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·HERNIA
BY
SIR HENEAGE OGILVIE
KBE MA M Ch., MD FRCS
Consulang Surgeon Guys Hospital
LONDON
EDWARD ARNOLD (PUBLISHERS) LTD

·©Sir Heneage Ogilvie 1959
FIRST PUBLISHED 1959
Printed in Great Britain by
IV & ] Afaclay & Co Ld, Chatham

·PRETACE I have written this book for two reasons förstly because it gives me the chance to assemble a number of scattered contributions that I have made in the past Secondly because I believe that there is room in thus branch of surgery more than any other for a review that is personal and dogmatic rather than transcriptive and obsequious Having taught anatomy for three years and worked at gencral surgery for ten times that period, I have formed vicus about the anatomy of the inguinal anal that I know to be unorthodox but that I believe to be sound Having operated on many hemiae I have arred at methods of repair that I consider to be rational and that have in my hands stood the test of ame I cannot claim a complete follow up a luxury that is possible only to those who have University Grants or a large private income but I hasc made a sincere effort to encourage the reporung of failures In two closed communities that provide most of my hiemnia patients I think I have succccded I have tried to g1 c rcasons for my recomincndations and equally to give rcasons for my dislikes I have re-used some ideas and occasionally re-used phrases that appeared for the first time in my section on Hemia in Maingot s Post- Graduate Su I anı very grateful to Mr Maingor for perinission to do this

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·CONTENTS
Page
I
7
17
30
58
Chapter
1 The Place of Apparatus
General Principles in the Operative Repair of Hemia
3 Inguinal Hernia
4 General Prinaples in Operations on the Inguinal Canal
s Speaal Problems in Inguinal Ilcmia
6 Inguinal Hemua—Standard Operations that are not
Recommended and Why
7 Hernua belou Poupart s Ligament
8 Herniae in the Rectus Sheath
9 Incisional Hernia
10 Hemiac in the Pelvic Region
Index
71
90
109
122
1.8
133

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·CHAPTER 1 THE PLACE OR APPARATUS A hernia is defined as the displacement of an organ from the cavity in which it is usually contained through an opening in the walls of that cavity The term is normally used in connexion with hermation of the abdominal contents through the abdominal parictcs and the opening through wluch hertuation occurs is either a natural foramen or channel through whuch blood vessels or other structures leave the abdomen, or the site of some injury Thus the common herual sites are the inguinal and crural canals the umbilicus the ocsophageal luatus in the diaphragm and the scars of operations or war wounds When hoscier prolonged or repeated increase of abdominal pressure coinades with general wasting almost any of the fibrous junctions in the abdominal wall may give way Thus in the old and debilitated inmates of geriatric institutions whose abdominal walls wasted by discase and malnutriton, are subjected to the strain of constant coughing it is not uncommon to find four distinct hernias in cach groin protrusions through the linca semilunaris and under Poupart sligament lateral to the femoral artery in addition to the more common inguinal and femoral ones A patient sometimes comes for advice about a large hernia which he has noticed acadentally only within the last few days though he has clearly had it for months or years Another will say that lic has known of the swelling for several years but he did not report it carlier because it has given him no trouble and has not increased apprccably in size Usually however a hemia causes some disability from the start in any case when a surgeon has discovered a hemma whether or not it appears to be giving trouble he must advise control or curc that is some retentive or protective apparatus or an operation No herrua left to itself will undergo cure nor can it be guaranteed to remain stationary or even tolerable for any length of time The hernia is the result of abdominal pressure acting on a weak spot Abdominal pressure is a continuous force keeping the viscera in position against I ·2 HIERNIA the force of gravity daving the blood in the great veins back to the heart and aiding the retum of the diaphragm after its descent It is increased in order to expel the contents of the abdominal or thorac viscera, in vomiting micturition defaecation, partungon and coughing or to fix the trunk as a base for the limbs in muscular work With this force constantly acting any hernia is bound to increase in size and the hernia in turn will tend to inhabit or interfere with abdominal movements and to give a sense of insecurty during any strenuous exertion To these disabilities is added the danger of strangulation present at all times in some hernuae appearing only later in others Thus no hernia may safely be disregarded and some form of treatment should be urged as soon as the diagnosis is certain Because it is inherent in human nature to avoid any course that involves risk, pain expense or loss of time many patients will wish first to discuss the question of a truss The success of surgical repair in herniae of moderate size is sufficiently well known to induce the majority of active and healthy men to demand operation On the other hand the skilfully worded advertisements of those who claim to build up the tissues by patent apparatus most of which are rather clumsy trusses relying on rubber bands instead of springs obligc thc surgeon to discuss in simple terms the Pros and cons of trcatment by apparatus In general terms it must be pointed out that a truss must not be expected to cure a hemia but merely to retain it It must be worn permanently not merely for the rest of the patient s waking active life but in most cases at all times of the day and night It is therefore iksome to an extent that vanes with the sensibility of the patient the type and strength of the apparatus that he requires the nature of his work, and thc delicacy of his skin. It is effectie only if it is made exactly worn constantly kept in repair and renewed when weak. It is more cffcctise in some types of hernu than in others but in all it is liable to produce some degree of pressure atrophy and therefore to become less effective with ume On these gencral grounds alone the adoption of apparatus should be discouraged in the young and healthy The place of the truss Two questions are often asked. Can a truss cure a heruar and Can a well made truss retain a herniz prevent it enlarging and allow work in rcasonable comfort without the risk of strangulaton?

