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·HERNIA
The Pathologic Anatomy of the More Common Hernias
and Their Anatomic Repair
By
CHESTER
McVAY MD PHD
Clinical Professor of Surgery and Associate Professor of Anatomy
The University of South Dakota School of Medical Sciences
Surgeon, The lankton Clinic
Yankton South Dakota
BOKS
THOMAS
NJIH
BOL
LDERSH
CHARLES C THOMAS
Springfield Illinois
PUBLISHER
USA

·CHANLES C THOMAS PUBLISHER
BANNERSTONE Blouse
3012327 East Lawene Arenuc Springfield Illinois U.S.A
Pubuted rimul cously in the British Commongrelth of Tatimi iwey
KLANTEL SCIENTIT LBLICATTOYS LT otron ENGLAND
Published simultaneously in Canada boy
TIL RIRSOY FRII TORONT
This monograph is protected by copyright. So
part it may be reproduced in any mannet
without written permission from the publisher
Copyright 1954 by CHARLES C THOMAS
PUBLISHIFR
Library of Congress Catalog Card Sumber Sfinem
First Edition Toomber 1954

·A Monograph in the
PICTORIAL SURGICAL TECHNIQUES SERIES
Edited by
ALTON OCHSNER, MD
The William Henderson Professor
and Chairman of the Department of Surgery
The Tulane University of Louisiana
School of Medicine
New Orleans

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·Introduction I comprehensive but rather that they tedd be T IS NOT INTENDED that this atlas should be anatomic defect are presented In every in stance the anatomic defect has been prepared brief and tied intimately to the illustrations so from a cadaver dissection of the hernia so that that the text for the figures will always be either the alteration in the musculoaponeurotic strucon the same or the opposite page There are a ture will be accurate in every detail The ananumber of excellent texts on hernia some of tomic plate in each type of hernia is a postenor them encyclopedic in scope that cover the sub view of the anterior abdominal wall in the reject in detail including variations in type of a gion of herniation and although this will be an given hernia and a host of different surgical unfamiliar approach to the problem for many techniques Now here in the field of surgery is surgeons the author hopes to impress upon there such a multiplicity of operations for a his readers the importance of the innermost of given anatomic defect this not only reflects the musculoaponeurotic layers the transversus basic misunderstanding of the problem involved abdominis The more superficial internal obbut is most confusing to the young surgeon lique and external oblique layers are only of The purpose of this atlas is to present the secondary importance for once a hernia has common types of hernia in simple form stress penetrated the transversus abdominis layer a ing the anatomic defect either congenital or hernia exists and the oblique musculoaponeu acquired and to present the methods preferred rotic lamınae only serve to modify or direct the by the author for surgically correcting these de course of the developing hernia Moncontribu fects in anatomic structure The external ap tory structures such as peritoneum preperito pearance of hernias of the abdominal wall and neal fat and fascri and in some instances mus the management of the peritoneal sac have not cular fascia have been removed so that the been emphasized except for the appearance of fundamental musculoaponeurotic defect may incisional hernias and the management of the be clearly seen slıding type of hemia likewise the diagnosis The surgical repair was first performed upon and the differential diagnosis of the vanous her the cadaver so that anatomic detail would be nias will not be discussed Occasional pictorial accurate and then modified where necessary to reference will be made to the shin incision but conform to the surgeons view at the operating in general this author believes that all skin in table It has been the authors teaching crperi cisions should be in the lines of skin cleavage ence that not only is it frequently difficult to irrespective of their location The final closure transpose the anatomy from the dissecting table of the wound is omitted as noncontributory to to the operating table because of a difference this atlas and while no specific discussion of in perspective but also that a surgeon who re suture material will be presented non absorb pairs hernias is not ipso facto an anatomist It able suture of the smallest caliber commensurate is a curious incongruity that most of our recent with good surgical repur is the authors prefer generation of surgeons are only haphazard anat omists this is duc in part to a decreasing em A constant pattern has been adopted for the phasis on gross anatomy in our medical schools presentation of each type of hernia First an in the past three decades and in part duc to anatomically accurate vies is shown of the the increasing emphasis on the more dramatic musculoaponeurotic defect stressing the basic albeit important basic sciences in our gradu alterations of normal anatomy that permit the ate training programs In many branches of hemia to des clop and second the successive surgery this is of no serious consequence but a major steps in the surgical correction of this hemia is an anatomic derangement and to un ence ·Jerstand the cause and especialls the repair of atlas with multiple references to the literature i hema a detailed knowledge of the analoms bibliographic rcferences, including the authors of the layers invoked is alsolutely essential To own contnbutions will be omitted attempt the repair of hemias without intimate The crcellence of an atlas is dependent ind detuled knowledge of the anatomy of the upon the quality and accuracy of the illustri egion is to invite a formidable recurrence male tions In this instance I am cspcaallı indebted Onc has only to reucu the many methods of to Virs Lucille Cassell Innes whose excellener cpairing an inguinal hemia to realize that of illustration is obvious and for her suggestions omething is very ndically amiss otherwise concerning surgici perspective which should here would have been no necessity for such a help to clinfy the many problems encountereel nuluplıcıty of operations in so small an area in teaching the gical repair of hernias I also It is recognized by the author that there are wish to copress my deep appreciation to tun manı "accepled" methods of repairing a given men who hasc profoundly influenced me as nomia and conccming inguinal and femoral an anatomist and as a surgeon Barry ) Anson hernias the methods arc lcgion however, in this Professor of Anntomy, Northwestem University itlas only one method is presented for each Vedical School and Frederick A Coller Pro type of hemia and it is obviously the authors fessor of Surgery, Unis crsity of Michigan Veddo preference To avoid cncumbering this simple cal School CB 1cV ·Preface THE HERNIA PROBLEM IN GENERAL Tan TO UNDERSTAND the fundamental defect in parlance that it seems pertinent to define a any hemia it is absolutely necessary for fascia and especially to differentiate a fascia the surgeon to know the basic anatomy of the from an aponeurosis A fascia is a layer of areoregion involved and yet it is frequently appar lar fibers and the fasciae are disposed as sheets ent at the operating table that the surgeon has of tissue throughout the body where they in only the vaguest idea of the anatomy of the re vest muscles neurovascular bundles and par gion in which he is working Because the trans enchymatous organs There is no organized ar versus abdominis layer is all important and rangement of the fibers and regionally the fas because one sees only isolated areas of it in the ciae are modified by the demands of the body conventional anterior cadaver dissections the varying greatly in thickness and in their con Frontispiece is presented to show the extent tent of fat In places they may even contain and conformation of the transversus abdominis smooth muscle fibers or elastic fibers and in muscle and aponeurosis this can only be ac places a fascial plane may be converted into complished in a posterior view of the abdominal an aponeurotic lamina by virtue of muscular wall It should be an obvious fact that when origin or insertion eg the intermuscular septa the innermost musculoaponeurotic layer is per- of the thigh or the so-called lumbodorsal fascia forated a hernia exists and conversely if the In the embalmed cadaver they may appear to transversus abdominis muscle and aponeurosis be tough, resistant membranes but in the living with its attached transversalis fascia remains subject they have very little tensile strength intact that a hernia of the abdominal wall is unless reinforced by aponeurotic fibers An apo impossible All too frequently in the conven neurosis on the other hand is a flattened tendon tional anterior approach the strategic impor with collagenous fibers disposed in organized tance of the transversus abdominis layer is not bundles its tensile strength is great and directly realized by the surgeon because his attention is proportional to the number of fibers per unit consumed by the more obvious and superficial area The aponeurosis (tendon) of a muscle has musculoaponeurotic lamınae As the first step as many fibers as the muscle has muscle fibers in the hernioplasty the surgeon should so plan In the abdominal wall the resistance to hernia his operation that the anatomic structure of the tron is dependent upon the strength and dispo transversus abdominis is returned to normal sition of the musculoaponeurotic fibers and not It should be further understood that the res upon the fasciae The rectus sheath so com piratory diaphragm and the pelvic diaphragm monly referred to as a fascia is a complex in form an integral part of this same layer al terdigitation of aponeurotic fibers of insertion though named differently Also the transver of three anterolateral abdominal muscles salis fascia the infradiaphragmatic fascia and and not a fascia although these aponeurotic the superior fascia of the pelvic diaphragm are plates are invested by fasciae all the same fascial plane with regionally differ Whereas the transversalus fascia is routinely ent names The endopelvic fascia is simply the mentioned in hernia discussions it should be transversalis fascial layer turned upward upon pointed out that the transversalis fascia alone the viscera that perforate the pelvic diaphragm 15 a layer of ertremely variable thickness and an analogous situation exists where the esopha with very little intrinsic tensile strength By gus perforates the respiratory diaphragm definition the transversalis fascia is simply a The word fascia is so loosely used in surgical muscle fascia investing the inner or abdominal LX ·ispect of the transiersus abdominis muscle and acquired protrusion of parietal pontoneum iponeurosis and differs in no special way from through and between the musculoaponcurolic iny other muscle fascia In some slender, ath fibers Esophageal hiatus hemma umbilical her etic individuals especially in the inguinal re nia indirect inguinal hemia, femoral hernia mon and especially in the cadavenc state the and obturator hema are duc to a congenital prepentoneal connective tissue may be almost defect in the musculoponeurolic apparatus otally devoid of fat and appear as a substantial As this latter group of hemiis enlarge thes ascial plane It is undoubtedly this character displace musculoaponeurotic fibers in the sime stic of the prepentoneal connective tissue in manner as the first group so that therr surgical he ingwnal region that has led to the confusion repair presents in idential problem In general a nomenclature, the important point, however, then, after disposal of the heral sac, the her s that this laser is worthless in the repair of mal defect should be closed along lines that par hernias allel the musculoaponeurotic fibers of the layers In the Frontispiccc the transı ersalis fascia concerned Small incisional hernias can be re has been removed to show in detail the muscu prired according to this principle by dissecting lar and aponeurotic fibers of the transiersus out the individual layers but large incisional abdominis and the respiratory diaphragm Ac hernias in a vertical incision defy anatomic required hemins, incisional hemias excepted rep- pair In this type of hernia there is actual re resent a separation of these fibers and surgical traction of cut aponeurotic fibers with a fired correction of the hernia should take into con contracture of the corresponding muscle fibers sideration the lines of contraction of the muscle The defect is too large for redevelopment of fibers ie, the line of closure should carefully the layers with an anatomic closure and cien parallel the direction of the musculoaponeurotic when the margins of the vertical defect can be fibers and not be at night angles or an oblique approximated it is alu zys under extreme ten angle to these fibers If this principle is violated sion and the same muscular pull that ciused the muscle pull will tend to cause a dehiscence of hemia in the first place will continue to act and the wound Furthermore sutures tend to pull attempt to separate the closure Aponctirotic out from between the cut ends of the aponcu ("fascial") grafts aponeurotic suiture material rotic fibers when the line of closure is perpen and more recently the addition of wire mesh dicular to these fibers the ini csting fasciae and rre at best only a mrkesluft in an attempt to the variable decussation of the poneurotic solc a problem to wlucht there is no wholly fibers are the onls {catures that present this satisfactory solution from happening routinely further any abdom The only possible solution to the large in inal incision that accomplishics closure across cisional hernia problem is prophylactıc in that the lines of muscle pull and relies upon the of the vertical rectus incision were abandoneel healing scar to withstand this muscle pull is there would be no serious difficulty in rcpuring potentiallı 1 candidate for the des clopment of the incisional hemins that occur in transverse an incisional lemia lxcause eventually the scir Incisions Although the small tricly musel and will stretch and attenuate The ndiocates of the poncurosis splitting incision that is used for routine use of the vertici abdomını incision appendectomi cannot be used for the more mi cinnot be fully cognizant of this vies of the al jor zlxlomınal operations lectuse of inadequate dominal wall or the structural composition of crposure the long trinsipisc incision incises a the rectus sheath minimal number of musculoaponeurotic filxers In considering this postenor view of the al as compared to the vertical incision which in dominal wall and before the hemias are con cises all of the files for the length of the in sidered andu edulli it is well to realize that cision An important frature of the long trans traumatic Wigphragmatic hernia episastge her CTSC incision iſ propxsls mide is thirt none of nia semilunar (Spigolyn) hemın direct in the musculoiponcrotic filxers of the trannerstas furnal lietnia and lumbat hemii are due to the fxlominis lies are sms Creed and this is the ·most important of the three anterolateral ab plished in layers without excessive tension dominal musculoaponeurotic plates in the pre The use of the inguinal ligament as the an vention of incisional herniation One or both choring structure in inguinal and femoral herrectus abdominis muscles may be sectioned nioplasty has no factual anatomic basis and so with impunity The transversus abdominis pull will not be presented in this atlas Although is directly transverse in the mid abdomen and some surgeons will consider this a serious omis the resultant of the actions of the external sion the technique of inguinal ligament hernia oblique and internal oblique muscles is also repair is so readily available elsewhere that the transverse so that an incisional hernia in a trans author feels no obligation to present an opera verse incision never offers a very wide defect tion that he feels is anatomically unsound to be approximated and it can be accom CB McV

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·Contents INTRODUCTION Vil PREFACE-THE HEANLA PROBLEM IN GENERAL LI DIAPHRAGMATIC HERNIA Esophageal Hiatus Hernia Traumatic Diaphragmatic Hernia 3 3 5 EPIGASTRIC HERNIA 7 11 11 11 UMBILICAL HERNIA Small Umbılıcal Hernia of Infancy Large Umbilical Hernia HERNIAS OF THE INGUINAL AND FEMORAL REGION Small Indirect Inguinal Herria Medium Indirect Ingwda) Hernja Large Indirect Inguinal Hernia Direct Inguinal Hernia Femoral Hernia 15 19 21 23 25 29 INCISIONAL HERNIA 33 LUMBAR AND PELVIC HERNIAS 39

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·List of Plates Page PLATE I RESPIRATORY DIAPIIRACM Frontispiece PLATE II ESOPHAGEAL HIATUS HERNIA 2 PLATE III TRAUMATIC DIAPHRAGMATIC HERNIA PLATE IV EPICASTRIC HERNIA 6 PLATE V EPICASTRIC HERNIA 8 PLATE VI SMALL UMBILICAL HERNIA 10 PLATE VII LARGE UMBILICAL HERNIA 12 PLATE VIII HERNIA IN THE LINEA SEMILUNARIS (SPIEGELS HERNIA) 14 PLATE LX THE ANATOMY OF THE INGUINOFEMORAL REGION 16 PLATE X SMALL INDIRECT INGUINAL HERNIA 18 PLATE XI MEDIUM INDIRECT INGUINAL HERNIA (FEMALE) 20 PLATE XII LARGE INDIRECT INGUINAL HERNIA 22 PLATE XIII SLIDING HERNIA 24 PLATE XIV DIRECT INGUINAL HERNIA 26 PLATE XV FEMORAL HERNIA 30 PLATE XVI SMALL INCISIONAL HERNIA 32 PLATE XVII LARCE INCISIONAL HERNIA 34 PLATE XVIII LARCE INCISIONAL HERNIA 35 PLATE XIX LUMBAR AND PELVIC HERNIAS

