber die Behandlung des Leistenbruckes. Arch K/in Chir 40: 429, 1890. Zimmerman LM, Anson BJ: Anatomy and Surgery of Hernia, 2nd ed. Baltimore, Williams & Wilkins, 1967, p 13. Anson BJ, McVay CB: The anatomy of the inguinal region. Surg Gynecol Obstet 66: 186, 1938. Anson BJ, Morgan EH, McVay CB: Surgical anatomy of the inguinal region based upon a study of 500 body-halves. Surg Gynecol Obstet 111: 707, 1960. McVay CB, Anson BJ: A fundamental error in current methods of inguinal herniorrhaphy. Surg Gynecol Obstet 74: 746, 1942. Anson BJ. Morgan EH, McVay CB: The anatomy of the hernia regions 1. inguinal hernia. Surg Gynecol Obstet 89: 417, 1949. McVay CB: The anatomy of the relaxing incision in inguinal herniorrhaphy. Quart Bull Northwest t&d Sch 36: 245, 1962. Ponka JL: The relaxing incision in hernia repair. Am J Surg 115: 552, 1968. Glassow F: Recurrent inguinal and femoral hernia: 3,000 cases. Can J Surg 7: 284, 1964. Glassow F: The surgical repair of inguinal and femoral hernias. Can h&dAss J 108: 308, 1973. Glassow F: High ligation of the sac in indirect inguinal hernia. Am J Surg 109: 460, 1965. Glassow F: Controversy in Surgery. Philadelphia, WB Saunders. (In press.) Glassow F: Hernia, 2nd ed. Philadelphia, JB Lippincott. (In press.) Shearburn EW, Myers RN: Shouldice repair for inguinal hernia. Surgery 66: 450, 1969. McVay CB: lnguinal and femoral hernioplasty. Surgery 57: 615, 1965. McVay CB: The normal and pathologic anatomy of the transversus abdominus muscle in inguinal and femoral hernia. SurgClinNorthAm51: 1251. 1971. Glassow F: Recurrent inguinal and femoral hernia. Br Med J 1: 215, 1970. Glassow F: Femoral hernia following inguinal herniorrhaphy. Can J Surg 13: 17, 1970. Halverson K, McVay CB: lnguinal and femoral hernioplasty. A 22 year study of the author’s methods. Arch Sufg 101: 127, 1970. lies JDH: Specialisation in elective herniorrhaphy. Lancet 1: 751, 1965. lies JDH: lnguinal hernia repair. A&d Trial Tech Quart 1: 448, 1973. Burson LC: Personal communication, 1975. Zimmerman LM: A critique of the McVay operation for inguinal hernia. Surg Gynecol Obstet 87: 621, 1948.

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