Repair ‘4FOURTH ANGELO
of Inguinal PRINCIPLE
AND MODIFIED TECHNIC
hl. hlAy_, M.D. AND G. FREDERICK
HE repair of inguinal hernia, although well and standardized, is still subject to refinement and improvement. The still prevalent IO per cent incidence of recurrence more specificaIIy chaJJenges thought and action in this direction . Although hundreds of modifications and special technics have been devised, all with merit, three basic principIes in the repair of inguinal hernia remain. AI1 these principles depend on the Iayer of the abdominal waJ1 above which the cord is to be transpJanted. The first and simplest operation, performed mainly in chiIdren, employs the principle of dissection and obhteration of the hernia1 sac with high Iigation of the indirect sac at its junction with the genera1 peritonea1 cavity; simple cJosure is done over the cord of the clefect in the abdomina1 waI1 as occupied by the sac and the conjoined tissues are sutured to the sheIving edge of the inguina1 Iigament . This procedure, known as the Ferguson operation, has been generaIIy accepted as sufficient for the treatment of inguinal hernia in children. This operation is also employed in patients with a direct sac or when combined direct and indirect components are present, or even in the case of a continuous congenita1 sac which invoIves a continuation of the hernia1 sac with the tunica vaginalis. In the Bassini operation the principIe of transpIantation of the cord above the natuya1 muscJe IeveI marks the surgeon’s first understanding of the deficiencies of the inguina1 region which exist in the phenomenon of inguinal hernia. By transpIanting the spermatic cord above the interna obIique muscIe before it is sutured to the sheIving edge of the inguina1 Iigament, it is acknowIedged that a structural change has taken pIace in the region of the musctes of the Iower abdomen. This change
has rendered the area prone to the spreading of muscle fibers adjacent to the internal inguinal ring \vith vulnerability to recurrent herniation. Anatomists have albvays indicated that as the last fibers of the internal oblique and transversus abdominis muscles inserted into the latera aspect of the rectus sheath in its proximit>- to the tubercle, they form a firm tendinous structure, blending together ancJ fastening themselves to the rectus sheath in the inferior border of Hesselbach’s triangle. Surgeons performing herniorrhaphy have sometimes found it dif%cuIt to identify the conjoined tendon, particuIarIy when considerable hernia1 disease has been present and have found it necessarv to suture the lateral border of the rectus fasc’ia to the shelving edge of the inguina1 Iigament in the lower portion of the hernia1 repair. It is probable that the conjoined tendon exists more favorably in those specimens examined without surgical hernial discase, and that the relative absence of the conjoined tendon has some bearing on the condition which is responsibIe for the herniation being present. At any rate, the approximation of tissue to the inguina1 Jigament ancJ the resultant tension in this area in a certain proportion of cases Ied to the third step of recognition of physioIogic and anatomic deficiencies in the inguinal area. The HaIsted operation [?] encompasses the transplantation of the cord through the exterrial obIique fascia and the cIosure of the fascia under the cord, usually with an overIapping, so as to strengthen the Iower inguina1 region further. In addition, careful closure of the fascial ring about the cord is done to prevent further herniation through the indirect route. DoubIe transpIantation of the cord was especiaIIy designed to prevent recurrence when a direct sac or direct component is found. The
May and Norman mesh  and stainless steel vvire mesh [j] vverc introduced into surgery for the purpose of forming a Iatticework in which connective tissue coulci grolv. These substances vvere first usec1 in connection with ventral hernias ancl recurrent inguinal hernias which required prosthetic inserts to be adequately repaired. Such prosthetic inserts were found to be quite valuable and have been quickly accepted throughout this country. Microscopic studies show that not only does metallic mesh act as a support during the but also connective tissue heafing process, grows through the apertures of the metal and forms a dense fascia-Iike structure which in time is many times stronger than the mesh itself. Tantalum mesh and stainIess steel mesh each have their advantages. Stainless steel mesh is easier to handle and less likely to break off; on the other hand, tantaIum mesh has been shown to be Iess reactive to tissue than stainless stee1 mesh, and