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·HERNIA ·DIAPHRAGVATIC HERNIA Plate II ESOPILACEAL HIATUS HERSLA 1 The incision is trans erscly placed in the epigastrium at the lonel of the 8th costal cartilages The anterior rectus sheath is incised for the length of the skia Incision and the rectus muscles transected ligating the main branches of the superior epigastric vessels with suture ligatures The Ebers of the postenor rectus sheath and the linca Alba are then separated and the pentoneal cavity entered on either alde of the round and falciform ligaments of the liver which are then cut between suture ligatures This Incision is also used for all types of gastric surgery and abdominal vagotomy and is therefore frequently used It is the incision of choice for anatomic reasons (ser Frontispiece Preface and suction on Incisional Ilemlas) incision Skin on L mediastinal pleura b Diaphragm aponeurosis muscle? Stom b Erposure of the enlarged esophageal hlitus The tri angular ligament of the left lobe of the liver has been cut and the lobe retracted to the patients right ander pack and retractor All packs are omitted from the figure for clarity The hernia has been reduced and the margins of the histus delineated The diaphragmatic peritoneum hus become moved in the figure to demonstrate the musculoaponeurot fibers of the diaphragm. Care must be exercised to svold tearing the left medlastinal pleura or lacerating the splere with retractors or by undue traction upon the stomach. Esophagus Spléen Peritoneum Diaphragm. oponcurosis muscle You c Tic TIERA REPAIR. (Closure of the enlarged mophe gcal hiatus) The defect has been closed with Interrupted medium silk sutures in a direction parallel with the muku Loaponeurotic filxcts of the diaphragm, ptaking the mostu gus posteriorly between the crurn of the diaphragm A pro. pet closure of the esophageal hlatish is considered, mos Et for the esophagus and the surgeon, lader forgery Thun abelorninal esophagu and adjacent fundur of the stomach are suture drcumferentiaDy to the margin of the IT structed hialus to prevent sliding with melon of the diaphragm and leaving the foundation for the recurreno of the lernu. The vaceta are allowed to frsuror that mee spretire polims the splorst Lasncted for Wr!198 al thor abonnal wound oud without drsinaga Gastro hepatic Stomachst بے ·Diaphragmatic Hernia W: ESOPHAGEAL HIATUS HERNLA bottom of a deep hole as is always the case in the abdominal approach to the esophageal hra- HILE EITHER the abdominal or the tho tus Good surgical anesthesia is an absolute neracic approach may be used for the re cessity and as m most major surgical procedures pair of an esophageal hiatus hemia the author intratracheal ether orygen is our anesthetic of uses the abdominal approach in most instances choice If the left mediastinal pleura is acciden- However if the hernia is unusually large and the tally torn or if the abdominal incision is extend history suggests long duration or if roentgeno ed into the thorax the patient and the anesthegraphic examination suggests ulceration or car tist are ready without delay or difficulty The vi cinoma the thoracic approach is used the ab cinity of the hernia is provisionally exposed with dominal approach is through a transverse inter pack and nbbon retractor on the stomach and costal incision (Fig a) and although the level the triangular ligament of the left lobe of the of the incision varies slightly depending upon liver is incised back to the bare area The left the width of the subcostal angle it is usually lobe of the liver is then folded back upon itself located between the 8th costal cartılages In the covered with a pack and retracted There is such patient with a narrow subcostal angle exposure variation in the shape of the left lobe of the is more readily obtained through a left vertical liver that it cannot always be retracted in the rectus incision extending up into the angle be same way but manipulation with the hand will tween the left costal margin and the base of the demonstrate the best maneuver as a rule the xyphoid process Although this incision should lateral edge of the left lobe is turned posteriorly probably be used by the surgeon who is unfa and to the patients right The peritoneal reflecmiliar with the operation the author never uses tion from stomach to diaphragm is incised and 1 vertical incision in the upper abdomen be- then by blunt dissection with the finger and cause the incidence of incisional herniation in traction on the stomach the herdia is usually rethe vertical incision in this location is too high duced with ease and the enlarged esophageal The substitution of an incisional hernia for an hiatus exposed A penrose drain placed around esophageal hiatus hernia is a poor exchange the esophagus and used for traction is helpful Occasionally the author has had difficulty in Before establishing forceful traction or retraction reducing and repairing this hernia through the upon the stomach the size position and fixation transverse intercostal incision but the fault was of the spleen should be carefully determined If it not in the incision but in the fact that the tho is fixed to the diaphragm by adhesions it should racic approach should have been used When be freed or manipulated in the retraction very the surgeon discovers that the hernia cannot be gently A lacerated spleen or an avulsed seg. sıfely reduced by the abdominal approach the ment of capsule necessitates splenectomy to transverse intercostal incision at the level of the control bleeding and while this is a simple pro- 8th costal cartilage lends itself well for extension cedure it is an unnecessary addition to the opinto the left 8th intercostal space and a com eration of esophageal hiatus hernioplasty The bined thoracoabdominal operation This is not real danger is not recognizing a lacerated spleen the case when the vertical incision is used and to avoid this catastrophe the spleen should After the incision is made as illustrated and be carefully inspected again for injury as the described (Fig a) the secret of performing the last procedure before wound closure operation with facility is in the exposure (Fig After adequate exposure and reduction of the b) While this platitude is true of any operation hernia the margins of the defect are tnmmed of it is especially true when one is working at the fragments of peritoneum and fascia so that the 3 ·DIAPHRAGMATIC HERNIA Plate ILI TRAUMATIC DIAPHRAGNLATIC HERNIA 8th a. Schematic view of the left lateral chest wall to ladi cate the incision for the repair of a hernia through the left leat of the diaphragm The skin incision parallels the 8th nb extends from the costochondral junction to the pose terior anillary line and is carried down to the periosteum of the nb separating the fibers of the pectoralis maxim and the serratus anterior muscles The Bih rib is then remoned subperiosteally for the length of the incusion and the pleural space entered through the rib bed. This stres excellent exposure and the wound is more easily closed than when an intercostal incision is used. The operation is performed with the patient is the supino position with the left upper estresnity secured to the overbead operating table frame. rib Skin'incision b Pericardsum Peritoneal cavity Tund b Transthoracic exposure of the hernial defect in the left leaf of the diaphragm. The abdominal viscera bave been separated from the thoracic viscera and reduced into the abdominal cavity The attenuated aponeuroticolasdal war gins of the hernial defect have been excised along with tags of diaphragmatic pentoneura and pleura to reveal the actual aponeurotic margins of the hernial defect. The diaphrag matic pleura is remored in this figure to illustrate the di rection of the musculoaponeurotic fibers of the respleatory diaphragm which the sugeon spust understand for the correct closure of the defect. Invariably the long arts of the defect will be in the direction of the musculoaponev rotic fibers of the diaphragts and the closure must parallel these fibers to accomplish closure without tension. Diaphragm muscle apon C THE ILONIA REPAIR. "Three of the mattress futures are tied and the remainder are in place Teady to be ded. The mattress futures of 00 silk or nylon evert the edges of the hernial defect on the pleural side and they aro placed closely enough to prevent pieces of omentum from man truding through into the pleural space ia the postoperative period. In a defect of this size the phrenic nerve is not cushed but in larger defects it is crushed just above the diaphragin as it still lies between the mediastinal plewa Rad the pericardtury. This is usually done after the abdom inal viscera have been reduced but before the repair & started. The chest wall is closed La Layers with Interrupted 00 tik mattress sutures for the Intercostal musculofuschal layer after severing the Sth Intercostal nerve at the posterior ansla of the facision. The fasciae of the pectoralis major and my ratus anterior muscles, the subcutaneous fasala and Un ar all closed with Interrupted fine allk mature's The plural space is drained through a stab wound la tha toch inter costal interspace posterolaterally by a catheter that to con Dected to in underwater scal bottle. The general praciples of an open chest operation are observed throughout the procedure, especially the expensia of stelecutte lung com pressed by the hernia LC INNIS 4 ·musculoaponeurotic fibers of the diaphragm are say that even in the uncomplicated and unobused in the repair and not the thinned out fas structed case, gastric suction is established be cia The usual position of the defect as related fore the operation is started and maintained in to the esophagus is as shown (Fig b) but at the postoperative period until normal bowel may be medial or posterior to the esophagus In sounds appear If there is any degree of intesany event the esophagus should be pushed pos tinal obstruction a long tube is passed well tenorly between the crura of the diaphragm and down into the small intestine preoperatively the enlarged hiatus closed anterior to the esoph Decompression of the small intestine not only facilitates the reduction of the abdominal vis agus (Fig c) The line of closure should care cera and repair of the hernia but makes for a fully parallel the direction of the fibers of the diaphragm for a closure without tension Inter- smoother convalescence as in any case of partial rupted medium silk or nylon sutures are used intestinal obstruction The supine position on and the hiatus snugly closed To prevent sliding the operating table and good positive pres sure intratracheal anesthesia make the transof the esophagus the margin of the reconstructed hiatus is sutured to the serosa of the fundus pleural exposure of this hernia (Fig a) a safe and simple procedure of the stomach at the cardia with the same su Most traumatic hernias of the diaphragm will ture material Occasionally the presence of a not have a pentoneal sac and so the abdominal congenitally short esophagus makes this type of viscera are immediately encountered The pareprocedure unsatisfactory in which event the tal pleura should be opened with the same cauprocedure of choice is probably to transpose the upper end of the stomach into the posterior tion that the peritoneum is opened as colon or stomach may be adherent to the paretal pleura mediastinum and suture the margins of the hia at the site of incision After careful inspection tus circumferentially to the stomach Recurrence of the herniated abdominal viscera they are of a hiatus hernia following adequate repair sug gests that a short esophagus was unrecognized enlarging the hiatus in the direction of the mus freed and reduced into the abdominal cavity at the time of the original operation culoaponeurotic fibers if necessary Should a TRAUMATIC DIAPHRAGMATIC HERNIA segment of bowel be devital and resection ind cated this can be done readily through the The thoracic approach is always used in this thoracic approach by enlarging the diaphrag type of hernia because the herniated abdom- matic defect and is not an indication for the inal viscera are invanably densely adherent to abdominal route as advocated by some authors the thoracic viscera and pleura The blind re The average defect such as illustrated (Fig b) duction of the abdominal viscera by traction in is closed as shown (Fig c) crushing the phrenic the abdominal approach is extremely hazardous nerve when necessary to gain a closure without or even impossible Even with the chest open tension Larger defects that cannot be approvi and the herniated abdominal viscera under good mated present a problem that will tax the in direct vision their separation from the thoracic genuity of the most skilled surgeon and are viscera can be a time consuming and assiduous hardly the province of thus atlas However the job When the hernia is of long standing the ad surgeon faced with this dilemma should realize hesions are dense and the planes of cleavage that he must either borrow tissue which can be may be ill defined. Even though the hernia done by cutting the costal attachment of the could be safely and easily reduced by the ab diaphragm and advancing it superorly to make dominal approach the technical aspects of the a flat transverse diaphragm or decrease the size repair of the defect in the diaphragm are much of the thoracic cage on that side and this can simpler by the transpleural route be done by lower rib thoracoplasty A strong The preoperative preparation and postopera surgeon and strong suture material are not a tive care of these patients follow sound surgical substitute for inadequate diaphragmatic muscle principles which will not be discussed except to and aponeurosis 5 ·Xiphoide ransvensus abdominis m and apon EPIGASTRIC HERNIA Plate IV Posterior view of the abdominal wall in the epigastric region with the pentoneum and prepentoneal connective tissue removed to demonstrate three types of epigastric hernia Perforating blood vessels are common in this area of the linea alba and one frequently observes a small lobule of prepentoneal fat, without a peritoneal sac protruding through a vessel aperture as at (a) and shown below to sagittal section at (a) The fat is incarcerated, usually painful and the hernia requires surgical correction At (b) is a large epigastric defect which contains a fully deve! oped hernial sac as shown in sagittal section at (b) An epigastric hernia such as shown at (b) and (b') undoubt edly begins in the manner shown at (a) and (a) with gradually more and more preperitoneal fat pushing through the small defect enlarging it and eventually pulling the parietal peritoneum through the aperture too Occasionally one sees a cluster of apertures through the linea alba as seen at (c) and the three defects indicated by the arrows are seen in sagittal section at (c) Multiple apertures such as these are converted into a single larger defect and handled as a large epigastric hernia such as at (b) LCUNES Umbilicus Linea alba Vessels -Preperitonealfat -Peritoneum b' Linea alba Preperitoneal fat ć -Peritoneum 6 ·Epigastric Hernia NLY TENNIAS of the linea alba between when a cluster of protrusions occur (c and c'), under this heading Rarely epigastric hernias pair occur lateral to the rectus muscles in the linea Small epigastric hernias containing only a semilunaris but since most surgeons will never protrusion of preperitoneal fat (a and a') presee such a hernia in the epigastrium only one sent a simple problem for repair but they may type of linea semilunaris hernia will be pre be difficult to detect especially in the obese pasented and that under the heading of Spiegels tient They are regularly incarcerated and pain hernia hereinafter In general these hernias are ful, and unless discovered the patients sympsmall and although they may occur anywhere toms are usually ascribed to duodenal ulcer or in the linea alba between xyphoid and umbili gall bladder disease Sharply localized tendercus they are most common immediately above ness in the contracted abdominal wall not agthe umbilicus The larger variety of epigastric gravated by deep palpation with the muscula hernia is invariably in the supraumbilical re ture relaxed is a useful differential diagnostic gion While these hemias must be considered and The repair of these small defects is simple as acquired from an etiologic point of view and consists of exposing the herniated lobule of there is certainly a congenital predisposition or fat through a small transverse incision over the anatomic fault that permits them to develop mass If it is pedunculated it is excised after which was well recognized by the early anat Ligating the base with a suture ligature because omists All epigastric hernias begin as small of the blood vessels that invariably accompany protrusions of preperitoneal fat between the the fat If it is sessile it is simply reduced The decussating aponeurotic fibers of the linea alba aponeurotic defect is always enlarged laterally and in most instances the initial defect is cer on either side to facilitate reduction and for tainly the aperture for a perforating blood ves adequate inspection to rule out a peritoneal sel (at (a) and (b) in the figure on opposite component of the hernia After the fat is repage] These perforating blood vessels are seen duced the margins of the aponeurotic defect routinely in cadaver dissections and at the are approximated in a transverse direction with operating table unassociated with a hernia but interrupted mattress sutures (Fig a' next it is also true that perforating blood vessels in page) The author prefers 32 gauge stainless variably accompany the fat of even the smallest steel wire sutures not only for this small type epigastric hernia and must be ligated to avoid of epigastric hernia but for all epigastric and bleeding in the extraperitoneal space While umbilical hernias These hernias should never there is a paucity of fat in the preperitoneal lay be closed in the vertical plane because the con er in the upper abdomen it is always abundant traction of the abdominal musculature will tend between the layers of the falciform ligament of to separate the closure whereas a transverse the liver which lies behind the linea alba and closure is under no tension even with violent it is this fat that protrudes in epigastric her contraction of the muscles [Frontispiece Fig nias In elderly patients one occasionally sees (a) opposite and Fig (al) next page] When clustered epigastric herniations which are appar the linea alba is very broad as in diastasis recti ently due to attenuation of the aponeurotic even a moderate sized epigastrc defect can be fibers of the linea alba with multiple lobules of repaired by simple transverse closure or a lim fat presenting through the interstices of the ited “vest over pants” closure usually referred linea alba Typical examples of epigastric her to as the Mayo operation In the larger defects niation are presented on the facing page and closure cannot be accomplished by this simple 7 ·Plate V EPICASTRIC HERNIA a' Ant, rectus sheath al THE BERNIA REPAIR of a small epigastric defect as shows at (a) and (a') in the Agwes on the preceding page The blood vessels are ligated and the protruding lobule of fat either reduced, or excased after ugation of the pock. The sht like defect is simply closed with interrupted mattress sutures that evert the edges Sınca alba by An Incarcerated epigastric bernia such as shown in (b) and (b') in the figures on the preceding page. The tightly constructing ring of the aponeurotic defect to the linea alba is cut laterally on each side and the incision ex tended laterally as shown. This permits easy reduction of the hernial contents after opening the sac to ascertain their viability The peritoneal sac is then disposed of in the con ventional manner b' Incision in ant rectus sheath sacu Rectus! abd m Linea alba a Hernial defect a THE HEANIA REPAIR. The peritoneal sac has been ligated and the rectus muscle on either side retracted laterally in the incision through the anterior sheath. The posterior rectus sheath is then Incised transversely on either side as shown at (l) on the left side of the fgure The superior flap of the posterior rectus sheath is then Incised vertically on either side immediately adjacent to the linea alba as shown at (2) The transverse Incision in the pose terior rectus sheath on either side is then closed with mat tress sutures so as to shorten the vertical length of the posterior sheath in the area of the hernia repair On the right side of the figure the sutures are in place and after suturing the transverse incision on the left side in a simi lar manner the retracted sectus muscles are allowed to resume theu original position. The device of cutting the posterior rectus sheath as demonstrated at the numbers (1) and (2) has been adopted by the author to gain mo bulty of the superior flap for an overlapping closure of the aponeurotic defect. In a hernia of this size the eponeu sotic defect is too large and the margins too rigid to permit satisfactory closure as illustrated in figure (a ) above Post. rectus sheath Rectus abd m Ant rectus sheath b b THE MEANIA REPAIR COVTEVUED The Erst Layer of mattress sutures are placed for the overlapping or "vest over pants" closure of the defect Two of the futures are tied on the left hand side of the figure and in between the tied mattress sutures is a tied slogle interrupted suture Another interrupted suture is in place but not tied. These are placed in between the mattress sutures to Insure com plete closure It now becomes apparent that the incision (2) in the above Egure has permitted mobilization of the superior flap in a smooth line for overlapping. The cut edge of the posterior rectus sheath adjacent to the finca alba is labeled with the number (2) in this figure all of the first layer of mattress futures are then tied and inter rupted single loop futures placed between the mattress suturas Pectus obdm C. Ture UNNIA NDAR COMLETO