Symposium on Surgery of Hernia
The Marcy Repair of Indirect Inguinal Hernia
Charles A. Griffith, M.D., F.A.C.S.*
Surgical trainees often question the circumstance that many different repairs are recommended for the single entity of indirect inguinal hernia, and ask which is the best repair and why. The purpose of this review is to answer their questions with fundamental anatomic, physiologic, and surgical concepts.
THE ANATOMIC CONCEPT The basic defect in the abdominal wall through which an indirect inguinal sac herniates is the internal ring in transversalis fascia. Therefore, an indirect inguinal hernia may be conceived as a funnel of peritoneum within a funnel of transversalis fascia. The neck of the perito~ neal funnel is the neck of the hernial sac, and the neck of the transversalis fascial funnel is the internal ring (Fig. 1). The transversalis fascial margins of the internal ring are usually described as pillars or crura that form a horse-shoe shaped sling, closed medially and open laterally. However, these crura are actually thickenings in the continuous sheet of transversalis fascia. At the lateral open aspect of the horseshoe, transversalis fascia is relatively thin and inconspicuous, but nevertheless it exists to complete the ring, as diagrammed in Figure 1. Full appreciation of this anatomic concept requires dissections both from within and outside the abdominal wall. From within the abdomen the neck of the sac is readily apparent, and its palpation reveals that it is encircled by a firm but elastic tissue. Exposure of this tissue by a circumferential incision of the neck of the sac reveals it to be the transversalis margins of the internal ring. Further dissection brings to light a most important fact-namely, the internal ring in transversalis fascia
'Clinical Associate Professor of Surgery, University of Washington School of Medicine, Seattle, Washington Surgical Clinics of North America- Vol. 51, No.6, December 1971
Transversalis fascia Internal spermatic
Figure 1. The anatomic concept of indirect inguinal hernia. The internal spermatic vessels and vas deferens and indirect sac leave the abdomen and enter the inguinal canal at the internal ring. At this point, transversalis fascia funnels around the vas, vessels, and sac to form the internal ring. From the internal ring, transversalis fascia continues as the internal spermatic fascia, which encases the vas, vessels and sac in the inguinal canal. From Nyhus, L. M., and Harkins, H. W.: Hernia. Philadelphia, J. B. Lippincott, 1964, reproduced with permission.
is an anatomic entity unto itself, and its transversalis fascial margins may be dissected completely free of the more superficial transversus abdominis, internal oblique, and cremaster muscles and the inguinal ligament. Once the internal ring is delineated by this dissection from within the abdomen, its exposure by dissection from outside the abdomen via the inguinal canal reveals another important fact; the cremaster muscle and the arcuate fibers of the internal oblique and transversus abdominis muscles, and also often the inguinal ligament, are real obstacles to adequate exposure of the internal ring. The cremaster muscle, particularly when well developed, is the greatest obstacle, and must be removed or at least detached from its origin along the iliopubic tract of transversalis fascia (the cremaster muscle may be adherent to but does not arise from the inguinal ligament). This dissection of the cremaster muscle entails ligation and transection of the external spermatic vessels. Furthermore, the arcuate fibers of internal oblique and transversus abdominis muscles must be retracted sharply upwards, and the inguinal ligament often must be retracted sharply downward, in order to see and delineate the true transversalis fascial margins of the internal ring.
THE PHYSIOLOGIC CONCEPT As the intrinsic fascia of transversus abdominis muscle, transversalis fascia moves with this muscle whenever its fibers contract. In the inguinal region the fibers of transversus abdominis muscle are oblique. Contraction of these fibers therefore pulls transversalis fascia in an oblique direction, which results in both a narrowing of the internal ring and its displacement laterally and cephalad beneath the arcuate inguinal edge of transversus abdominus muscle.
THE MARCY REPAIR OF INDIRECT INGUINAL HERNIA
The significance of this motility of the internal ring cannot be appreciated when the transversus abdominis muscle is functionless, in cadavers or in patients under general or spinal anesthesia. During operations under local anesthesia, however, the transversus abdominis muscle remains quite functional and contractile, and the effects of its contraction may be demonstrated as follows. After disposing .of the sac, the medial margin of the internal ring (Le., the interfoveolar ligament of Hesselbach) is tagged with a clamp. The patient is then requested to cough. With the cough and consequent contraction of transversus abdominis muscle, the internal ring snaps upward and laterally out of sight beneath the transversus abdominis muscle, jerking the clamp with it. In addition, the open internal ring at rest changes abruptly with the cough into a narrow slit as the crura approximate each other and clamp around the spermatic cord. The obvious effect of this physiologic mechanism, which was first described in detail by Lytle,lO is to protect against indirect inguinal hernia.