·TIIT PLACE OF APPARATUS A truss may be able to cure an inguinal or an umbilical hernua in an infant but thiesc alone A congcrutal inguinal herua is duc to the fuersistence in whole or in part of the proxessus funicularis or the canal of Nack, diverticula from the coclomic cavity that normally remain patent just before binh Persistmice of the peritoneal pouch after this somewhat arbitrary date is evidence of delay but not necessanily of failure in chic process of obliteration luch may take place some wecks or even montlus later Such a natural cure is possible only of the empty sac is ncier distended A truss muse thereforc be well made and must be som day and night for the firse year Asken of wool truss is perfectly useless If the hcmia comes down during this trial period the clunce of cure is probably lost and if it appears after a year natural closure is no longer possible It has been stated that the prolonged u caring of a truss may bring about the natural curc of an inguinal hemia cven in adult life through the oblitcrauon of the sac at its neck by adhesions It is however most unlikely that adhesions will occur cxialy at the ring or that they will obliterate the lumen completely Adhesions that follow the saning of a truss are usually between the sac wall and its contents and not at the neck of the sac but half an inch or so farther down further they are usually bands or partial adhesions Such attempts at repasr have no valuc in prevenung the entry of bowel into the sac but rather favour strangulation if it docs come down The second question whether a truss can rctain a herma with comfort and safety can only be answered with regard to particular hemiae Joblique inguinal hernia If the hernia is an carly one that is if the neck is small the internal ring neither stretched nor displaced inwards and if the muscles arc good or put in another way of the hemia when reduced with the patient standing will not come down unless he coughs strains or walks about it can be retained by a well fitung cruss against any but the most violent straining efforts On the other hand, this Турс of hemia is normally seen in hicalthy young men dit is onc for which a simple type of operation is sufficient and in which a permanent cure is almost certain. In proportion as the hernia is old the internal ring cnlarged the muscles weak or the patients occupation a strenuous one a truss will be less effective The continued pressure of a truss tends in time to produce atrophy of the inguinal muscles, thuckening ·2 HERNIA the force of gravity driving the blood in the great seuns back to the heart and aiding the retum of the diaphragm after its descent It is increased in order to expel the contents of the abdominal or thoracic viscera in vomiting muctunition defaccation, parturition and coughing or to fix the trunk as a base for the limbs in muscular work With this force constantly acting any herria is bound to increase in size and the hernia in turn will tend to inlubit or interfere with abdominal movements and to give a sense of insecurity during any strenuous exertion To these disabilities is added the danger of strangulation present at all times in some hernuae appearing only later in others Thus no hertua may safely be disregarded and some form of treatment should be urged as soon as the diagnosis is certain Because it is inherent in human nature to avoid any course that involves risk, pain, expense or loss of time many patients will wish first to discuss the question of a truss The success of surgical repair in herniac of moderate size is sufficiently well known to induce the majority of active and healthy men to demand operation On the other hand the skilfully worded advertisements of those who claim to buld up the tissues by patent apparatus most of whuch arc rather clumsy trusses relying on rubber bands instead of springs oblige the surgeon to discuss in simple terms the pros and cons of treatment by apparatus In general terms it must be pointed out that a truss must not be expected to cure a hernia but merely to retain it It must be wom permanently not merely for the rest of the patients waking active life but in most cases at all times of the day and night It is therefore irksome to an extent that varies with the sensibility of the patient the type and strength of the apparatus that he requires the nature of hus work and the delicacy of his skin It is effective only if it is made exactly wom constantly kept in repair and renened when ucak It is more cffective in some types of hemia than in others but in all it is liable to produce some degree of pressure atrophy and therefore to become less effective with time on these gencral grounds alonc the adopuon of apparatus should be discouraged in the Young and healthy The place of the truss Two questions arc often asked Can truss Cure a herust and Can a well made truss retain a hernua prevent it enlarging and allow Work in reasonable comfort without the risk of strangulation ·Tur Lact Of AFTARATUS A truss may be able to cure an