The free edge of the superior flap to now sutured in place with a kries of mattress futures which completes the bernta repair The subcutaneous fascta and skin are closed in the usual mandat 8 ·method without considerable tension and a more described in the accompanying legends The extensive operation is necessary transverse incisions in the posterior rectus Fully developed epigastric hernias with a sheath (Fig a) serve a dual purpose first they peritoneal sac are also exposed through a trans allow adequate treatment of the peritoneal sac, verse incision over the mass and the aponeurosis and second, they facilitate the first stage in the of the linea alba and the surrounding anterior repair of the hernia To the reader who may not rectus sheath are exposed for a sufficient area have been faced with the repair of one of these about the hernia to accomplish an overlapping large defects the problem may not be exactly closure without having fat on the flaps It is in clear but unless one manages the incisions cleaning the sheath and the linea alba about (Fig a 1 and 2) as described in the legend a the hernia that the small perforating blood ves difficult situation presents itself If just the an sels referred to above are always encountered terior sheath is used an insecure closure results The neck of the sac and the hernial ning are in the linea alba because of the rigidity of the clearly delineated by sharp dissection but be hernial aperture If one attempts an overlapping fore the sac is opened the aponeurotic defect closure an awkward arrangement exists which is enlarged laterally on either side well into can be visualized (Fig a) If the point on the each rectus sheath (Fig b) This is done for leader from the label Post rectus sheath" is two reasons first because adequate dissection brought down to the point on the leader from and ligation of the peritoneal sac cannot be ac the label Ant rectus sheath” Not only is this complished through the ngid and constricting an unanatomic exchange of layers with the rec aponeurotic hernial ring and second because tus muscles dislocated from their normal line it is impossible to satisfactonly repair the her of pull but it still does not give adequate rena by simple closure of the rigid margias of laxation for a secure closure of the linea alba the defect in the linea alba After the anterior To circumvent this problem and gain an aderectus sheath is incised on either side (Fig b) quate closure without tension the author uses the rectus muscles are retracted laterally and the device as shown (Figs a b and c) The the posterior rectus sheath incised laterally transverse incisions in the posterior rectus (Fig a, 1) The pentoneum is then freed up sheaths originally made for exposure are closed from the margins of the hernial ring and from with mattress sutures so as to foreshorten the the under surface of the linea alba and posterior postenor sheath (right side of Fig a) The ver rectus sheath by a combination of sharp and tical incisions in the posterior rectus sheath im blunt dissection The freeing up of the perito mediately next to the linea alba (Fig a 2) gain neum and the closure of the peritoneal sac (Fig mobility for the superior flap of the linea alba a) are by conventional methods but the un and then the linea alba and the anterior rectus initiated should be warned that the peritoneum sheath on either side can be used as a single in this location is extremely thin and friable layer (Fig b) and brought down over the in After disposing of the hernial sac the hernia ferior flap without undue tension for a double is repaired as illustrated (Figs a b and c) and layer closure (Fig c) 9 ·Plate VI SMALL UMBILICAL HERNIA a & Hernia Skin incision The skin incision is transversely placed either past above or just below the everted umbilical skin in this to stance just below It is transverse in direction to follow the Lines of skin cleavage for the best cosmetic result and the umbilical skin is never removed The incision is camned down through the subcutaneous fascia to the linea alba and the skin flaps developed for exposure of the hernial defect The superior skin flap with the umbilical skin is carefully dissected off of the hernia) sac to avoid button houng the skin The peritoneal sac is opened the contents reduced the neck of the sac freed from the margins of the defect in the linea alba ligated and the excess pentoneum excised b Linea alba Fat -Hernia Peritoneum b On the left is a mudline saggital section through the hernial defect to demonstrate several features of this type of hemia In the immediate area around the umbilicus there is an almost total absence of fat between the peritoneum and the aponeurotic linea alba which makes the delineation of the nech of the peritoneal sac a delicate procedure if one is to avoid tearing holes in the peritoneum beyond where they can be repaired While there is abundant fat about the base of the hernual sac in the subcutaneous layer only a little areolar fissue separates the exerted wrbulica) shin from the peritoneum of the hernial sac and again it must be carefully separated to avoid button holing the skin. On the night, is a posterior view of the abdominal wall with the penitoneum and preperitoneal connective tissue removed to demonstrate the aponeurotic defect of the small umbilical hemia In this small type of hernia it should be noted that the defect is entirely within the lipca alba and does not extend into the reches sheath on either side It is also evident in this view why the defect should be closed transversely rather than vertically The margins come to gether without tension in the transverse plane and the con traction of the transversus abdominis and oblique muscles will pot tend to distract the closure as would be the case if the defect were closed in the vertical plane Umbilical skin everted d Umbilical skin inverted C. TIE HERNIA REPAIR The peritoneal sac has been ligated at its base and the excess escused The mattress su tures of fine silk or stainless steel wire are placed ready to be tied. The exerted unbilical skin in the superior skin flap is demonstrated by a probe d TIIT REPAIR CONTEVED The mattress sutures in the linea alba have been tied everting the edges. The *pci of the umbilical skla is futured to the linea alba adjacent to the closure of the herbal ring with three interrupted fine silk sutures The subcutaneous fascia is closed in Layers with Ene sulk sutures so as to obliterate the dead space about the umbilicus After the skin is sutured and before the dressing is applied the umbilical dimple is packed with fine mesh gaute or when the Ilalsted sier loll is used as the wound dressing the paper is wadded up and packed Into the umbilical dimple This serves to fashion . Dora! appearing and open umbilicus 10 CANOS ·Umbilical Hernia TWO EXAMPLES of umbilical hemia are pre level and may be placed either above or below TS sented First the small congenital umbili- the umbilicus, depending upon the relationship cal hernia of infancy and second the larger of the aponeurotic defect to the umbilical proacquired umbilical hernia of adulthood Om trusion The incision is therefore placed as near phalocele or hemia into the umbilical cord is the aperture in the linea alba as possible with à difficult surgical problem for which no single out crossing the umbilical skin and whether it procedure can be presented and is omitted from is above or below the umbilical dimple is imma this atlas terial One must bear in mind the possibility of un adjacent and coeustent epigastric hernia SMALL UMBILICAL HERNLA OF INFANCY The umbilical skin is carefully preserved and in Most of these hernias which become appar the skin closure is used to reproduce a normal ent in the first few weeks of life can be man appearing umbilicus While the umbilical dim aged conservatively and ef kept reduced with a ple is admittedly an unnecessary feature of our block of sponge rubber held in place with tape anatomy and has no esthetic value its absence the hernial ring will become both relatively and will be readily noted by other children and may actually smaller until the nng closes usually by become a basis for derogatory comments and the 10th or 12th month Unless the child be questions In the adult this is not usually a comes sensitive to the rubber the author pre consideration but even so it is a nicety of the fers the block of sponge rubber to other pres surgeons art to fashion a normal appeanng sure devices because of its even pressure when umbilicus compressed and because the retaining strip of In children these hernias are usually reduced tape is less tightly applied it will stay in place with ease and the peritoneal sac ligated with longer without injury to the skin The mother out enlarging the hernial ring but if this is necshould be impressed with the importance of essary the linea alba is incised on either side in keeping the hernia continuously reduced not the transverse plane After ligation of the neck just applying the sponge rubber and tape occa of the sac the defect is simply closed by a senes sionally The simple device of changing the of interrupted mattress sutures (Fig c) The direction of the tape occasionally and painting reconstruction of the umbilical dimple and clos the skin with compound tincture of benzoin ure of the subcutaneous fascia and skin are as usually obviates any senous imtation of the illustrated and described (Fig d) skin Many small umbilical hernial rings close LARGE UMBILICAL HERNIA spontaneously without any treatment but the sponge rubber compression bandage is easy to The large ubilical hernia seen in the adult apply and is reassuring to the mother If an is usually considered to be acquired but cerumbılıcal hernia is present esther with or with tainly there is a congenital predisposition in out compression treatment after one year of that there is a weakness of the umbilical scar age it should be repaired surgically at a suitable They are most commonly seen in the obese time The author prefers to wait until after three multiparous female and yet in the authors se years of age unless the hernia is symptomatic ries the senous complication of strangulation in which event it is repaired promptly In our has been most common in the elderly debili experience the compression treatment is worth tated male Whereas incarcerated contents are less after one year of age rare in childhood these hernias in the adult The skın incision which follows the lines of usually contain an irreducible segment of skin cleavage is exactly transverse at umbilical omentum that is densely adherent to the dome 11 ·& Lines -alba Plate VII LANGE UMBILICAL HERNIA Posterior view of the abdominal wall in a case of inea alba rans abd apost Targe umbiscal hernia with the pentoneura and prepento Skin neal connective tissue removed to demonstrate the large Hernal difesa defect in the linea alba which also ertends on either side into the rectus sheath. It also demonstrates the transverse direction of the transversus abdominis aponeurotic Ebers Peritoneum and the decussation of aponeurotic fibers from other side of the transversus abdominis Internal oblique and external ablque muscles It is interesting to note that the resultant of the pull of the Internal oblique and the external obligue Sbers is in the transverse plane Thus the summation of Fat the musculoaponeurotic action of the two oblique muscles and the transversus abdominis muscle is exactly is the transverse plane at umbilical level. This points out very clearly why these berałal defects should be clased to the Everted umbilical skın transverse plane and in general why a vertical incision either in the linea alba or the rectus sheath 's anatomically Hernial sac legated and physiologically unsound On the night is a midline sagittal section through the im- Rectus abd m bilical hernia to again demonstrate the relationship of the layers b THE HERNUA NEPAD The hernial sac has been ligated and excised The anterior and posterior rectus sheaths have been incised on either side for two reasons First, it may be necessary to do this for reduction of incarcerated coa tents but in any event it facilitates the dissectioa and Biga tion of the hernial sac second it is difficult to close a rigid Lineaalkor Anterior and ring of this size without gaining mobility and this is done posterior rec tus sheath in exactly the same manner as previously Wustrated for the large epigastric hernia After Incising the posterior restas sheath transversely as at (1) the posterior rectus sheath of the superior flap is incised vertically on either side as at (2) Mattress sutures placed the transverse Incision in the posterſar rectus sheath on either side as demonstrated at (1) on the left side of the Egure are tied to foreshorten the posterior rectus sheath The rectus muscles are allowed to resume their normal position and the first layer of mat tress sutures with alternating single loop sutures are placed exactly as illustrated in (Fig b) for the closure of Large epigastric herna c Shows a method of removing the dome of the umblu cal skin in a large umbilical bernia which in addition to being excessive is frequently nonviable after it I dissected off of the hernial sac, Tho margins that are left arc then sutured together as shown, to form an urbilical dimple of normal size The sutures placed as demonstrated to the everted umbilical skin are then available for removal in the postoperatise period when the umbilicu ts to the inverted position as shown at (1) in the nat figure d. TIE JIERYIA REPAIR COMITED Dernonstutes the completed hernia repair (2) for the large umblical herala. the details of which have been previously Dastrated for the large epigastric hernia. The reconstructed umbilicus has been laverted at (1) and the packing is inserted with the forceps The apes of the ambitical sido bruturd to the apopeurosis of the overlapping tip v demonstrated st (3) with Interrupted fise ilk sutures The subcutaneous fasela i carefully closed to obliterate deadspace about the umbilicus and the skin closed is the usual may bat to this bostance the perfumedical subcutancous spaccato dnalped 12 d ·of the peritoneal sac The skin of the umbilicus nia is exactly the same as for the large epigas is always discolored and shows the changes tric hemia which is shown in more detail unsecondary to decreased blood supply The skin der that heading The transverse and vertical Incision for this hernia is the same as for the incisions in the posterior rectus sheath are small infantile umbilical hernia and is either shown (Fig b) and the final closure (Fig d above or below the umbilicus, whichever is the 2) In these large umbilical hemias there is more expedient The umbilical skin is carefully usually a diastasis recte and some umbilical dissected off the hernial sac even though much hernias with a neck of intermediate size may of it may be excised in the reconstruction of the be closed by overlapping the linea alba and umbilicus without entering the rectus sheaths for the more If there is any question of strangulation of extensive and plastic closure The procedure the hernal contents the sac is opened before advisable in any individual case will have to be the aponeurotic margins of the defect are in evaluated on the operating table after the sac cised so that they may be inspected for viabili has been excised and the peritoneum closed ty It is disconcerting to say the least to have The determining feature is whether the linea the contents spontaneously reduce if there is alba can be adequately closed without tension any question of viability of a contained loop of After the hernioplasty an umbilicus is fashbowel and should this occur one must laborious ly examine all of the mobile intestine that could ioned from the skin of the everted umbilicus which covered the dome of the hernual sac possibly have been contained within the hernia This adds considerable time to the operation (Fig b) Whereas saving the shin and inverting not to mention the trauma of the procedure It is a simple procedure in the small umbilical Once the contents are found to be viable the hernia the fashioning of a normal appearing hernial ring is enlarged laterally on either side umbilicus from the stretched out atrophic and into the rectus sheath retracting the rectus frequently avascular skin of the large umbilical muscles and incising both anterior and posterior hernia is a more complicated process Obvioussheath preparatory to starting the hernia re ly if the patient is a poor risk the added time pair After this is done the pertoneal sac is involved of saving the skin in the first place more easily freed from the aponeurotic margins and of making an umbilical dimple in the secof the ring and the neck of the sac is more avail ond place would be poor judgment, and the able for incision and reduction of the contents author excises the umbilical skin with the el- Adherent bowel is of course carefully freed lipsoidal segment of skin and subcutaneous tis from the sac and reduced however when the sue at the beginning of the operation However omental adhesions are massive it is frequently when the time permuts, the author takes subtle more expedite to amputate the omentum con pleasure in reconstructing an umbilicus This tained within the sac as no distinct plane of possibly picayunish procedure can be accom cleavage may be found Mass ligature of the plished in several ways one of which is demon contained omentum should never be done first strated (Fig c) By the time one is ready to because it is a crude procedure leaving a large close the skin it is usually apparent that the wad of devitalized omentumn within the abdom central segment of the old umbilical skin is not inal cavity, and second because a knuckle of viable and also that the circumference of the transverse colon is frequently found in the cen dilated umbilicus is too great A pack is placed ter of the omental mass The defect in the peri in the vault of umbilical skin to reconstruct the toneum is closed in the conventional manner hermal bulge and an ellipsoidal segment of the with a purse-string suture or it may be easier skin is excised including a portion of the nng to simply close it with a continuous suture in (Fig c), making certain that the margins of a straight line choosing the direction of closure excision are viable The edges are then sutured indicated by the available pentoneum together with interrupted fine silk sutures (Fig The hernioplasty for the large umbilical her c) and the new umbilicus inverted (Fig d 1) 13 ·Plate VIII HERNIA IN THE LINEA SEMILUNARIS Transv abd.apona (SPIEGELS HERNIA) Linea Semicircular FUmbilicus Hernaf By definition this spontaneous type of bernia occurs in the linea semilunaris but must be above the point at which defect the infenor epigastric vessels cross it, otherwise it must be termed a direct inguunal herma While hernias are recorded along this line above the level of the linea semicircularis they usually occur just below the point where the linea semicircularis intersects the linea semilunaris This is a lepigastri potential weak point because the aponeurotic fibers of the transversus abdominus are changing from the posterior to the anterior rectus sheath This uncommon type of hernix is usually difficult to diagnose in its early laterstitial stage and especially in the obese patient It begins in a manner similar to the epigastric bernia with a protrusion of preperitoneal fat which in turn pulls through the attached panetal peritoneum It may be that a perforating blood vessel is a contnbuting factor It may remain interstitial a beneath the external oblique aponeurosis for a long time but of not corrected eventually protrudes