THE SURGICAL CONCEPT With the foregoing anatomic and physiologic concepts in mind, the repair of an indirect inguinal hernia is best conceived in terms of restoration of normai structure and function. This repair entails excision and high ligation of the sac plus closure of the internal ring with sutures placed through the ring's transversalis fascial margins. Three different anatomic approaches may be used to accomplish this repair-the transabdominal, the preperitoneal, and the inguinal approaches (Fig. 2).
Figure 2. The surgical concept of indirect inguinal hernia. The arrows indicate the transabdominal, pre peritoneal, and inguinal approaches to the internal ring. Via the inguinal approach, the spout of the funnel (internal spermatic fascia) is incised longitudinally to expose the sac and cord structures (vas deferens and internal spermatic vessels). The spout of the funnel is next incised circumferentially at its junction with the wide mouth of the funnel to define the internal ring as a hole in transversalis fascia. The internal ring is closed to cover the peritoneum with its normal encasement of transversalis fascia. This is fascial repair of the internal ring, which is the normal anatomic keystone against recurrence of the indirect hernia. From Nyhus, L. M., and Harkins, H. N.: Hernia. Philadelphia, J. B. Lippincott, 1964, reproduced with permission.
The Transabdominal Approach Marcy recognized the application of the transabdominal or intraperitoneal exposure of the internal ring and in 1892 wrote,·5 "It may rarely happen to the operator, who has opened the abdomen for some other purpose, to find the complication of hernia. When the section has been made considerably large, as in the removal of a large tumor, the internal abdominal ring is within reach of the surgeon. Upon reflection, it would naturally occur to any operator that under these conditions it is better to close the internal ring, and reform the smooth internal parietal surface from within by means of suturing. My friend, Dr. N. Bozeman, of New York, easily did this at my suggestion in a case of ovariotomy more than 10 years ago." Many years later Andrews· also recognized repair of the internal ring from within, and stated, "Even now it is clearly recognized that the most efficient way to close a hernial ring is from within. If one is performing any laparotomy in the neighborhood, a few stitches in the peritoneum and transversalis fascia are far more effectual than any other herniotomy. One has the feeling he is really sewing up a hole and not going through the motions of a complicated plastic operation." In using the term "complicated plastic operation," Andrews referred to suturing one or more of a variety of muscular and aponeurotic structures to the inguinal ligament with or without transplantation of the spermatic cord and with or without imbrication of the external oblique aponeurosis.
The Preperitoneal Approach The preperitoneal or extraperitoneal approach to the internal ring dates back to the works of Cheatle3 • 4 in 1920 and 1921 and of HenryS in 1936. Although Marcy did not use this method, the internal ring is approached from within the abdominal wall as with the intraperitoneal approach. The plane of dissection is in the preperitoneal fat between peritoneum and transversalis fascia. Nyhus is perhaps the most enthusiastic of the current advocates of the preperitoneal approach, and the interested reader is referred to his detailed description!6
The Inguinal Approach Marcy first described his technique 100 years ago ... As he stated in a later publication,12 "In 1871 I first published in the Boston Medical and Surgical Journal two cases, operated upon by me the previous year, in which I closed the internal ring with interrupted sutures of carbolized cat-gut, followed by permanent cure. So far as I know they were the first cases operated upon in this manner." Therefore, in keeping with the custom of referring to the various repairs by names, the technique of excision and ligation of the sac plus closure of the internal ring via the inguinal canal may be rightfully called the Marcy repair. Marcy u-14 published four papers on the surgical treatment of inguinal hernia in 1871, 1878, 1881, and 1887. It is of historic note that all of these papers predated the first and independent reports of BassinP and Halsted 7 in 1889. Finally, in 1892, Marcy·5 published his complete work, The Anatomy and Surgical Treatment of Hernia. The excellent
THE MARCY REPAIR OF INDIRECT INGUINAL HERNIA
anatomic descriptions and illustrations in this monograph are worthy of study today, and clearly indicate that Marcy was thoroughly schooled in the contributions of Camper, Cloquet, Cooper, Hesselbach and Scarpa. Although British surgeons frequently refer to Marcy's technic as the Marcy repair, reference to Marcy's name is rare in this country and not nearly so common as the names of Bassini, Halsted, and others. The relative obscurity of Marcy's name today is perhaps best explained by the fact that many of his colleagues considered him a surgical maverick. For example, upon his return to Boston from Europe, Marcy12 described himself as "a young man fresh from his European studies, and an ardent admirer of Professor Lister, whose views, at the time, I believe were not accepted by a single surgeon in the Boston district." These unaccepted views concerned not only the application of Lister's principles of antisepsis but the use of Lister's carbolized cat-gut sutures as well. As indicated by the titles and contents of his first three papers on hernia,1l-13 Marcy emphasized the use of cat-gut much more than the anatomic details of his operation. In addition, Marcy stirred up more controversy by recommending elective operation for hernia in an era when operation was considered a radical