inçitinal or an umbilical lemia in an infant, but thicsc alone conşeital inguinal hcmia 11 due to time persistence in whole or in part of the proxruit fumculans of the canal of Nock, diverticula from the coclamic cmt; uut normally remuain parent till just before birth l'ersisimce of the penionesl pouch after this somewhat arbitrary date is evidence of delas, but not necemu sanly of failure in the proxess of obliteration which tray wke isce some socks or even months later Such a natural cure it puble oily of the empty ut is noiet distruded A Inuss must thicsfore be well made and must be worn day and niplit for the fine car A skan of wool truss is perfectly useless If the hermia come down during this inal period, the chance of curc is probably lost and iſ te afprin after a year natural dosure is no longer pouble Ic has been stated that the prolongad ni caring of a truns may brine about the natural cure of an inguinal hernia cum in adult life through the obliteration of the sac at its neck by adhesions It is lourvey most unlikely that adhesions will occur exactly at the ring or that they wall obliterate the lumen completely Adhesions thus follow the "caning of a truss are usually between the suc wall and its con the and not at the nech of the sac but half an inch or 10 Carther down further they are usually bands or partial adhesions Suh attempts as repair have no value in presenting the entry of bouclinto the uc boss rather favour strangulauon if it does come down The second question whether a truss can retain a hemu with mr an fort and safety can only be answered with regard to parucular hemus Joblique inguinal hernia If thc hernia is an catly one that is if the neck is small the internal ning neither stretched nor displaced inwards and if the muscles are good or put in another way sf the hernia when reduced with the panent standing will not come down unless hic coughs strains or walks about it can be retained by a scll fitting truss agunst any bur the most violent straining efforts On the other hand thus tyre of hernia is normally seen in healthy young men fot is one for such a of operation is suffiaent and in which a permanent cure is almost certain in proportion as the hemia is old, the internal enlarged the muscles weak or the pauents occupation a strenuous ring one a truss will be less effective The continued pressure of a truss tends in time to produce atrophy of the inguinal muscles thickening simple type ·4 HERNIA in or of the sac near the internal ring and adhesions between the sac and its coverings and contents Such changes have two results Abdominal contents coming down into a hernia pressed on by a truss are more likely to become strangulated and an operation for repair when it is reqwred cannot rely upon simple removal of the sac but must include some plastic manoeuvre to reinforce the inguinal canal Direct inguinal hernia direct herua unless it is really large is particularly suitable for a truss It appears late in life it tends to enlarge very slowly it can be retained by the simple backward pressure of a pad and when so retained it will not cnlarge appreciably over many ycars The sac is a wide-mouthed bulge and there is no tendency for adhesions to form round it or for bowel to be trapped in it Many seamen and general labourers are able to carry on their strenuous callings wearing double inguinal trusses for direct hera without appreaable loss of efficiency Femoral hernia In inguinal hernia a truss is often effective and it is discountenanced merely because it is unwisc In femoral hernia on the other hand a truss should be recommended only for excepuonal reasons The hau ker of patent apparatus will claim to curc all herniae femoral as well as inguinal but a survey of the anatomical features of femoral hernia will throu considerable doubt on the ability of any apparatus however ingenuous to control such a hernia The inguinal canal belongs to the trunk and a well fitting truss embracing the pelvis will lie securc dunng all movements and main. tain a constant and even pressure on the weak spot The femoral canal is in the thigh and all movements at the hip joint must necessanly displace a pad lying over the saphenous opening and attached to a spring or girdle enarcling the trunk. Even us cre it possible to maintan even pressure by a fruss on the crural canal (as it would be for instance in a patient with an ankylosed hip joint) such pressure would be cffccave only on the fundus of the sac and the distal half of the canal The neck of the sac and the abdominal end of the canal lie behind and above Poupart s ligament where any pressure short of that which would obstruct the femoral citiis powerless to present entry of abdominal contents into the hernia. the ·Tiit TLACT OP APPARATUS The potential dangers of a femoral hernia arc far greater than those of any other tyro Strangulation is common progresses more rapidly to gangrene and is more fatal in its outcome truss should never be ordered or allonaiamif the patient suggests it except in the