through the er Umbilicus Ext oblique apon, ternal oblique aponeurosis where it inay be felt and has all Incision the characteristics of a hernia The neck is invarlably nar row and strangulation of the contents is a real danger a Posterior view of the aponeurotic defect in a case of left semilunar or so-called Spiegels hernia The pentoneum and preperitoneal connective tissue have been removed to show the anatomic relationsłups of the aponeurotic structures concerned The bracket labeled with the asterisk in dicates the most common distribution of hernias in the linea semelunaris If the herala is below the inferior cpi gastric vessels at is through Hesselbach s triangle and is WHernial therefore a direct inguinal hernia b Anterior view of the left semilunar herola presenting through the erterpai oblique aponeurosis The exposure is through a transverse skin incision in the authors limited erpenience with this type of hernia there is a considerable amount of fat surrounding the peritoneal sac which bears b out the lipoma theory of ongin of this bernia. An incision is made in the external oblique aponeurosis both above and below the hernia (heavy line) and this Layer retracted to expose the neck of the hernia as it comes through the transversus abdominis and Internal obliquc aponeuroses. Ext obl The pentoneal sac is disposed of in the conventional man ner and the fat simply pushed in unless there are peduncu apon lated processes in which esent the bases are ligated and the lobules excised There are always blood vessels to the fatty lobules c Tire HERNIA REPAIR The peritoneal sac has been remored and the apopeurotic defect closed (asterisk) At this level of the abdominal wall and below the aponeurode fibers of the transversus abdominis and Intemal oblique layers closely parallel each other tuually have started to Int. decussate and so are handled as a single layer with closure by interrupted fine silk sutures (asterisk) The external apon oblique aponeurosis is then closed with the same sutures as indicated in the upper angle of the wound. The closure of the layers in this type of hernia is identical with the closure of the muscle splitting appendectomy incision Although this type of hernia may be decult to diagnose in the carty stages it is one of the casiest to repair because thrte im signifcant disruption of the normal musculoiponetretín mechanism. There should never be a TCUTETOR obl mit LONNES 14 ·Hernias of the Inguinal and Femoral Region IN 'N TILE ENTIRE history of surgery no subject has derstand the problems involved in these her been so controversial as the repair of groin nias without a thorough understanding of the hernias The inguinal hernia problem has been anatomy as it is here presented While some so hopelessly confused in the past 50 years by groin hernias may be technically very difficult such an enormous number of operations that to repair because of obesity or the scarring sec one can only conclude that the proponents of ondary to the injection treatment or to pre most of these operations did not understand vious operations in general these hernias are either the normal anatomy of the inguinofem. simple to repair if one understands the altered oral region or the pathologic anatomy of her anatomy in the various types of groun hernias nias It is little wonder that the young surgeon and the steps necessary to reconstruct a normal is lost in the maze of contradictory opinion and inguinal wall In this atlas every effort has been so he usually mimics his preceptor and eventu made to simplify the defect and the repair of ally adds a twist or two of his own so that in these hernias and so a constant pattern of presstead of the 76 operations known to the author entation is used First the anatomic defect as for ingwnal and femoral hernioplasty there are seen from behind in the cadaver is presented probably thousands Certainly the underlying as this is the only way that the true character fault is inadequate and frequently inaccurate of the hernial ring can be shown with the mu knowledge of the normal anatomy of the in tual relationships of important_adjacent strucguinal region tures It is also the only way that the posterior It is small wonder that there is misunder- inguinal wall (the transversus abdominis apo standing and confusion when our textbooks of neurosis and fused transversalis fascia) can be anatomy perpetuate such artefacts as the con viewed in its entirety with the important atjoined tendon the falx inguinalis as labeled in tachments to Cooper s ligament and the femoral anterior views of the inguinal region and the sheath In each type of hernia an ide tical view interfoveolar ligament A sharp archung border of the postenor inguinal wall is presented for of the "conjoined tendon” is a product of the orientation The next figure in each series then dissector s knife and not of normal anatomy shows the appearance of the hernia as seen in The inguinal ligament cannot be seen in pos the anterior view at the operating table and terior views of the inguinal region unless the then the successive steps in the repair of this transversus abdominis layer (posterior inguinal defect wall) is removed and yet this is a commonly Reduced to its simplest form hernioplasty for used figure in anatomic discussions of the in the small indirect inguinal hernia requires only gunal region The inguinal ligament should the removal of the congenital pentoneal sac be taken for what it is simply the lower free and closure of the dilated abdominal inguinal edge of the external oblique aponeurosis and ring designated “ABDOMINAL INGUINAL RING not an anchoring structure to which everything REPAIR The large indirect inguinal hernia, the in the vicinity should be sutured It is em- direct inguinal hernia and the femoral hernia bedded in its own fascia which is continuous all represent destruction of the posterior inwith the fascia lata and other structures in this guinal wall in varying degrees and from differregion have only a contiguous relationship ent approaches The problem of the hernioplas Before the reader begins the study of this ty is the same and a single operation is used for series on inguinal and femoral hernioplasty he these three hermas or any combination of groin should carefully study the anatomic plate on hernias designated "RECONSTRUCTION OF THE the following page for one cannot hope to un- POSTERIOR INGUINAL WALL 15 ·m Symphysis Ext. obliquc apon a pubis Pubic Int Transversalis Rectus abd fascial tubercle obliquem fascia Ext Coopers Transv Ant rectus sheath Lacunar lig abd mit Joblique apon Inguinal lig I apon. Linea alba Int Position of Cordat 7-obliquem femoral Labdings vessels Transv abd ring apon Cremaster fościa lata Abd.ing ring Subcutaneous Inglig ing ring d Femoral (sheath Femoral artery Abd ing ring Cooperslid and vein Pectineus m Femorala v Spermatic cord fascia Femoral ring Pubic tubercle Lacunar Cooper's lig lig Insertion, transv Ext oblıquc m Inguinal Rectus abd m Int obliquem and fascia b Transv abd m Lacunar Pyramidalis m V Transversalis fascia lliacus fascia Abd inguinal ring Transv abd apon Extiliac artery fused with and vein transversalis fascia abd apon e Linca alba Extiliac infepigastric vessels a v Ant rectus sheath- Rectus abd fascia Femoral ring -Obturator canal Extobi YObturator apony foramen ling ligt Lacunar lig Pubię tubercle Symphy Sis pubis Femoral ring Coopers lig Cooper s log CIN Plate IX THE AMATOVY OF THE INCUROFESIONAL REGION Anterior view of the lower abdominal wall dissected Indicated in outline for better orientation Special attention to show primarily the right transvetsus abdominis muscle should be directed to the Insertion of the lower part of the and aponeurosis in the region of Inguinal and leproral her transversus abdominis aponeurosis fato Coonets Igument Ala. Important layers are labeled and the body pxlvis is and that lateral to this the transversalis fascla continors 10 ·Into the thigh as the anterior layer of the femoral sheath. It only when the ngd insertion of the inguinal ligament should be noted that the inguinal ligament is nothing more known as the lacunar ligament is reached. It should be than the lower free edge of the external oblique aponeurosis apparent that in the small indirect inguinal hernia there is and that the lacunar bgament is nothing more than the in no alteration in the normal anatomy of the musculoa podeu sertion of this lower edge of the external oblique apodeu rotic Layers of the angunal region The only aberration is rosis into the pubic tubercle and the medial end of Coopers the presence of a congenital diverticulum of peritoneum Ligament. It is particularly important to understand the which enters the inguinal canal at the abdominal inguinal anatomic relationships in the small area around Coopers ning and if the hernia is repaired before there is any sig ligament as illustrated and shown in more detail and from nificant dilatation of the abdominal ning the only opera different angles (Figs c d and e) To avoid confusion only tron necessary is to remove the peritoneal sac and tighten two fascial layers are shown, the innermost known as the the very slight dilatation of the abdominal faganal nag transversalis fascia and the outermost known as the Additional plication of layers or sutures placed between innominate fascia which is the covering of the external the so-called conjoined tendon and the inguinal ligament oblique muscle and aponeurosis and it continues into the only serve to open the avenue for a direct inguinal hernia thugh as the fascia lata Along the upper cut edge of the tion by the sery trauma of passing needle and suture figure the transversalis fascia can be dissected free as a through an intact and anatomically normal transversus ab sheet from the transversus abdominis muscle and aponeu dominis aponeurosis rosis and thus has been done to show that this fascial layer c View of the superior pubic ramus looking directly continues medially to invest the rectus abdominis muscle down upon the bone with Cooper s ligament, the inguinal and become known regionally as the rectus fascia. This Ligament and the lacunar Ligament drawn in to show their fascial continuity becomes of surgical significance after the anatomic positions and mutual relations The femoral ves relaxing incision is made because it is this fascia along sels are dotted in for onentation. The arrow 1dicates the with the rectus muscle that prevents the development of distance between Cooper s ligament and the enguinal Lga a hernia through the relaxing incision Lower down in the ment in this projection. inguinal region where direct inguinal hernias occur the d. The projection is the same as in figure (a) except transversalis fascia is usually inseparably fused to the that all of the musculoaponeurotic layers have been cut aponeurosis of the transversus abdominis and from a prac away except for the attachment of the transversus abdominis tical surgical standpoint, the transversus abdominis aponeu aponeurosis to Coopers ligament and its medial continua Tosis and its investing fasciae form a single layer tion over the tendons of origin of the pyramidalis and rectus b Posterior view of the lower abdominal wall with the abdominis muscles and thence down upon the body of the specimen talted to emphasize the nght inguinal region The pubic bone The relative positions of the abdominal inguinal peritoneum and all of the preperitoneal connective tissue ring and the femoral ring are indicated. Again the mutual have been removed A wiadow of the transversalis fascia relations of the inguinal ligament, the lacunar ligament and has been removed to more clearly illustrate it as a definite Coopers ligament should be noted in this antenor view fascial layer In this posterior view it should be especially especially the distance between the medial border of the noted, as was pointed out in the anterior view that the femoral ning and the Lacunar ligament. lower portion of the transversus abdominis aponeurosis in e Posterior view of the pubic bone and attached liga serts into Cooper s ligament. The breadth of this insertion ments-the projection is the same as in the detailed figure is indicated by the bracket, and while there is some nor (b) The "shelving" border of the inguinal ligament is 11 mal vanation in the breadth of this insertion, it is always lustrated in this view because of its popular nomenclature mucb narrower in a case of femoral hernia because of the and especially to again show the interrelatronsłup of the enlarged femoral ning Along the cut edge of the left side three ligaments The honzontal arrow above Coopers liga of the figure, the medial continuation of the transversalis ment is inserted to emphasize the distance between the fascia as the rectus fascia is again demonstrated. Indirect medial margin of the femoral ning which is the lateralmost inguinal, direct inguinal and femoral hernias occur in such attachment of the transversus abdominis aponeurosis into a small area that it is especially important to understand Cooper s ligament, and the lacunar ligament. When a fetheir anatomic interrelationships An indirect inguinal her moral hernia exists and the femoral ring is enlarged medially na is the congenital persistence of a processus vaginalis then the medial margin of the femoral ning Lies adjacent through the abdominal ingunal ning at (1) A direct in to the lacunar igament and the space represented by the guinal hernia is an acqured defect through the apodeurosis arrow is obliterated. The vertical arrow is inserted to empha of the transversus abdominis (posterior inguinal wall) at size the distance between the inguinal ligament and Coop (2) A femoral hernia passes through the femoral ring and er s ligament immediately medial to the femoral vein, down the feinoral canal at (3) As the indirect inguinal Cooper s ligament (Lgamentum pubicun superius) is a bernua enlarges it pushes more and more of the transversus very dense composite structure Tying along the medial por abdominis aponeurosis (posterior inguinal wall) out around tion of the uliopectineal line and very strongly adherent to the bernial sac until in the very large vanety of this type the pubic bone. It is made up of periosteum, the insertion of hernia, the transversus abdominis aponeurosis n the of the transverstis abdominis aponeurosis and the transer ioguinal region is completely destroyed and the medial salis fascia, the pectineus fascia and some fibers of ongin margin of the abdominal inguinal ring rests against the of the pectineus muscle and medially by the insertion of lateral border of the rectus abdominis muscle When this the inguinal ligament, regionally known as the lacunar Liga situation exists the inguunal canal loses its obliquty and ment. Mot shown in these figures and contributing in widethe hernual sac passes directly through the abdominal wall ly varying amounts are the fals pogwaalis which is a lateral as in the case of a direct ingunal hernia. As the femoral expansion of the rectus abdominis tendon of origin and the ning enlarges with the contained femoral hernua its medial adminiculum lineae albae which are aberrant laterally margin expands medially toward the figure (2) and stops expanding fibers from the Linea alba. 17 ·Plate X SMALL INDIRECT INGUINAL HERNIA a Restus abd Iransy abd mand apon Cord a. Postenor view of the right inguinal regioo with the Peritoneum and preperitoneal connective tissue rerdoret There is no alteration of the pormal anatomy cicept for very slgbt dilatation of the abdominal inguinal ring Since the peritoneum has been removed there is so hernial sac, which sharply outlines the aponeuroticofascial margins of the abu dominal wguinal ring After removal of the peritoneal sac, the surgical correction of the eusting faut consists of push ing the spermatic cord laterally and approximating the up per margin of the ring which is transversalis fascia and transversus abdominis aponeurotic fibers to the lower mat gin which is femoral sheath. Inf Enlarged abd ang ring Obturator canal epigastrid vessels Coppers s lig b Int obliquem Transvabdepon Ext obliquer Spons Cooper's lig b Anterior view of the right laguinal region as seen by the surgeon at the operating table (In this and rubscquemu operations for Inguinal and femoral herniat the drawing have been made eotch the artist standing at the elde of the patient in the portion of the surgeon and for uniformity right sided hernias only are presented it us hoped that the presentation of inguinal and femoral hernloplasty in this projection will help to better orientate the rurgeon and make the transition from anatomic plate to the operating table easter) The peritoneal sac has been dissected free from the cord structures well above the fascial margins of the ab dominal inguina ring and ligated Attenuated transversalis fascia and internal spermatic fascis have been croised to sharply delineate the aponeuroticofascial margins of the sbghtly enlarged abdominal laguinal ring It should be noted that the posterior ioguinal wall (transversus abdom inis aponeurosis) is intact in the asea of direct Inguinal herniation and that there is a normal breadth of Insertion into Cooper s ligament. Both the femoral ring and the in tegrity of the posterior fagulaal wall were checked fora Peritoneally by the surgeons finger prior to ligation of the $3c. Enlarged abd ing ring ctineus m fascia Sutures for closure of abd ing ring Cord Ext oblique apon Ingunan ug poral sheath The sac has been ercised and 0000 suk mattress su tares placed for closure of the dilated abdomios) inguinal Tiog The lateral component of the lateralmost ruturo can be seen to pick up small bites of the fascia of the cond. Thus is done to present suding of the cord within the remon structed abdominal Inguinal ring. Abding ring Famoral sheath d. Torx HERNIA REPAn (ABPOSICAL INCTIVAL RNC Rs PAR) The sutures are tied and cut. This closure it-estab lishes the normal anatomy by approximatiog the transvet salis fascla to the interior Layer of the femoral sheath The closure of the abdominal inguinal ring a toado fourt ught etough to Et sougly about the components of the cor and the end of the surgeons filth finger The spermatic cord thea dropped back into its bormal position agabout the posterior Inguinal wall and the external oblique aponeurals closed over te making & similarly rug closure of the pube culascous inguinal rog. 18 ·To further and the reader in his orientation all into the abdominal cavity and then by a comof the groin hernias in the following senes are bination of palpation from within and inspec nght sided and beginning with figure (b) in tion from without the status of the posterior ineach instance the figures correspond with the guinal wall can be accurately determined At surgeons view at the operating table In other the same time the femoral ring is felt, to be sure words, the head of the patient is to the readers that there is not a coenstent femoral hernia or left and the feet to the nght lipoma of prepentoneal fat in the femoral canal Over a seven year period on the authors Most surgeons expect the posterior inguinal service 562 groin hernias have been repaired wall to be a dense aponeuroticofascial structure with an overall recurrence rate of 06% This and when it is then they feel that they must re represents all types of inguinal and femoral enforce it with the more superficial internal hernias including recurrent hernias and in this oblique and external oblique layers The pos group the operations were performed by 12 dif terior inguinal wall is rarely a heavy aponeuferent surgeons including interns and residents roticofascial plate on the contrary it is usually thin and may even be translucent