the instances of serous effusions are Iess with the tantalum material than with the stainless stee1. Even if fragmentation does occur, the connective tissue stroma developing in the tantalum mesh soon overcomes the weakness to fragmentation in practically every instance. These two interna prostheses have been wicleIy utilized in the repair of recurrent hernias. Surgeons have been reticent, however, to substitute the new for the old, and there has been a delay in the employ-ment of these new materials in the primary repair of inguinal hernias. During the last five years vve have employed a prosthesis of stainless steel wire mesh in the repair of primary direct and indirect inguinal hernias in cases in which we thought widening of the abdominal wail was present. The procedure has been standardized as foIlows. An incision is made paralIe1 to the inguinai starting approximately 2 inches Iigament, media1 to the anterior iliac spine, down to the region of the pubic tubercle. The incision is ca,rried through the skin, subcutaneous tissue the external oblique and Scarpa’s fascia, aponeurosis being exposed. Incision is made in the internal oblique fibers between bundles of fascia from a point approximately 3 inches above, down to and through the externa1 inguina1 ring, care being taken to expose and avoid cutting the ilioinguinal nerve. The Ieaves of the external aponeurosis are carefuIIy dissected free from the underlying muscle, both
underIying motive was to provide tissues strong enough to attach to the inguinal Iigament rehection in the lower part of Hesselbath’s triangIe, where the obvious presence of a Iarge bulge and the absence of strong fibrous or thick muscular tissues in this area has allowecl this buIging to be present. The Halsted procedure also found favor in the repair of recurrent hernias, particularly in the repair of recurrent hernias in which a direct component or direct recurrence \las observed. Recurrence rates in inguinal hernia remain sizable in spite of the inteIIigent applications of these three basic principIes to the various types of hernias found, and in spite of the improvement in surgical technic and type of suture materia1 used. Surgeons have sought new ways to overcome the probIem of having to reperform an operation which had been successful the year before. In the opinion of the authors, the foIIowing innovations have been among the most successfu1 during the Iast two decades. (I) Anson and McVay’s method [I] of suturing the transversalis fascia and the conjoined tendon to Cooper’s ligament instead of the reflected edge of the inguinal Iigament; (z) the formation of a Bap  from the anterior Ieaf of the rectus sheath and the utilization of this flap as a substitute for good tissues in the inguina1 defect; (3) free transplant of a ffap of fascia Iata  to cover the defect in the area; (4) the reIaxing incision made in the anterior rectus sheath and suture of the reffected sheath to the sheIving edge of the inguina1 Iigament; and (5) careful isolation and cIosure of the transverse abdominis muscIe before a hernia1 repair is performed. The principle of inserting tissues and fascia into the hernia1 defect without suturing the conjoined tendon to the shelving edge of the inguina1 Iigament constitutes a fourth principle in the repair of inguina1 hernia. This principIe is particuIarIy important when widening of the Iower portion of the abdominal waI1 has occurred due to relaxation of the abdominal musculature or thinning of the lower fibers of the interna obIique muscIe. With the exception of deflecting the anterior sheath of the rectus, it is diffrcuIt to obtain autogenous tissue to fill this defect. Advances in the fieId of medicine have often come with the introduction of substances from other scientific endeavors. TantaIum wire 440
FIG. I. A, incision I inch media1 to anterosuperior spine down to pubic tubercIe. B, external oblique fascia and externa1 ring exposed; incision through fascia opening ring. C, incision through cremaster muscIe over buIge of hernia using scissors. D, isolation, opening, dissection and Iigation of indirect sac, separating vas deferens from sac. E, imptantation of ligation suture through internal obIique muscle; closure of incision into cord; elevation of cord and division of spermatic branches of inferior epigastric vesseIs. F, preparation of stainIess steel wire mesh insert. G, wire mesh in situ, sutured to sheIving edge of inguinal Iigament, to top of rectus fascia and top of interna oblique muscIe, iIioinguina1 nerve eIevated. H, cIosure of external oblique fascia, reconstructing origina external ring; closure of skin with vertical mattress sutures.