unusual asc of a vide-mouthed and casily reduable swelling in a patient so old and focble that an operation csen under local anaesthesia is considered unufc Umbilical lemia In the umbilical hernua of infants a belt with a pad or arm a homenude teenuse apparatus of strapping will norinally retain the protruston and effect a curc by the end of the first car Ilerc the abdominal wall is normal right up to the edge of the onfice there is little subcu. tancous fat, and the pad will remain in position over the opening and keep the sac empty The umbilical ficruac of adults are a different problem The whole abdonunal wall us sagging the linca alba is stretched the hernial onficc 18 a somewhat indefinite opening in the fasaal layer oftcn multiple and lying bencath a thick layer of far the sac is lobulated and the contents are usually adherent to it and reduable en part only if at all It is difficult to maintain a pad in the correct position or to apply its pressure to the ring and even if thc hemia can be reduced and kept back, ur sall slıp pase the pad with any cxtra cxcrtion or sudden moven ment of the abdominal wall Because of the liability of these hemiac to strangulace and the high mortality of strangulapon a truss should be advised only for small and completely reduable sssellings in cases where the risk of operative repair is considered prohibitive Incisional hernia The officiency of a belt depends enurcly on the size and character of the hertua A wide bulge involving the whole scar can normally be retained by a belt alone or by a belt with a pad over the protrusion It will not increase in size and the belt will allow a fairly normal life and a considerable degree of exertion When on the other hand the sac has a large fundus with a narrow neck passing through a small aperture in ngid scar tissue control by any form of pad is uncertain and strangulation on account of the defiaency in the peritoncal Linung and the many adhesions is extremely likely ·6 HERNIA UP The place of apparatus in the treatment of herna The foregoing remarks may be summed as follows I A truss should be ordered (a) As a possible method of cure in all inguinal and most umbilical hermae of infants during the first year of life Operation should be undertaken dunng this penod only for progressive incrcase in size in spite of conscientious use of the truss by the mother for inability to wear the truss owing to skin soreness or other reasons or for threatened complications (b) To prevent increase in size and avert the risk of strangulation in cases where operation will be undertaken at a later date In inguinal and umbilical herniae of infants from the end of the first year after which a cure can no longer be expected) till the carliest suitable age for operation (in my opinion four years for ingmunal and two years for umbilical hernia) In reducible oblique hemia in adults when operation is advised but postponed for social or economic reasons or on account of local or general disease () As a safeguard after an emergency or limited operation which cannot be regarded as a mdıcal cure In many operations undertaken for strangulation or in the aged for thrcatened strangulation, the sac is removed but the measures that would appear necessary to render the herual opening proof against future yielding have not been carned out because of the condition of the patient In such cases a truss with quite light pressure is usually sufficient to prevent a recurrence (2As the only possiblc safeguard in all reduable heruac when operation is out of the question. 2 A truss may be permitted In most direct ingunal hemiae and many inatsional hemiae where the patient is a poor operative risk. 3 A friss should be discouraged In oblique inguinal hernia in a healthy patient 4 A truss is dangerous In femoral herrua in the umbilical hernize of adults in irreduable inguinal herruse and in inasional herniac with a large sac and a small rigid opening ·CHAPTEN 2 GENERAL PRINCIPLES IN TIR OPERATIVE REPAIR OF VERRIA Flemua surgery is highly important but it is not dramatic surgery Some operations save life or restore a sick man ta reasonablc health and adequate working epony by srcasting the anatomy and function of thc parts affected by discase flernia surgery restores form and function to nonnal and returns a temporarily incapacited luman being to full health and caring areats Jernua operations require no special technique beyond that of good surgery the division of structures by clean cutting the definition of planes without blunt dissection or forable retraction the avoidance of nerves and major blood sessels meticulous haemostasis and the obliteration of dead space and the approximation of donded structures without tension and without strangulation by sutures of the finest diameter companble with strength The basic prnaples of hernia surgery are simple the removal of the sac to its neck and the closure of the hertual opening at its commencement of these mo demands the second is the more important There may be no sac, the