The impor- SMALL INDIRECT INGUINAL HERNIA tant consideration is that it is intact and that it The small indirect inguinal hernia accounts remains undamaged during the operation Refor between 60% and 70% of all groin hernias tractors should never be placed against it nor which adequately expresses the importance of should it be handled with instruments its proper repair The term small refers only to While high ligation of the peritoneal sac is the diameter of the neck of the sac at the ab universally recognized as the most important dominal inguinal ring and not to the length or single step in the operation for an indirect inthe size of the hernial sac Whether the sac is guinal hernia this does not mean the same thing short and confined to the inguinal canal or long to all surgeons To the author, high ligation and of the so called complete congenital type is means separating the peritoneum well up of little consequence for the primary considera through the fascial abdominal inguinal ning tion is the dilitation of the abdominal inguinal pulling the pentoneum up medially from un ning The cure of this type of hernia consists der the epigastric vessels until the lateral edge simply of high ligation and excision of the perz of the urinary bladder is seen and after the sac toneal sac, and reduction of the aponeurotico is ligated and the excess excised to see the fascial abdominal inguinal ring to normal size stump retract at least 2 cms from the fascial Any of the “standard operations that plicate margins of the ring The stump is never fixed to the layers or suture "conjoined tendon” to the the overlying musculature inguinal ligament are not only unnecessary but After the sac is disposed of a little sharp dis the suture holes placed in the posterior inguinal section at the medial margin of the abdominal wall may well be the cause of a recurrence as a inguinal ring will demonstrate the continuity of direct inguinal hernia As long as the postenor the transversalis fascia with the anterior layer inguinal wall is intact it should be left strictly of the femoral sheath (Fig b) This involves alone and of course its attachment to Coopers incising the internal spermatıc fascia as it starts ligament is not disturbed out onto the cord which is of course the same Preparatory to removing the peritoneal sac fascial layer as the transversalis fascia The cord cord the spermatic cord is structures are pushed laterally and the ring elevated from its bed by incising the very deli closed by suturing the transversalıs fascia to cate cremaster fascia along the upper border of the anterior layer of the femoral sheath until the the cord While this is not necessary for the re ning is reduced to normal size (Figs c and d) pair of the hernia it is important to carefully Normal size is considered a nng that just ac examine the consistency and continuity of the commodates the cord structures and the tip of posterior inguinal wall which cannot be done the surgeons fifth finger The external sper with the cord in place After the posterior wall matc vessels frequently do not come through 15 exposed the sac is opened and a finger passed the abdominal inguinal ning but through a sep- 19 from the spermats ·Skin incision Abd ingring -Ant b Ext oblique apon Round N Sac lag Int oblique? Cremaster in and fascia clipated rd lig, sac and Plate XI MEDIUV INDRECT INGUINAL HERNIA (FEULALE) a Posibon of the skin locision used in the repair of all inguinal and femoral hernias It is placed in the lines of Pubic skin cleavage and is situated at the level of the abdominal tubercle inguinal rung The abdominal ingusa) ning is projected 02 the skin by taking one-half the distance along a line draw between the apterior superior iliac spine and the pubic tubercle The Incision extends from & vertical line projected зар llac upward from the pubic tubercle lateralward for 1 or 2 spine cins beyond the abdominal inguinal nas This incision us adequate for the repair of all Indirect inguinal, direct inguinal and femoral hernias irrespective of size. It heals with a fine linear scar that is almost impcrccpuble after a year s time The more conventional oblique Incision fre quently leaves an unsightly scar Round lig b Antenor view of a small indirect inguinal hernia in ligated a female The round bgament is routinely cut at the pubic tubercle Igating at erstally because of the contained blood vessels Then the peritoneal sac and closely adherent round ligament are dissected free from the cremaster muscle and abd fascia well above the fascial margins of the abdamınal lo japon guinal ring and ligated as shown. A pedunculated pro trusion of preperitoneal fat is shown which comes through the abdominal inguinal ring with the pertoneal sac. This is also ligated at its base and excised These pedunculated masses of preperitoneal fat are frequently seen associated with an indirect inguldal bemia and it is very important Femoral sheath that they be discovered and removed for they can be the entering wedge for the recurrence of a hernia There may be one or as many as five in number and furthermore u less they are removed a Ught closure of the flag is om possible c The peritoneal sac and the pedunculated fatty pad have been excised. The attenuated fasdae that encased the hernial saç have also been excised which leaves the en bayad Larged abdominal inguinal ring with a sharp strong mar pon gin. The Insertion of the transversus abdominis aponeurosts (posterior inguinal wall) into Cooper s ligimeat la pormal oopers In breadth suling out a coexistent femoral hernia and the posterior Inguinal wall is everywhere intact so that direct Inguinal herniation is not a consideration at the lateral ctineu Reus fasc angle of the ring the first mattress suture has been placed Femoral sheath which will approximate the transversalis fasda to the anterior femene sheath the attachment of both the transversus abdominis aponeurosis and the pectineu fascla to Coopers ligament is clearly showa la this Sgure. The cretaaster muscle is usually left in place but is resected in this figure to more clearly show the femoral sheath d Tuz IARNIA Reram (ADDOMINAL INCITYAL RINC REPAD) The mattress sutures which re-establish normal anatomy by approximating the transversalis fascia to the anterior Isyer of the femoral sheath have been placed and tied Because the Inguinal portion of the round ligament has been semoved with the peritoncal sac the abdomiau inguinal ring is completely closed it is the opinion of the author and of his wynecologic consultants that the cutting of a round ligament is of do consequence as regards sube port of the uterus. The removal of tbe structure that parves through the abdominal inguinal sing makes for a very alm. ple type of berpla repair the layers are easily dealifed and this type of heraloplasty is ideal for the youdy sus from who I fust beginning to tussle with the rigtos of the hemla problem. 20 Cremaster (out) Closure of d obd ang ring ·arate aperturc mcdial to the cord The author the abdominal inguinal ning and makes for a nice usually doubly ligates these vessels, cuts them anatomic demonstration of the continuty of and includes thuis little foramen the closure the transversalıs fascia into the anterior layer of of the abdominal inguinal ring The lateral limb the femoral sheath It is an ideal teaching case of the lateralmost mattress suture, or a separate for the beginner in hernia surgery If one at single loop suture fixes the cord fasciae to the tempts to save the round ligament it is fretransversals fascia to prevent preperitoneal fat quently difficult to avoid tearing the penitofrom slıdıng through the ring which could be neum as it is reflected over the round ligament the entering wedge for another hernia through and still obtain a high ligation of the sac One the abdominal inguinal ning usually ends up with a defect in the side of the This concludes the operation for the small sac formerly occupied by the round ligament indirect inguinal hernia The cord is dropped in that is similar to a sac from which a sliding against the posterior inguinal wall and the ex hernia has been removed While leaving the ternal oblique aponeurosis closed over it mak round ligament is technically feasible it is an ing a snug subcutaneous inguinal nng This te unnecessarily complicated maneuver when the stores the important normal obliquity of the in simple expedient of removing the round ligaguinal canal ment with the sac is an alternative This series also gives the author the oppor MEDIUM INDIRECT INGUINAL HERNIA tunity to show a pedunculated process of pre- The postenor view of the inguinal region is peritoneal connective tissue and fat that ac essentially the same as for the small indirect companies the peritoneal sac down into the ininguinal hernia and is not repeated In its place guinal canal These fatty protrusions are very a diagrammatic figure is presented to demon common in indirect inguinal hernias in both strate the incision that is used for all inguinal seres may be multiple may be the presenting and femoral hernias irrespective of size The lo part and form the bulk of the hernia are concation of thus incision and its extent are de- fusing to the unınıtiated and unless they are rescribed in the legend It is shorter than the clas moved prevent adequate closure of the abdom sical oblique incision but because of its place inal inguinal ring Furthermore if they are left ment it is adequate and because it follows the in place they can be the entering wedge for the Ines of skin cleavage it gives a superior cos. recurrence of a hernia through the abdominal metic result The upper portion of the usual inguinal ring incision that bisects the angle formed by the The dilated abdominal inguinal ning as shown linea semilunaris and the inguinal ligament is in this series (Fig c) is intermediate between beyond the field of operation but necessary for the designations of small and large indirect in adequate mobilization of the shu flaps gunal hernia and is the upper limit of size that This indirect inguinal hernia in the female can still be repaired by simple closure of the is presented for several reasons first it per abdominal inguinal ring ( ABDOVINAL INCUI mits a demonstration of the closure of the ab NAL RING REPAIR") It also shows the direction in dominal inguinal ring unencumbered by the which an enlarging abdominal inguinal ring spermatic cord passing through it second it expands Compare the size of the defect in demonstrates the management of a peduncu (Fig c) with (Fig c) in the preceding plate lated process of preperitoneal fat and connective and (Fig c) in the following plate As long as tissue and third, it shows a dulated abdominal the expanding abdominal inguinal ring does not ingwnal ring that is the upper limit of size that extend over into the area of direct inguinal can still be closed by the simple technique of hernia and attenuate the transversus abdominis "ABDOMINAL INCUINAL RING REPAIR aponeurotic fibers that insert into Cooper s liga Since the loss of support of the round liga ment, the defect which is the enlarged abdom ment does not adversely affect the patient or al inguinal ring can still be repaired by the the support of the uterus removing it with the procedure of "ABDOMINAL INGUNAL RINC RC pentoneal sac greatly simplifies the closure of PAR" (Fig d) 21 >>> ·a Ext oblique apon Plate XII LARGE INDIRECT INGUINAL HERNIA a Posterior view of the right inguinal region Lo a mise Rectus abdul ransv abd m.and of large indirect Inguinal hernia The peritoneum and the m fasc. pon preperitoneal connective tissue have been removed to show -Cord the all important aponeuroticofascial defect. If the heraia were larger the inferior epigastric vessels would be pushed Femoral sheath even farther medially and would Le behind the rectus ab Enlarged abd. dominis muscle Also in the very large variety of this type ing! Log of hernia the medial margin of the abdominal ring world abut agaiast the lateral margin of the rectus abdominis "Coopers lig muscle From this figure and projecting even further en largement of the abdominal inguinal ring it should be b Relaxing incision Int obliquem apparent that the large induect inguinal hernia destroys the posterior Inguinal wall fust as effectively as a large transv abd apon duect inginal hernia atténuated by b Antenor view of the right inguinal region la a case herria) of large indirect inguinal hernia The enlarged spermatic cord due to the contained hernial sac and hypertrophied musculofascial layers is retracted to show the bulglag ds lated abdominal inguinal ring which extends over into the region of direct Inguinal herniation. The transversus ab Cooper alig dominis aponeurosis and underlying transversalis fascia which surrounded the normal abdominal inguinal ring have Pectinaus m fasc been attenuated and pushed out to form the fascial lavest ment of the base of the cord The solid line marked by the Inguinal lig asterisk indicates the incision that is made to excise the thinned out portion of the posterior laguinal wall. It begins at the abdominal inguinal ning and ends at Cooper s Liga Relaxing incision ment and should leave a strong margin of transversus abdominis aponeurosis and fascia superiorly which is to be Hernal defect used in the repair of the hernia In this hernia the incision ends at about the midpoint of Cooper s ligament but in the Coopers lig very large variety of indirect inguinal hernia it ends at the pubic tubercle because the entirety of the posterior to guinal wall has been destroyed The dotted loc labeled Sac "relaxing incision“ shows the point in the rectus sheath that is incised to gain mobility of the new posterior In lugated guinal wall. With the external oblique aponeurosis reineus m fasc tracted this incision is made fust off center from the mid line and extends from the body of the pubic bone superforly femoral sheath for a distance of 4 to 8 cms depending upon the stue of the defect to be repaired It is usually necessary to inciso Inf epigastrica v the accessory slip or sheath that encases the pyramidalis Kinguinal lig Ext muscle to obtain free sliding of the sheath. In 3% of patients iliac v a the wall will not slide because of the direct Insertion of trans) ersus abdominis aponeurotic fibers into the lateral margin of the rectus abdominis muscle c. The incislop outlined by the solid line to the above figure has been made and sell attenuated aponeurosis and fascia excised The margin of the anterior femoral sheath is clearly delinealed from the abdominal inguinal ring to Cooper s ligament and the after cleaned of the attached and fragmented posterior Ingulaal wall. The peritoneal ac has been dissected free from the cord structures Ugaled » high as possible and excised Alkough the dissection of the Rectus abd m peritoneal sac is begin before the weakened posterior wall is excised its final dissection is postponed until the attentu ated fasciae of the posterior wall are crcised and to the way a much higher lication can be obtained because of the additional carrosure The relsdng incision las been made along the dotted line indicated to the above bure d. Tic Ilonxu Roi (RECOSITALCTION OF Tyre Pr. TERIOR (XCITVAL WALL) The new and strong margin of the transYeTIUS abdomfnls sponeurorts with faxed trans 20 ndalis on ·LARGE INDMECT INCUINAL HENNIA the pertoneal sac, all prepentoneal connective The large indirect inguinal hemia, especially tissue and fat that has pushed out around the in the obese patient, is usually the most difficult sac, and by excising most of the hypertrophied of all the groin hernias for the surgeon to evalu fascia and cremaster muscle If a varicocele is ate and the preparation of the layers for the present it is also excised repair of the defect is equally difficult The mus It greatly facilitates the dissection of the base culofascial layers of the cord are greatly hyper of the sac if the incision along the line marked trophied preperitoneal fatty protrusions accom with the asterisk (Fig b) is made before the panying the sac are common and a slıdıng her sac is dissected away from the fascial layers of nia is a frequent complication to the manage the cord preparatory to its ligation This in ment of the peritoneal sac Unless the surgeon cision begins at the supenor lateral edge of the knows how to deal with this great wad of abdominal inguinal ring and following the martissue that fills the abdominal inguinal ning gin of the greatly dilated ring incises the juncthe inguinal canal and extends into the scro tion between strong posterior inguinal wall and tum, the repair of the hernia is impossible that which has been attenuated and pushed out This hernia lacks the simplicity of the small around the hernial sac With this maneuver of indirect ingunal hernia and the sharp definition course one has entered the prepentoneal space of layers that characterize the direct ingunal and by a combination of sharp and blunt dissec and the femoral hernia It is not necessary to tion the under surface of the remaining posterior reduce the size of the cord mass beyond the inguinal wall is freed of adherent fat and con margins of the subcutaneous inguinal ring and nective tissue The under surface of the postefrequently it is advisable to leave fragments of rior wall is the transversalis fascia which is adthe pentoneal sac in the scrotum rather than to herent loosely to the transversus abdominis traumatize the vascular fascial layers in an atmuscle and densely to the aponeurosis The intempt to completely remove the sac However cision extends medially and inferiorly in a curv along the course of the inguinal canal and ing line to Cooper s ligament (Figs b and c) through the abdominal inguinal ring it is ab In a hernia of this size the medial portion of the solutely necessary to reduce the size of the posterior ingenal wall is not disturbed if it is spermatic cord to normal limits for a tight and sufficiently strong and intact (Figs a, secure closure of the abdominal inguinal ring After disposing of the sac and trimming the This is accomplished by the usual removal of spermatic cord down to appropriate size the b and c) versalis fascia is first sutured to Cooper s ligament at (1) abdominal inguinal ning us snugly closed as descnbed in The sutures placed approximately 2 mins apart, begin at the closure of the abdominal inguinal ring in the small in the point where the undamaged postenor inguinal wall at direct inguinal hernia If the transversus layer at this level taches to Cooper s ligament and end 3 or 4 mms from the 15 aponeurotic the ſtill thickness of the Layer is of course wall of the femoral vein These sutures are all placed beused but if it is muscular then only the underlying trans fore any of them are tied because it is easier to place the versalis fascia is sutured to the femoral sheath After the sutures through Coopers ligament with the exposure af repair is complete it will be noted that the relaxing Incision forded in the figure above After they are all placed they which was formerly only a shit is now a roughly triangular are then tied beginntag medially and progressing toward defect through which the rectus and pyramidalis muscles the femoral vein The next suture at (2) is called the "tran can plainly be seen. The size of the defect in the rectus sition suture" because it makes the transition from the sheath where the relaxing incision was made is directly deeply placed Cooper Ligament to the more superficially proportional to the size of the hernial defect. The author placed anterior femoral sheath. It approximates the trans has never seen a hernia that was too large to repair by this versus layer to the medial side of the femoral sheath but method