mediaIIy and IateraIIy, cleaning the sheIving edge of the inguinal Iigament IateraIIy and exposing the sheath of the rectus muscle mediaIly. Attention is then given to the dissection of the spermatic cord. It is our procedure to dissect the spermatic cord free from the upper extremity to the scrotum, a11 communicating vesseIs between the cord and the subcutaneous tissues being doubIy cIamped, divided and Iigated carefuIIy. In the technic of freeing the cord completeIy we note that there is an almost constant communicating artery and vein coming up from the inferior epigastric vesseIs to the cord. If this is Iooked for and doubIy clamped, divided and Iigated, much of the diffIcuIty of the entire procedure is avoided as the cord becomes much freer and
easier to move out of the way. The indirect hernia1 sac is then Iocated; it is aIways found in the anteromedia1 aspect of the upper portion of cord. An actua1 incision of the cremasteric fibers between two forceps with a pair of scissors is advisabIe so as to open the cremasteric Iayer of the cord cleanly. The incision is made Iarge enough so that the sac may be puIIed out without further tearing of the cremaster. The cremasteric incision is important, for when dissection of the sac is compIeted the cremaster fibers may be cIosed and the cord restored to its tubular character. The sac is next opened, the finger is inserted into the sac and the remainder of the sac is carefuIIy dissected free from the surrounding tissues of the cord. The sac is transfixed at its junction with the peri441
May and Norman tonea cavity by a double figure-of-eight transfixion suture. We find no harm in transfixing the neck of the sac through the interna obJique muscle at a point approximateIy 2 inches above its edge. We strongJy beIieve that any excess fatty tissue accompanying the sac shouJd be carefuJJy dissected and excised, as it is our opinion that a finger of fat in the first portion of the cord is sometimes the advance part of a hernia1 sac. With only the vas deferens, the vascular portion of the cord and the muscuJature of the cord Jeft, the cremaster is next closed, restoring the tubuJar configuration of the cord. An ova1 segment of stainIess steeJ wire mesh is then cut and fashioned so as to fit into the inguinaJ region. A sIit and hole are made in the upper portion of the ovaJ segment, the hoIe being fashioned so as to fit snugIy about the remodeJJed cord. No attempt is made to draw the tissues to the inguina1 Jigament; instead, the JateraI margin of the stainIess stee1 wire mesh is sutured to the reflected edge of the inguina1 Iigament. The media1 edge is made to Iie on top of the rectus sheath, a IittIe sIack being aIJowed so that there wiI1 be no tension when the patient is erect. The cord is fitted into the aperture through the sIot and the stainJess steeJ wire mesh is cIosed snugIy about the cord and to the anterior surface of the interna obIique muscIe above the cord. The externaJ obIique aponeurosis is cIosed simpIy over the wire mesh down to the origina region of the externa1 ring which has been previousIy marked by pIacing a suture there originaIIy. Scarpa’s fascia is cJosed and the skin is cJosed with interrupted sutures. Figure I demonstrates graphicaIJy the procedure which we have described. Although this procedure has been performed for primary herniaI repair in onIy twenty cases to date, certain immediate advantages have become apparent. The postoperative period has been marked by a reIative absence of pain. The necessity for narcotics on the usuaJ fourhour scheduJe is rare. Patients are abIe to ambuJate on the same day or on the folIowing day without distress, and even coughing does
not cause the patient to experience significant pain in the groin. The majority of our patients were discharged from the hospital on the fourth or fifth postoperative day and were abIe to come to the offIce on the eighth postoperative day without experiencing discomfort. Skin sutures were routineIy aJJowed to remain in pIace unti1 the fourteenth postoperative day. It has been our practice to remove the dressing on the first postoperative day, allowing the sutures to remain exposed to the air. No wound infections have been encountered and no accumuIations of Auid have been noted in any of the hernias repaired thus far. Two hernias were repaired five years ago and the majority have been repaired as recently as eighteen months before this writing. None of our patients have shown any evidence of recurrence to date. SUMMARY I. A brief review has been presented of the principles of repair of inguina1 hernia, with the eIaboration of a fourth principle. 2. A method of repair using stainless steel wire mesh is suggested. REFERENCES
C. V. and ANSON, B. J. Inguinal and femora1 herniopIasty. Surg., Gynec. c” Obsl., 88:
473, ‘949. 2. BASSINI, E.
Ueber die Behandlung des Leistcnbruches. Arch. f. klin. Cbir., 40: 429, 1890. 3. HALSTED, W. S. The radical cure of inguina1 hernia in the maIe. Bull. Johns Hopkins Hosp., 4: 17, 1893. 4. HALSTED, W. S. The cure of the more difficult as well
as the simpler inguinal ruptures. B&Z. Johns Hopkins Hosp., 14: 208, 1903. GALLIE, W. E. and LEMESURIER, A. B. The transplantation of the Iibrous tissues in the repair of anatomica defects. hit. J. .%r~.. 12: 289, 1924. JEFFERSON, N. C. and DAILEY, U. G. Incisional hernia repaired with tantaIum gauze. Am. J. Surg., 75: 575. 1948. PACKARD, G. B. and MCLAUTHLIN, C. H. Treatment of inguinal hernia in infancy and childhood. Surg., Gynec. Ed Obst., 97: 603, 1953. RYAN, E. A. Recurrent hernias, an anatysis of 369 consecutive cases of recurrent inguinal and femora1 hernias. Surg., Gynec. @ Oh., 96: 343, ‘953.