measure, justified only by the complications of incarceration or strangulation. These controversial issues completely overshadowed Marcy's recognition of the internal ring in transversalis fascia as the basic defect in need of repair. When he merely stated l l in 1871 that "two stitches of medium-sized cat-gut were taken through the walls of the internal ring," Marcy perhaps assumed that the medical profession at large was equally aware of the internal ring as the basic indirect hernial defect, and would therefore accept its transversalis fascial repair as the obvious and logical procedure to do. By the time all controversial issues concerning antisepsis and cat-' gut sutures were settled, and Marcy had detailed 15 the anatomic rationale of his repair in 1892, Bassini and Halsted had focused attention upon the use of the inguinal ligament. This structure and the various muscles and aponeuroses that may be sutured to it are much easier to identify than the transversalis fascial margins of the internal ring. The relative simplicity of the Bassini and Halsted repairs most probably had much to do with their rapid acceptance and continued popularity, and Marcy's repair and name were consequently relegated to obscurity. Technical details of Marcy's inguinal repair have previously been described 5. 6 with references to the reports of many other surgeons. Suffice it herein to reemphasize the following points. The first concerns those obstacles in the inguinal canal that hinder an adequate exposure of the internal ring. As previously stated, the greatest obstacle is the cremaster muscle which, if merely incised longitudinally, still prevents access to the ring in many instances. Although Marcy, Bassini, and Halsted stressed removal or at least an extensive dissection of the cremaster muscle in order to obtain an adequate surgical field, the importance of this maneuver continues to be considered unnecessarily radical by many surgeons who, unknowingly, cannot and do not expose the internal ring.
Also as previously stated, the arcuate edges of the internal oblique and transversus abdominis muscles and the inguinal ligament are often in the way towards visualizing the transversalis margins of the ring. Marcy emphasized all of these obstacles by depicting his repair with an illustration in which the cremaster and internal oblique muscles and the inguinal ligament had been removed. Once the internal ring is exposed, its transversalis margins are delineated. This delineation entails incising the transversalis fascia circumferentially at the ring to separate it from its continuation in the inguinal canal as the internal spermatic fascia (Fig. 2), and then dissecting the fascial margins of the ring free of the sac and cord structures. The last point concerns the maintenance of exposure of the internal ring, which often disappears beneath the transversus abdominis muscle with the ligated peritoneum after excision of the sac. Therefore, to keep the internal ring within the surgical field, its transversalis fascial margins are grasped with clamps before ligation and excision of the sac. As described by Lytle,to "The chief difficulty is to find the internal ring at operations, for if the routine method of removing the sac is followed, the ring with the stump of the sac retracts back into the abdomen and disappears from view. When the hernial sac has been dissected free from the cord, the ring can, however, be brought into full view by pressing it forward with the index finger which has been passed through the neck of the opened sac. The ring edge is then easily secured in artery forceps and its medial and lateral pillars are separated from the neck of the sac and from the spermatic cord. To expose, secure and separate the ring margins in this way, is the most important step in the operation. " Then, as stated by Marcy,t4 "draw up the peritoneal pouch quite sufficient to cause its obliteration upon the inner side and sew it evenly.... Then cut away the redundant pouch and allow the peritoneum to drop back. ... With the finger within the ring, to protect the peritoneum and guide the needle, I introduce it quite one half inch from the outer portion of the ring.... The stitches are repeated at distances of about one third of an inch, including both pillars of the ring, until the opening is securely closed-in the female completely-in the male, the parts are closed so as to carefully protect and secure the cord from injury." It is considered quite important that repair of the internal ring be made by sutures through transversalis fascia and only transversalis fascia. If the sutures include the fixed and unyielding inguinal ligament, the normal motility of the internal ring is impaired. The net result may be disruption of the repair when the patient coughs or strains and tears the internal ring away from the inguinal ligament. Marcy's technique is the only inguinal technique that accomplishes a repair of the internal ring identical to that accomplished by repair from within the abdominal wall via the intraperitoneal and preperitoneal approaches. Accordingly, and to borrow Andrews' expression, Marcy's repair also gives one the feeling he is really sewing up a hole and not going through the motions of a complicated plastic operation.
THE MARCY REPAIR OF INDIRECT INGUINAL HERNIA
The acme of surgical anatomic clarity is best demonstrated by LaRoque's combined inguinal-abdominal approach ,9 which provides simultaneous exposure of the internal ring both from within and outside the abdominal wall. This combined exposure demonstrates that repair of the internal ring with sutures placed via the intraperitoneal or preperitoneal approach is identical to Marcy's inguinal repair and, in a sense, mollifies the current controversy of the inguinal versus the preperitoneal techniques.