of sliding the rectus sheath into the position of the because this is usually a very thin layer it also picks up posterior ungunal wall. The lateral edge of the relating the fascia of the pectineus muscle This suture is necessary incision is sutured to the underlying rectus abdominis mus. not only to restore normal anatomic continuity but to avoid cle only when the latter is tendonous When it is muscular leaving an aperture through which prepentoneal fat can the edge is left to lie free against the muscle The spermatic protrude and lay the ground work for the beginning of a cord is then dropped in against the reconstructed posterior recurrent bernia The transversus layer is then sutured to inguinal wall and the external oblique aponeurosis closed the anterior layer of the femoral sheath at (3) until the over it making a snug subcutaneous Loguinal nog 23 ·Peritoneum of Ilcum Plate XIII SLIDING HERNIA Because a sliding hertua is so frequently encountered by the large indirect inguinal hernus thus plate is presented The management of the sliding hernia is simple of one understands the mechanism of its occurrence. Although the gradual transition of a small indirect inguinal hernial sac into a large scrotal sac is in part due to the stretching of the pre-existing sac, it is due in greater measure to the pulling down or sliding of panetal pertontum into the hernia in those instances when the cecum 15 a fixed viscus without a mesentery or the sigmoid colon has a sery short mesentery it is easy to see how these viscera become a portion of the wall of the hernial sac After the peritonew of the sac is incised as shown (Fig a) the viscus must be freed in the avascular prepentoneal layer adjacent to the mesentery or the mesenteric vessels will be damaged with resultant serious hemorrhage The surgeon who does a very high lgation of the sac will see more slidiog hernias than is generally indicated Cecum Ext. oblique apon Retrocecal fat b Cecum peritonealized a Suding hernia of the cecum in a case of right indirect inguinal hernia. The cecum and its visceral peritonem actually form the inferolateral wall of the hernial sac To reduce the cecum and not incorporate it in the begature of the hernual sac ít must of course be freed from the sac of the hertua This is accomplished by a horseshoe shaped in CISION which follows the line of reflection of the peritoneum of the sac up onto the cecum. The open end of the horse shoe embraces the ascending colon within the fascial mar gins of the abdominal inguinal ring The first suture in the Dentonization of the cecum is placed b Shows the peritonization of the cecum completed by interrupted fine silk sutures and the defect in the berntal sac formerly occupied by the cecum c Shows the cecum reduced into the peritoneal cavity The purse string suture is started and will be continued around the circumference of the neck of the bernial sac This is not considered the final closure of the peritoneumn but simply a means of gathering the margins of the Deck of the sac together for as high a ligation as possible. The purse string suture invariably leaves folds of peritoneum through which omentum or a portion of a bollow viscus could protrude and additional ligature of the sac is peces sary by one of several methods Simple encirclernent of the pursed peritoneum would suffice if the ligature would not slip off A sure method of additional ligation which will not slip is shown in the Inset (Fig d) Closure of hernia! sac Cecum reduced d The authors method of secure tigation of the herala! sac After the purse string suture has been tied, the limb of the suture threaded with the needle is taken around the sac 160 at (2) and passed through the base of the sac just distal to the purse-string suture and tied at (2) It is then taken around the sac 180 in the opposito direction at (3) and the base of the rac again transfired. After this the end of the suture at (4) is again tled and the Dertio Deum of the sac distal to the le is mcised A popular method of handling such . sc is to twist It repeatedly and theo suture-ligature the base While this is a npki gethol of dealiag with the sac there is danger of catching Om tum or bowel as the usc is progressively twisted. 24 d ·inguinal ning ragged cdge of the anterior femoral sheath is spected by carefully elevating the lateral edge trimmed to a sharp cican margin (Fig c) from of the relaxing incision and separating the recthe abdominal inguinal ring to Coopers liga tus sheath lateralward to the lateral edge of ment In the process the femoral vein and ar the rectus muscle tery are carefully located but not exposed as The normal obliquity of the ingunal canal is figured Tho inferior epigastric vessels, unless restored by dropping the spermatic cord in injured, usually cause no trouble but may be against the new posterior ingwnal wall and doubly ligated and cut if it facilitates the dis- closing the external oblique aponeurosis over it section of the sac A small artery and vein to with a snug closure of the subcutaneous in the pyramidalis muscle course along Coopers gunal ning ligament and these are routinely cut between DIRECT INCUINAL HERNIA Ligatures to avoid tearing them when suturing to Coopers ligament Aberrant obturator ves A direct inguinal hernia is fundam tally dif sels are frequently present arising either from ferent from either the indirect ingunal or the the external iliac or the inferor epigastric ves- femoral hernia in that it does not protrude sels and if troublesome should be cut between through a naturally occurnng aponeuroticofas- Ligatures As mentioned earlier the external cial aperture While the predisposition to a di spermatic vessels are usually divided because rect inguinal hernia may be congenital in the they prevent tight closure of the abdominal sense that there is a generalized weakness of connective tissue these hernias are acquired When the stage in the operation is reached and consist of a gradual stretching and attenuawhere the sac has been tied and the spermatic tion of the posterior inguinal wall With the ex cord reduced in size, the margins of the poste ception of the funicular type of direct inguinal rior inguinal wall Cooper s ligament and the hernia with a narrow neck and a small aperture femoral sheath sharply delineated and the re through an otherwise intact posterior inguinal laxing incision made (Fig c) the hernioplasty wall these hernias have a broad base with a is quite simply accomplished by suturing the wide nech and a relatively short sac Unless the posterior inguinal wall to its normal attach sac is long and contrary to the usual opinion ments (Fig d) as described in the legend they may extend into the scrotum the direct While placing the sutures and until they are all inguinal hernia rarely strangulates (the futied the prepentoneal fat must be pushed in nicular type excepted) Many middle aged or ward for clear visibilty This is accomplished elderly individuals are seen with either unilat by a small gauze pack and a narrow ribbon re eral or bilateral small pouting types of direct tractor introduced obliquely from the lateral inguinal hernias that cause no symptoms Unaspect of the wound The handle of a long tis less this type of hernia is enlarging and the sue forceps makes an ideal retractor for this patient is physically active herrioplasty is med purpose The sliding effect which permits the dlesome surgery because it exposes the patient transfer of antenor rectus sheath into the posi to the morbidity and mortality of an operation tion of a new posterior inguinal wall is readily that is unnecessary Furthermore when these apparent by comparing figures (c) and (d) hernias appear in the elderly and seem to cause Before the slide the relaxing incision is a mere symptoms the search for a cause of increased sht in the rectus sheath (Fig c) and after the intra abdominal pressure (such as prostatism, slide it is a defect which varies in size directly partial colon obstruction and chronic cough) with the size of the inguinal defect If the rectus and its correction is a more rational approach fascia is not disturbed there is no danger of a than hernioplasty hernia developing in this defect in the rectus A direct inguinal hernia is a breach through sheath The rectus fascia is the medial continua the posterior inguinal wall and irrespective of tion of the transversalis fascia which invests the its size demands "RECONSTRUCTION OF TZE Pos rectus muscle This fascial plane is easily in TERIOR INGUINAL WALL” The details of the op- 25 ·a b Relaxing Incision Int oblique abd apon -Relaxing Incision' Plate XIV DIRECT INGUINAL HERNIA a Postenor view of the right ingunal region in a case of direct inguinal hernia The peritoneum and the preperitoneal connective tissue bave been removed to show Transy abd m the aponeuroticofascial defect and its relationship to the important anatomic landmarks of the posterior ingvina) -Femoral ring wall It should be noted that the abdominal inguinal ring Direct herrial and the femoral ring are normal in size and are in no way defect concerned with the development of a direct inguinal hernia Coopers lig The size of the hernial ring in this case is only moderate Rectus abd m and is purposely chosen rather than a very large direct inguinal hernia so that its relationship to the regions of Ext oblique the other groun hernlas may be carefully observed apon b Anterior view of the night inguinal region fn & case of direct inguinal hernia The bulge of the hernia is covered by attenuated_transversus abdominis aponeurosis and transversalis fascia and as the hernia enlarges this posterior in gwnal wall becomes progressively thinner In this case the spermatic cord is normal in size and there is no associated indirect ingunal bernia nor is there a cocxistant femoral Transv hernia The problem is to remove the thinned out apo neuroticofascial components of the posterior inguinal wall (attenuated (transversus abdominis aponeurosis and fascia) and sub by hernia) statute a strong layer to repair the defect. The solid line Femoral marked by the asterisk follows the junction of stroog pos sheath terior inguinal wall and attenuated posterior inguinal wall Inguinal lig produced by the hernia It begins at the abdominal inguinal ring and extends to Cooper s ligament near the pubic tit bercle The dotted lune represents the reladog Incision in the rectus sheath and its exact location is described in the preceding hernia. Hernial defect c The incision outlined by the solid line in the above figure has been made and all of the attenuated aponeurosis and fascia exclsed down to Coopers ligament and the an. terior Layer of the femoral sheath Care should be exercised that small vessels along Coopers ligament, aberrant ob Inguinal lig turator vessels and the cluster of vessels arising from the external thac artery and vein are not inadvertently torn Coopers lag They may all be ligated if necessary to adequately crpose Pactineus m fasc Cooper s ligament and the femoral sheath but the bleeding that ensues following their accidental injury can be very Femoral sheath troublesome When there is dense scarring along this linc In epigastrica from previous surgery or the injection treatment of the >Extiliac va hernia it is expedient to Ligate these vessels at their origtos from the diac vessels and again distally rather than try to dissect them out of scar tissue Both Coopers ligament and the anterior femoral sheath must be sharply delineated and clean to adequately repair the hernia It cannot be blindly done by pushing the bulge of the hernia back and then trying to suture conjoined tendon" to Cooper s ligiment. In this case the deck of the hernial sac Is broad and there is no question of incarcerated contents the sac is therefore not opened but simply pushed back tato the abdomen. If the direct hernia is of the pedunculated type with a narrow Deck then the sac must be opened and treated as an for direct hernial sac to avoid Icaying incarcerated or even strangulated contents of the sac s pot opened especial care must be taken to rule out & concomitant consil indirect inguinal hernia and even though there is no peritocal diverticulum of a femoral hernia one frequently sees . pedunculated projection of preperitoneal fat in the femoral canal. This should be removed us it is the precursor of a femoral hernia The Telung Incision has bera mude along the line ladicated in the figure abose 28 v ·cration are shown in the accompanying figures normal insertion, which is Coopers ligament and legends and it should be noted that the Reconstruction of the posterior inguinal wall is repair of this type of hernia is essentially the a technically easy procedure (except in the same as for the large indirect inguinal variety obese) if the surgeon is anatomically oriented cxcept that the new posterior inguinal wall is as the author has demonstrated many times in sutured to the entire length of Coopers liga the training of interns and residents The operament from pubic tubercle to femoral vein This tion is an enigma to the surgeon whose ana is necessary because the hernia has destroyed tomic knowledge is based solely on the inguinal the wall up to the lateral murgin of the rectus ligament herniorrhaphes muscle and slides out over the superior ramus Irrespective of the size of a direct inguinal of the pubic bone from pubic tubercle to fem hernia or the number of recurrences the rectus oral vein (Figs a, b and c) In the case of the sheath between the relaxing incision and the small type of indirect inguinal hernia it has margin of the hernial defect (Figs b and c) is been me oned that the suturing of "conjoined invanably intact and there is sufficie aponeu tendon" to inguinal ligament is unnecessary as rosis to slide into the defect for reconstruction of well as meddlesome In the large indirect in the posterior ingunal wall The author has guinal hernia and in the direct inguinal hernia never had to resort to fascial transplants or the the use of the inguinal ligament as the anchor use of wire mesh in the repair of inguinal or ing structure for the posterior inguinal wall is femoral hernias an anatomic mistake as can be seen from con After resecting the aponeurosis and fascia sulting the figures on the Anatomic Plate and thinned out by the hernia delineating the strong opposite (Fig c) Except for attachment of the supenor edge of the postenor inguinal wall, ingunal ligament (locally called the lacunar clearing Cooper s lgament and the antenor fern ligament) along the medial 1 cm of Coopers oral sheath and making the relaxing incision ligament the two structures gradually become the hernioplasty of reconstruction of the pos more divergent in a lateral direction While terior ingunal wall is accomplished (Fig d) sutures placed through the lacunar portion of Before the closure is started one must make abthe ingunal ligament are in effect also attached solutely certain that there is not a coexistent in to Coopers ligament this is not true for the direct hernial sac This is easily determined by remainder of the inguinal ligament which is a the exploring finger if the direct hernial sac has free margin It is not the insertion of the pos been opened but as in most instances where the terior ingunal wall (see Anatomic Plate) nor is pentoneal bulge is simply pushed inward a it a suitable substitute The fact that it has small congenital indirect sac may be overlooked been used for 60 years and the statements to the The structures at the abdominal inguinal ring effect that it is more available than Coopers are carefully inspected for a diverticulum of ligament or that sutunng to Cooper s ligament pentoneum and incidentally for protrusions of is more difficult are not valid arguments against prepentoneal fat in among the cord structures the suturing of the posterior inguinal wall to its Because of the excellent exposure of the region d. THE HERNIA REPAIR (RECONSTRUCTION OF THE Pos As in the preceding hernia there is now a triangular de TERIOH INGUINAL, WALL) The cut margin of the trans fect where the relaxing incision was made It should be Versus abdominus aponeurosis and fused transversalis fascia realized that the aponeurosis used to repair the ingmaal is first sutured to Coopers ligament at (1) beginning at wall defect is rectus sheath (transverse abdominis and in the pubic tubercle and continuing laterally to within 3 or ternal oblique aponeurosis) that has been shifted laterally 4 mms of the medial wall of the femoral vein All of these and infenorly The defect left by this shift is protected sutures are placed before tying any of them for technical from herniation by the underlying rectus muscle and its reasons described before The next suture at (2) is the enveloping rectus fascia which is continuous laterally with transition" suture which appropmates the transversus the transversalis fascia This figure completes the operation aponeurosis and fascia to the medial wall of the femoral and all that remains to be done is to drop the spermatic sheath and the pectineus fascia The transversus Layer is cord in against the newly constructed postenor inguinal then sutured to the antenor layer of the femoral sheath at wall and close the external oblique aponeurosis over it, (3) until the abdominal inguinal ning is snugly closed making a snug subcutaneous inguinal ring 27 ·of the femoral ring it is easy to rule out a fem sion of preperitoneal fat is left in place, suturr oral hernia, but unless the femoral vein is the postenor inguinal wall to Cooper s ligame visualized one may miss a fatty protrusion will not close the femoral nng and the precurso down into the femoral canal If such a protru of a femoral hernia is left in place 28 ·Femoral Hernia or O" FALL TILE groin hernias, the femoral hernia anisms The indirect type is due to the conlends itself best to a demonstration of genital persistence of the processus vaginalis the anatomic relationships of the layers in the the direct type to an acquired defect in the pos inguinal region and their attachments The ab terior inguinal wall and the femoral hernia to a dominal inguinal ring is normal and one can narrowing of the insertion of the posterior in observe the transition of the transversalis fascia guinal wall into Cooper s ligament This coninto the anterior layer of the femoral sheath cept of the interrelationship of the three her without the distortion that is present in an in nias is very important in a consideration of the direct inguinal hernia The surgeon should take proper repair of the defect advantage of this opportunity to inspect the Whether the etiology of a femoral hernia is normal abdominal inguinal ring, for the plabili congenital in origin due to a narrow insertion of ty of the fascia and muscle in the living subject the transversus abdominis aponeurosis (posteis in sharp contrast to the rigdity and fixation rior inguinal wall) into Coopers ligament with of the ring in the cadaver The appearance of a correspondingly broader femoral ring the abdominal inguinal ring in its normal state whether it is an acquired hernia and the in should of course be the pattern for the "ABDOM sertion is secondarily narrowed by pressure of INAL INGUINAL RING REPAIR used in all small the developing hernia the author has never to medium sized indirect inguinal hernias The been able to settle It is perfectly true that it is importance of being able to fashion an anatomi cally correct abdominal inguinal ning is appar not congenital in the sense that there is a pre ent when one considers the relative frequency formed sac yet there is considerable normal Vanation in the breadth of the insertion of the of the indirect inguinal hernia The transversus abdominis aponeurosis and its fasciae as they posterior inguinal wall into Coopers ligament form the posterior ingunal wall furnish the sur with a correspondingly inverse variation in the geon another opportunity to examine normal transverse diameter of the femoral ring Irre anatomic structure in the absence of distortion spective of the underlying etiology the impor by herniation Invariably the posterior inguinal tant point is that the correction of the defect in wall is strong in the area of direct herniation a femoral hernia is to broaden the insertion of when a femoral hernia is present the posterior inguinal wall into Cooper s liga Although the mass of a femoral hernia is ment so that the femoral ring is closed The palpable and visible in the femoral region anatomy texts state that the medial margin of hence the terminology at is in fact another va the femoral ring is the lacunar ligament and it riety of inguinal hernia The anatomic fault that may be this inaccuracy that accounts for the permits a femoral hernia to develop is as truly failure of many surgeons to understand the inguinal in location as that of either the direct proper repair of this hernia While it is perfectly or indirect inguinal variety (Fig a) One should true that in a case of femoral hernia the medial again consult the Anatomic Plate (Fig b) that margin of the constricting nng lies against the precedes the presentation of inguinal hernias lacunar ligament this is a pathologic state It is and note the numbers 1 2 and 3 which repre also true that the lacunar and inguinal liga sent respectively the sites of origin of the in ments when stretched by a femoral hernia limit direct inguinal hernia the direct inguinal hernia the size of the ring and contribute to the rigido and the femoral hernia These three hernias are ty of the ring but they are part of a secondary all breaches in the postenor inguinal wall but at and more superficial ring as can be nicely dem different locations and due to different mech onstrated when the inguinal ligament must be 29 ·a Transv abd apon. -Cord Enlarged -femoral ring Cooper's lig Rectus abd m Int obliquem Plate XV FEMORAL HENNIA & Posterior view of the nght inguinal region in a case of femoral herniz. The pentoneum and the prepentoncal connective tissue have been removed to show the aponeurot icofascial defect in this type of hernia The abdominal inguinal ning is normal in size and the main area of direct ingural herniation is intact however the enlarged femoral ning has encroached upon the base of the posterior inguinal wall The inportant anatomic defect in this type of hernia is that the insertion of the transversus abdominis aponeurosis into Cooper s ligament is greatly narrowed, and conversely the correction of this type of hemia is to broaden this inser tion to normal width and obliterate the femoral ring The femoral hernial defect is always of constant size It cannot enlarge laterally because of the femoral vessels por loferior ly because of the superior ramus of the pubic bone covered by Coopers ligament. It enlarges medially until the more superfically placed lacunar ligament is encountered and may enlarge slightly anteriorly pushing the inguinal liga ment until it becomes taut. The fully developed femoral herria has an unyielding aponeurotic and bony ring which makes this type of hernia so frequently strangulating la char acter Ext.oblique apon Femoral sheath Fascia lata -Inguinal log Trongy abd apon Transvabd apon Femoral sheath. Pectineus m tascia bopers hig b Anterior view of the right inguinofemoral region in a case of femoral hernia. The inguinal region is entirely nor mal except for a slight bulge over the neck of the herntal sac and a broadening of the femoral sheath. The cord has been elevated to reveal the lower inguinal region and to give access to the neck of the femoral hernia The skin and subcutaneous fascia of the lower skla flap are retracted to show the fossa ovals and expose the femoral hernial sac. As demonstrated in the figure above the anatomic defect in a femoral hernia is a narrowing of the Insertion of the posterior inguinal wall (transversus abdominis aponeuros) Into Cooper s ligament by the enlargement of the femoral ring which surrounds the deck of the femoral hernia To reduce the hernia and repair this defect the only satisfac tory approach is through the inguinal region Since there is no weakness of the posterior inguinal wall as seen in a direct Inguinal hernia and no enlargement of the abdominal ioguinal ring as seen in an indirect inguinal hernia oso is not con cerned with an indirect inguinal hernial sac or with weakness or attenuation of the transversus abdominis aponeurosis To expose the neck of the hernla an incision is made along the dotted lipe fodicated by the asterisk The incision begins me dially at the insertion of the transversus abdominis aponeu rosis into Cooper s ligament and then comes up oses the bulge of the deck of the hernia and is continued laterally over the femoral vessels along the line where transversalis fascia be comes anterior femoral sheath. This opens into the preperitoncal space and exposes the femoral vein, Deck of the hernia and Coopers ligament. d Seeligated Ext Tranor abd apon Inguinal light c The incision of the posterior Inguinal wall and fem oral sheath has been opened and the femoral hernia has beco pulled out of the femoral region into the position of a direct foguinal hernial sac (white urtow) in smal fer- Dra) bernias this maneuver is usually accomplished with case but if the hernia Ls of the size Indicatod to the drawinz. or if there is much edema, it can not be reduced without releasing the Ughtly constrictios aponeuroticofascial ning 30 ·cut to release a femoral hernia The inner con broaden this insertion so as to close the femoral stricting nng is the dilated true femoral ring, nng (Figs d and e) It should be noted that the which is the transversalis fascia at the point final result in the repair of the large indirect and where it becomes femoral sheath and re en the direct inguinal hernia is essentially the same forced by transversus abdominis aponeurotic as in a case of femoral hernia Compare the last fibers of the postenor inguinal wall en route to figure in each plate Since the greater portion ther insertion into Cooper s ligament (Figs of the posterior inguinal wall is not disturbed in a and b) The normal femoral ring and its mar a femoral hernia the relaxing incision is usually gins and their relationship to the lacunar liga- not necessary to accomplish closure without ment can be seen in Figs (a) and (d) of the tension and so is omitted If the inguinal liga- Anatomic Plate ment is included in the sutures that approx- Since the posterior inguinal wall is the first mate the posterior inguinal wall to Cooper s ligand only satisfactory bulwark against hernia ament, it is not only an unanatomic procedure, tion in the groun and since the defect in a fem but is accomplished only with great tension as oral hernia is a narrowing of the insertion of is evidenced by the great number of heavy su the posterior inguinal wall into Coopers liga- ture materials that have been recommended in ment, the only rational method of repair is to the past for use in femoral hermoplasty e Cutting into the lacunar ligament medially may sufficiently to reconstruct the medial wall the femoral sheath and relieve the construction to allow reduction but if it does not, closes the angle between the level of the antenor femoral the lacunar portion of the ingunal ligament, or the inguinal sheath and Cooper s ligament. It should also be noted that ligament itself is completely divided with impunity When the incision does not extend into the abdominal inguinal this maneuver is necessary it is interesting to note that ring and therefore closure of the abdominal inguinal ning even after cutting the aponeurotic mguinal ligament there is not necessary in this type of hemma. is still a constricting band of fascia which must be incised and this is of course the fascia of the femoral sheath. After THE HERNIA REI AIR (REATTACHMENT OF THE Pos the herbal sac us in the position of a direct inguinal hernia TERIOR INGUINAL WALL) The posterior inginal wall is the sac is opened dissected free from the prepentoneal sutured to Cooper s ligament along the line of the incision connective tissue and unnary bladder ligated at its base in (b) except that it is camned laterally to within 3 or 4 and ercised. Particular care is necessary in opening a fem mms of the fernoral vein to close the femoral ring and oral heraual sac because the medial wall of the neck of broaden the insertion of the postenor ingunal wall to nor the sac is invariably urinary bladder mal at (1) The transition suture is next placed at (2) and approximates the transversus abdominis aponeurosis to the d Shows the normal posterior inguinal wall retracted pectineus muscle fascia and also picks up the anterior fem which reveals the ligated femoral hernial sac, Cooper s liga oral sheath. The remainder of the closure is then ac ment, antenor femoral sheath and the femoral vessels In complished by suturing the transversalis fascia, or the entire normal anatomy and in cases of indirect inguinal and direct transverstis layer when it is aponeurotic to the anterior Inguinal hernias the femoral sheath curves around the layer of the femoral sheath at (3) This figwe shows the medial side of the femoral vein to continue the continuity operation completed and all that remains to be done is to with the posterior femoral sheath. A femoral hernia so at drop the cord in against the posterior Inguinal wall and tenuates this medial wall of the fernoral sheath that the close the external oblique aponeurosis over it, making a snug contiomty is lost and it should be noted that the anterior subcutaneous inguinal ning A femoral hernioplasty is one femoral sheath disappears medially under the inguinal liga of the most satisfying of all hernia operations to the groin ment (beneath the retractor) This is noteworthy because because there is no shortage of aponeurosis and usually the the transition suture in this hertuoplasty first picks up the posterior inguinal wall is a heavy aponeuroticofascial layer Pectineus muscle fascia and then the anterior femoral sheath The relating incision not necessary 31 ·Lacum STA defect Plate XVI SMALL INCISIONAL HERNIA a Posterior view of the abdominal wall in a case of nght lower quadrant incisional hernia. The incision is the commonly used right rectus incision for appendectomy and was made two years prior to the operation for the fa cisional hernia In this case the defect is divided into two apertures by a bundle of attenuated but still intact aponeu rotic fibers of the transversus abdominis and Internal oblique layers This fenestration of Incisional hernial defects is a common arrangement and results in multilocular berpiai sacs in this case the hemlal sac is blocular (Fig c) What ever the contributing factors may be such as infection, drain sites or failure of suture material, the basic etiology of an incisional hernia is the inability of the closure to withstand the lateral pull of the transversus abdominis and the oblique muscles The arrow indicates the distance that the transversus abdominis muscle fibers have contracted The clefts lateral to the scar and the hernial defects are elongated suture holes due to the contraction of the muscles against the unyielding suture material Scar Herrioplasty inc1310n b Anterior view of the hernia in the lower pole of the old right rectus scar The dark line indicates the incision that is used with the excision of an ellipsoidal segment of redundant skin over the bulge of the hernia Ext oblique Scar. aponeurosis Harrual Sacs Int oblique and transv apon abd Anterior view of the small incisional hernia with the skin and subcutaneous fascia tetracted and the external oblique aponeurosis dissected off the hernia and opened widely in the direction of its fibers This demonstrates the principal aponeurotic defect, which is in the transversus ab dominis and internal abligue layers which are fused at this level to constitute the anterior Tectus sheath it is a bilocular sac because In this case the hernial defect is bridged by a band of Intact aponeurotic fibers Between this figure and the next, the two hemial apertures have been converted lato a single defect by ercislag the dividing band and the bemias 520 opesed ligated and escised in the conventional manner Adhesions between the peritoneum of the heralal #10 and its contents are invariably present and must be carefully dissected free Attenuated aponeurosis and fascia from the margins of the defect are excised back to normal tissue and firm scar in the line of the old Incision. Scar Extoblique d Tie IIERNA Repain. The hernial defect in the metus apon sheath has been closed transversely with Interrupted tuture of either fine silk or stainless steel wtre Thils closure 1 with out tension whereas if the defect were closed in the vertical plane again, the contracted transuersus abdominis and in teraal oblique Layers could only be approdmaled under Int oblique and transv tension, Medially the line of closure extends past the point where the external oblique aponeurosis fuses with the other Layers in the rectius sheath in the upper left hand COTIXT the closure of the external oblique aponeurosis has been started and this is continued in the line of the sponeurotic fibers regalong the small delect in the medial llap of the external oblique aponeurosis. 32 abd apon ·Incisional Hernia AN N INCISIONAL hernia is a type of ventral hernia in a vertical incision is a calculated risk hernia but is distinguished from other However, in the majonty of cases the little ad hernias of the abdominal wall by the fact that ditional time involved in making an anatomi it occurs through a previous surgical incision It cally sound incision and closing it correctly will is difficult to ascertain the true incidence of this reduce the incidence of postoperative wound type of hernia for many reasons but especially hernias because it is difficult to get a long term follow Because the problems of incisional hernioup on a large series An analysis of the available plasty are so complex and because at times statistical data reveals an incidence of incisional there is no good solution to the problem the hernia from 05% to 8% and while it is not the surgeon should so make and close his abdom province of a surgical atlas to discuss the sig inal incisions that the incidence of incisional nificance of this wide discrepancy it is axio- hernia is kept at an absolute minimum The matic that the careful surgeon who follows sound small muscle and aponeurosis splitting appen principles of surgical technique will have a dectomy incision that cuts no muscle or aponeu lower incidence of incisional hernia than the rotic fibers is the perfect abdominal incision In careless surgeon irrespective of the type of in the absence of infection and if accurately closed cision that is used all other factors being equal this incision should never result in an incisional which is of course impossible of attainment the hernia However the limited exposure afforded incidence of incisional hernia is directly related precludes its use for the more major abdominal to the type of incision that is used The ad operations and so a compromise must be made vances that have been made in the past 15 years and some aponeurotic or muscle fibers cut The that permit more extensive and radical surgery larger abdominal incisions should be made in with safety for the patient, frequently obtain ex such a direction that the number of fibers cut posure without consideration for the abdominal is kept at a minimum and with special attention wall and the eventual fate of the incision While to the direction of the transversus abdominis the adequacy of an operation should never be muscle and aponeurosis (see Frontispiece) The jeopardized by inadequate exposure through integrity of this layer must be maintained or an incision that is too small the surgeon should an incisional hernia is certain to develop no be aware that the longer the incision the great matter how solid a closure is accomplished in er the incidence of incisional herniation The the internal and external oblique layers Since old aphorism that the length of an incision is the direction of the fibers of the transversus of little consequence since a wound heals from abdominis are as the name indicates predom side to side and not from end to end is as in unately transverse, all abdominal incisions should accurate as the premise that the more scar tissue be transverse and the musculoaponeurotic fibers in a wound the stronger the wound After a of this layer carefully separated without inter long fatiguing operation rapid and careless rupting their continuity A varying number of wound closure while expedite will greatly in the internal and external oblique fibers must of crease the incidence of herniation urespective necessity be cut and this varies with the posi of the type of incision that is used Every sur tion of the incision and its length Incisional geon is occasionally faced with an emergency in hernias occur through these incisions (05% in which time is the essence and the speed with the authors cases) although not as frequently which an incision can be made and closed is as with the vertical incisions in the rectus important for the life of the patient In this in sheath When they do occur they are repaired stance the greater Likelihood of an incisional with relative ease 33 とり ·Plate XVII LARCE INCISIOVAL HERNIA HU Diaphragm Gostal Wangın 2. Posterior view of the right anterior abdominal wall ta a case of massive Incisional hernia Most of the long right rectus vertical facision has widely separated. The original Incision was a lower right rectus vertical incision for an appendectomy that was extended upward almost to the costal margin to do a cholecystectomy The peritoneum and prepentoneal connective tissue have been removed except for a cuff around the margins of the hernial defect. The dotted line represents the approximate position of the musculoaponeurotic junction of the transversus abdominis ta sormal anatomy and the shaded arrow indicates the marked lateral displacement of this junction in this case of large incisional hernia This represents a truc muscle contracture due to the inability of the original closure to keep the cut tendonous fibers in apposition. The Asterisks Indicate delts In the aponeurosis similar to those shown in the small in cisional hernia. The upper and lower poles of the scar are attenuated but still intact. A hernia of this size presents # problem to which there is no good solution. The delect Ls too long to approximate in a transierse plane and too wide to reapproximate in the vertical plane because the contrac ture of the transversus abdomlous and oblique muscles de unyielding es en under surgical anesthesia. rangu abd, muscle, -apon Hernial cavity Peritoneum Cord Inf epigastric vessels b <Costal margins Incisional hernia b Anterior view of the large incisional hernit. Multiple loops of intestine give the surface a nodular appearance siace they are covered by lime more than atrophic skin and peritoneum The viscera axe lavarlably densely adherent to the peritoneum of the bernts) sac and therefore the sac should be entered with caution or a segment of Lotestiar may be opened. The ellipsoidal skin focislon, indicated by the dark lines cises the atrophic stretched out skla mer the top of the bernal mass This acision of redaodsat and atrophic skin is provisional, and additional skla is usually excised when the skin is closed at the conclusion of the operation. Herrioplasty