RECURRENT INGUINAL HERNIA No supplementary measures to Marcy's inguinal repair of excision and high ligation of the sac plus closure of the internal ring, or the same repair via the intraperitoneal and preperitoneal approaches, are known to provide additional protection against recurrent indirect inguinal hernia. However, the subsequent development of a direct inguinal hernia in later years is a distinct possibility that poses the question whether to supplement Marcy's repair by buttressing the triangle of Hesselbach. If a buttress is elected (for example, suturing the transversus abdominis aponeurosis to the inguinal ligament), the sutures for the buttress are entirely separate and superficial to the deeper sutures placed in transversalis fascia for repair of the internal ring. Experience in the Armed Forces and Veterans Administration, where inguinal hernias are concentrated, indicates that the rate of recurrent indirect inguinal hernia is significantly higher than generally believed. For example, it is not at all uncommon to encounter an indirect inguinal hernia in a young serviceman who underwent his original operation in infancy or childhood. The usual cause of this recurrence is' the fallacious concept of "high ligation only" - that is, high ligation of the sac without repair of the internal ringP' 18 This fallacy may be realized at operation by digital palpation of the neck of the sac. In some infants and children the neck of the sac does not admit the finger tip, in which case the internal ring is not patulous and therefore r.eed not be repaired. In other instances, however, the neck of the sac permits entry of the thumb or even more into the abdomen, which indicates a patulous internal ring. It is failure to close these patulous rings in infants and children that permits recurrent herniation of an indirect inguinal sac in later life. Again, recurrence of indirect inguinal hernia in middle aged veterans who were operated upon in their late teens or early twenties is by no means' uncommon. Reoperation usually reveals a "repaired inguinal canal" but an unrepaired internal ring, and the recurrent sac has herniated along the inguinal canal beneath whatever has been sutured to the inguinal ligament. These recurrences do not appear in long term statistical analyses, and can only be prevented by applying the anatomic and surgical principles for proper repair of the internal ring laid down by Marcy a hundred years ago.
REFERENCES 1. Andrews, E.: A method of utilizing all white fascia. Ann. Surg., 80:225-238,1924. 2. Bassini, E.: Nuovo metodo per la cura radicale dell' ernia. Atti Congr. Ass. Med. Ital. (1887),2:179,1889. 3. Cheatle, G. L.: An operation for the radical cure of inguinal and femoral hernia. Brit. Med. J., 2:68-69, 1920. 4. Cheatle, G. L.: An operation for inguinal hernia. Brit. Med. J., 2:1025-1026,1921. 5. Griffith, C. A.: Inguinal hernia: An anatomic-surgical correlation. SURG. CLIN. N. AMER., 39:531-556, 1959. 6. Griffith, C. A.: Indirect inguinal hernia with special reference to the Marcy operation. In Nyhus, L. M., and Harkins, H. N., eds.: Hernia. Philadelphia, J. B. Lippincott Co., 1964. 7. Halsted, W. S.: The radical cure of hernia. Bull. Johns Hopkins Hosp., 1 :12, 1889. 8. Henry, A. K.: Operation for femoral hernia by a midline extraperitoneal approach. Lancet, 1 :531-533, 1936. 9. LaRoque, G. P.: The intra-abdominal method of removing inguinal and femoral hernia. Arch. Surg., 24:189-203, 1932. 10. Lytle, W. J.: The internal inguinal ring. Brit. J. Surg., 32:441-446, 1945. 11. Marcy, H. 0.: A new use of carbolized catgut ligatures. Boston Med. Surg. J., 85:315-316, 1871. 12. Marcy, H. 0.: The radical cure of hernia by the antiseptic use of the carbolized catgut ligature. Trans. A.M.A., 29:295-305, 1878. 13. Marcy, H. 0.: The cure of hernia by the antiseptic use of animal ligature. Transactions Internat. Med. Congress, 2:446-448,1881. 14. Marcy, H. 0.: The cure of hernia. J.A.M.A., 8:589-592, 1887. 15. Marcy, H. 0.: The Anatomy and Surgical Treatment of Hernia. New York, Appleton and Co., 1892. 16. Nyhus, L. M.: The Preperitoneal and iliopubic tract repair of all groin hernias. In Nyhus, L. M., and Harkins, H. N., eds.: Hernia. Philadelphia, J. B. Lippincott Co., 1964. 17. Russel, R. H.: Inguinal hernia and operative procedure. Surg. Gynec. Obstet., 41 :605609,1925. 18. Turner, P.: The radical cure of inguinal hernia in children. Proc. Roy Soc. Med., 5: Part I, Section for the Study of Disease in Children, 133-140, 1912. 1041 116th Street N.E. Bellevue, Washington 98004