incison CA 34 ·Plate XVIII LARGE INCISIONAL HERNIA C Mediaflap of redundant aponeurosis perftone Lateral flaply dant apon land WWE of redunt c THE HERNIA REPAIR A stage in the closure of the large incisional hernial defect Prior to this stage of the herioplasty the skin flaps with attached subcutaneous fascia have been developed beyond the margins of the aponeurotic defect and the central portion of atrophic skin excised The hernial sac has been opened vertically for its full length equidistant from the medial and lateral margins of the defect and the constituents of the sac, peritoneum and at tenuated fascia and aponeurosis carefully preserved as a single layer This entails palastaking dissection to release the viscers from the sac and yet not button hole the flaps which must be used in the closure Adherent loops of colon, small intestine and opentum are separated from one another be fore reducing them into the abdominal cavity At this stage in the hertuoplasty the medial Aap of fused pentoneum fascia and aponeurosis has been trimmed to fit the hernial defect and sutured to the lateral margin of the aponeurotic defect with laterrupted No 30 or No 32 gauge stainless steel wire as indicated in the figure A sheet of stainless steel wire mesh is cut to exactly fit the defect and is sutured in place circumferentially as shown. No attempt is made to decrease the size of the defect by pulling and sutunng the flaps under tension as the success of this unanatomic closure depends upon healing without the layers separating at the suture lines Umbilicus d Lateral Flap of redundant aponeurosis and peritoneum Linea alba d THE HERNIA REPAIR. The last stage in the closure of the incisional hernual defect The lateral flap of redundant and fused aponetrosis fascia and pentoneum has been turned medially and trmmed to exactly fit the defect as was done for the previously sutured medial flap The approumaton of the edge of this flap to the medial margin of the defect has been partially completed. It should be noted that these sutures are double loop sutures and that they include the edge of the wire mesh as well as the me dial margin of the defect In position they alternate with the previously placed sutures that hold the sheet of wire mesh in place lo spite of the most careful hemostasis a wound of this size principally involving scar tissue will have a great deal of capillary bleeding and oozing of serum and therefore must be drained Furthermore the metallic wire mesh acting as a foreign body will increase the amount of serum that is formed and accentuates the necessity for drainage Io the authors experience the wire mesh is tol erated better when it is placed between the flaps of the hernial sac rather than in the subcutaneous space as an added layer to the aponeuroticofascial closure an ordinary penrose draia is split lengthwise and one piece of drain left in the space occupied by the wire mesh and the other drains the entire length of the subcutaneous space Both drains are exteriorized through the lower pole of the wound and are gradually removed at the daily dressing so that they completely removed in a penod of sux or seven days After this the drain sinus is probed daily until serum ceases to form. The subcutaneous fascia and skin are each closed with a single layer of interrupted fine silk sutures 35 ·The great majority of incisions through the the strength of collagenous fibers of a tendon or abdominal walls of the American people are an aponeurosis Slowly and inerorably scar tisvertical, transecting both anterior and postenor sue stretches and if this is the only feature upon rectus sheath and therefore most incisional her which the surgeon bases his wound technique nias occur in vertical incisions, due primarily to there will be a gradual stretching and thinning failure of union in the posterior rectus sheath of the scar Fortunately the process is slow and The vertical incision through the rectus sheath if no actual rent easts through the posterior or through the linea alba severs all of the ten rectus sheath most patients live out their life donous fibers of the three anterolateral abdom span without a true hernia developing although inal muscles for the length of that incision After very thin and bulging vertical scars are common closure of the incision and even in the absence place of such aggravating factors as abdominal dis As a group, incisional hernias are the most tension, cough and wound infection the con difficult of all hernias to repair surgically They traction of the transversus abdominis and two are so varied in size and shape and the avail oblique muscles constantly tends to pull the ability of good aponeuroticofascial layers is so wound apart The aponeuroses do not lend unpredictable that one can not categoncally themselves to accurate approximation in the state that a certain operation should be used for way that a round tendon does nor is it possible a given hernia and certainly no single operation to put the abdominal wound at rest as is the will cover all types of incisional hemias Each case with tendons of the hand and so there is con incisional hernia is a problem in itself and the stant tension along the line of closure with fre most suitable repair in a given case must be de quent and sudden increases in tension Every cided at the operating table Incisional hernias surgeon has had the disheartening experience tax the ingenuity of the surgeon more than any of seeing his needle or suture pull out from be- other type of hernia tween the fibers of the rectus sheath in closing It is important for the surgeon to realize that a vertical incision The decussation of the an incisional hernia in a vertical scar represents aponeurotic fibers in the sheath plus the ad a retraction of the aponeurotic fibers lateral to hesive character of the investing fasciae are the the defect and a contracture of the correspond two features which prevent this from happening ing muscle fibers Whenever possible the deroutinely The contraction of the fibers in the fect should be closed along a line parallel with posterior rectus sheath when they are separated the predominant muscle pull which is almost transversely only tends to bring the margins of always in the transverse plane When this is the incision in close approximation The force impossible as in a vertically long oval defect that tends to separate the incision in the an. and the hernial orifice is closed in the vertical terior rectus sheath is the resultant of the pull plane again the closure is always under catremc of the intemal and external oblique fibers sev tension and should be re-enforced with an ered but when the incision is transverse the pull aponeuroticofascial transplant or with wire of the muscles is oblique to the incision and the mesh in the very large defect such as shown in tension is roughly one half that of the vertical the accompanying figures it is a mechanical im Incision In the vertical cision one must not possibility to approximate the margins of the only consider the pull of the muscles on the hernial ning and one must resort to a closure by side of the incision but their counterpart on the substances other than homologous tissue Vari opposite side of the abdomen ous substances that have been used in the past It is probably true that the rent that permits will not be reviewed for the author considers the incisional hernia to develop occurs in the the wire mesh available today to be superior to carly postopcratic period although it may not substances previously used become apparent for months or years but addi For this section on incisional hernias only two tive to this is the gradual stretchung of the scar types of heraias are presented but they repre- Scar tissue has no clasticity and does not have sent the extremes In between the small and the 38 ·very large incisional hernia shown there is such Except for the cases in which there is a total a variety of aponeuroticofascial deficiency that separation of the wound in the early postoperait is impossible to describe an operation that tive period with a massive defect most incision would be suitable in every instance However al hernias begin as small defects frequently at of the surgeon follows the basic principles out the site of a drain The nght lower quadrant lined in the foregoing paragraphs has a reason vertical rectus incision is the most common able degree of ingenuity and is thoroughly fa erample of this and next in frequency is the miliar with the anatomy of the abdominal wall nght upper quadrant vertical rectus incision for a solution to the closure of the defect is usually cholecystectomy Another common site is the apparent Whenever possible the layers should upper end of a suprapubic midline incision in be developed individually and closed along the the vicinity of the umbilicus It is probably true natural lines of musculoaponeurotic stress as that most of these hernias are seen by some outlined for the small incisional hernia shown physician while they are still small and rela- However, when this is not possible or practical tively asymptomatic but it is factual that most as is frequently the case in the group of moder ate sized defects no attempt is made to free up til the neck has enlarged and there is considerof these hernias are ignored for a long time un individual layers they are left in the fused state able mushrooming of the sac in the subcutaneand handled as a single layer with an overlap ous layer It is easy to understand the reticence ping vest over pants" closure in the transverse plane in a manner similar to the closure of mod of the patient to submit to an operation for such erate sized epigastric and umbilical hernias a small relatively asymptomatic defect and the The peritoneum is left attached to the fused physician may be reluctant to urge prompt reand scarred aponeuroticofascial plates without pair especially of the original incision was his any attempt to accomplish a separate closure of However, it is in this stage that these hernias the peritoneum unless it is loose and mobile but should be operated upon for the problem is this is rarely the case When the hernia does not relatively simple for the surgeon and a minor involve the entirety of the previous incision and procedure for the patient When allowed to it is possible to obtain a transverse closure that develop into the classical incisional hernia with portion that is not actually part of the hernial a large ngid defect in the abdomial wall and a defect is left undisturbed even though the scar large subcutaneous sac not only are they sympmay be thinned out and with some drastasis If tomatic but there is eminent danger of strangu the defect is a vertical oval and cannot be lation Unfortunately it is usually when this closed in the transverse axis then all of the old stage is reached that the patient seeks relief scar is excised prior to closure The reason for and the skill of the surgeon is taxed to the limit leaving an attenuated portion of the scar when to fashion a new abdominal wall the hernial defect can be closed transversely is The massive incisional hernia shown in the that the author would prefer to perform a sec accompanying figures presents a problem to ond operation in the future if another hernia which there is no good solution Irrespective of develops in the remaining scar and also close the substance used to reinforce the closure, the secondary hermua in the transverse plane The whether it be wire mesh or homologous aponeu reason for avoiding a vertical closure of these roticofascial grafts the end result is scar tissue defects should be obvious The original incision and because it covers such a large area it will was vertical the defect represents a retraction inevitably stretch to an alarming degree The and fixed contracture of the transversus abdom patient should never become obese and should inis and oblique muscles lateral to the defect at all times wear a firmly supporting abdominal and vertical closure will be under greater ten girdle or corset Weight reduction prior to opsion than the original surgical closure The in eration is an absolute prerequisite for the obese cidence of recurrent herniation in this group is and the prognosis should always be guarded One of these large defects closed with the aid 37 excessive ·of a sheet of wire mesh may feel very strong aponeuroses of the hernial sac The subcutaneand firm in the first months after operation, but ous space as well as the space occupied by the this should not lull either patient or surgeon wire mesh should be drained because of the into a feeling of false security, for eventually the accumulation of serum which always occurs wire mesh fragments and the sole support for The author uses a penrose drain split length the wound is the scarred flaps that have been wise putting one portion in the subcutaneous used plus the scar tissue incident to the presspace and the other in the space occupied by ence of the wire mesh If the patient is coopera- the wire mesh, exterionzing both of them at tive in the years after such an operation and no the inferior pole of the wound The wound is discrete aperture appears in the closure, these first dressed in 24 hours and the drain started patients get along satisfactorily with limited out Thereafter the wound is dressed daily and physical activity The obdurate patient who at each dressing the drains are moved so that gains weight and returns to hard physical labor they are completely out in sıx or seven days is doomed to recurrent trouble After this the drain site should be probed daily In the authors experience, there is less serum until there is no further accumulation of serim, drainage and more prompt wound healing of the usually 12 to 14 days In the postoperative man wire mesh is incorporated in the aponeurotico- agement of these patients the abdominal wall fascial flaps of the closure rather than adding should be supported by a scultetus or surgical at to the closure so that the mesh lies in the sub corset until the wound is healed Before dismis cutaneous space This is not always possible, but sal from the hospital these patients should be the attempt should be made to save sufficient fitted with a firm girdle or corset and instructed covenng for the wire mesh from the attenuated to wear this support the rest of their life 38 ·Lumbar and Pelvic Hernias UMBAN JIENNIAS are hernias through the lum versus abdominis and internal oblique layers a Ubar region and they are usually subdivided lumbar hernia will develop Conversely, if these unto superior lumbar hernias through the trian layers are intact an inferior lumbar tnangle her gle or rhomboid of Grynfeltt and inferor lum nia will not develop even if a large triangle of bar hernias through the triangle of Petit There Petit is present is such descriptive variation in the superor lum PELVIC HERNIAS In the pelvic portion of the bar triangle that no attempt will be made to figure are two examples of a pelvic hernia These discuss hemation in this region except to say hernias, present in the same specimen had that the layers should be reconstructed separate pentoneal sacs but they were small and conly and as in hernias elsewhere through the ab tained no viscera The peritoneal sacs with a dominal wall, the reconstruction of the transver cuff of pentoneum have been left for better sus abdominis layer is the most important The orientation In the treatment of these hernias inferior lumbar triangle or triangle of Petit is rather constantly present in cadaver dissections after the sac has been pulled out, the defect and with considerable variation in size but the must either be plugged firmly with wadded up exstence of this triangle is in no way associated sac and preperitoneal connective tissue or prefwith the development of a hernia in this erably obliterated by approumating the region margins except of course that the hernia does protrude of the defect In the case of an obturator hernia through the triangle The propensity for the this may be difficult because of the rigidity of development of an inferior lumbar tnangle her the margins of the obturator canal, and in a nia us predicated upon the deficiency either con sciatic hernia great care must be observed lest genital or acquired of the transversus abdominis the superior gluteal vessels be torn or the lumand internal oblique layers In the accompany bosacral trunk of the sacral plexus incorporated ing figure it can be seen that the base of the in the attempted closure Each case of pelvic inferior lumbar triangle of Petit is the posterior hernia will have to be individualized at the time iliac crest and the other two sides of the triangle of operation and the best procedure chosen are projected by the dotted lines marked with Sciatic hernias may also gain egress through the the asterisk The posterior boundary of the tri greater sciatic notch below the pyriformis musangle is the antenor border of the latissimus cle at the location of the stump of the inferior dorsi muscle and the anterior boundary is the gluteal artery in the figure or through the lesser posterior border of the external oblique muscle sciatic notch along with the converging fascicles In this specimen although there is a deficiency of the obturator internus muscle of the transversus abdominis layer as shown at So called internal hernias are primarily a prob (t) the more superficial internal oblique mus lem of the relief of intestinal obstruction and cle is perfectly intact and prevented the devel except for the congenital malrotations of the opment of a lumbar herria Irrespective of the intestine they present no particular problem existence of a lumbar triangle or its size if there from the standpoint of hernia repair and so are is a deficiency of the more deeply placed trans not considered in this atlas 39 ·Ext oblique m Int oblique m Transv abd m Iliac crest Latissimus dorsi m Iliacus m Lumbordorsal apon. Sacrospinalis Quadratus lumborumm Psoas major m Il.olumbar lig -Symphysis pubis Sup gluteal a Obturator int m Pyriformis m OBTURATOR HERNIA Sacral plexus CINNOS Inf gluteal a Coccygeus m' SCIATIC HERNIA Ischial spine Plate XIX. LUMBAR AND PELVIC HERNIAS loternal view of the left lateral pelvic wall and the lower of repairing these hernias This Egure is presented primarily lumbar arca to show the anatomy of the region. Lumbar to show the anatomic relationships of these beralas and also and pelvic hernias are so infrequently seen and the authors because it was an interesting cadaver specimen in which crperience with these hernias has been so limited that it is there were both an obturator and a superior gluteal type felt that nothing can be added to the documented methods of sclatic hernia 40 ·This Book HERNIA The Pathologie Anatomy of the More Common Hernias and Their Anatomic Reparr By CHESTER B MCVAY, MD Ph.D was set and printed by The Oord Bell Press Inc of Ful ton Missouri It was bound by Pantagraph Printing & Statronery Co of Bloomington Illinois The engravings were made by G R. Grubb and Company of Champaign Illnokt The page trim size is 85 * 11 inches The type page is 39 54 picas The type face w Caledonia set 11 point on 13 point The text paper is 70-pound Wartens Olde Style Wove The cover is Roxste LS 5149 21 Blue Morocco Tuo tone BOKS TIOMA L DERSHIRE With THOMAS BOOKS careful attention i gioen to all details of manufacturing and design It is the Publishers desire to present books that are satufactory as to their physical qualities and artistic possibilities and appropriate for their particular use THOMAS BOOKS will be true to those lasos of quality that assure a good name and good will

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