sac may have nieck or it may be so short and wide that removal is unaccessary bur, except in certain instances secure cosure of the bemal onficc is an indispensable step without which removal of the sac is of no more than temporary value The chuc exception is an oblique inguinal hernia with a congereal sac into which contents have only recently or occasionally descended. in such a hernia there is no hemial onfice in the sense of an abnormal opening The internal inguinal ring is a normal structure that only becomes abnormal when it 13 stretched in a herma of the type under discussion it is only the structures passing through the ning that are abnormal There should be vas vessels and nerves only but in such a case there is in addigon a thin-walled and collapsed pentoncal tube If this peritoneal sac is removed without trauma all abnormality 15 removed with it and the inguinal segon becomes normal 7 ·8 HERNIA In all other cases however the opening is an abnormal one which must be securely closed after removal of the sac. The method required for closure will depend upon the size of the opening the nature and strength of the tissues that bound it and the strain to which they are subjected In some cases the tissues in the neighbourhood, drawn aghter by absorbable sutures will provide satisfactory repair In others the closure must be reinforced by drawing down adjacent assues or by turning in flaps from structures in the neighbourhood In others free transplants of living connective tissue from some other part of the body may be used to repair the defect In others again unabsorbablc foreign material may be used The principles alone of these different methods can be discussed here, their detailed application must be left to the sections dealing with individual hemiae In most surgical operations catgut is used today for all deep sutures The value of catgut is that it is absorbed when its work is donc leaving notlung but living tissues at the site of operation It must be pointed out that the work of catgut indeed of all sutures is one of approximation only No sutures even unabsorbable ones can keep tissues together against a tension tending to separate them for more than a short time In the presence of continued tension, sutures if not absorbed will cut out and the parts will return to their orginal site unless they are fixed by the permanent agency of living connectic tissue Thus there is little value in the stouter sizes of argut indeed in this material size is little indication of strength In my experience No o and even No oo is usually as strong as No 1, and the sizes above No I are often weaker and more unreliable than the finer oncs while they cause a greater reaction Kangaroo tendon provides an absorbable suture material of greater strength than catgut While this strength gives it a place in bonc surgery its bulk and the insecurity of the knots aed with it make it unsuitable for use in hernia repair Soft tissues should never be subjected to a tension greater than can be exerted by sutures of No i catgut Catgut and kangaroo tendon, though they can be absorbed arc not recensed kindly by tissucs Being foreign proteins they provoke a considerable reaction as any surgeon who has been obliged to reopen 3 wound during the first ten days after suture will have been able to ascertain for himself in the presence of infection they resist absorphon and prolong local sepsis till they are discharged. Sutures of Living fasaa were introduced by Gallie and Ic Mesurier ·GENERAL PRIYCIELTS OF OPERATIVT REPAIR 2 in 1921 These surgcons showed that free transplants of connectic tissue could remain alive and keep their structure and strength indefinitely and beconic united to their surroundings by fibrous tissue However if this connectic tissue bond was small in amount or if it was subjected to strain the union between the graft and its bed became stretched By using sinps of fasaa woven into the receiving tissues instead of patches satched to them the graft became incorporated into its bed by a living utuon and displacement s as impossible Gallic sutures are usually taken from the fasaa lata on the outer side of the thigh The sutures strips about $ in wide and the greatest length that the fasaa will allow are seniosed through an inasion about 1. in. long down to the fasaa lata the superfiaal fascia being reflected backwards and forwards for the scquisite distance Alterna ovely serps of fascia may be removed through a small incision at either end of the so-cıbral band by an instrument designed for the purpose These fascistomes arc seldom satisfactory since they are apr to bring out irregular wisps of inadequate length with muscle and lat adhening to them when a number of full-width and full-length sutures are desired, direct exposure is best The fasaal strips are used svith special needles with a wide cyc (Fig 1) One end of the suture is passed through the eye and ucd co itself with fine silk the free end is similarly nied with silk to present splitting in taking the first storch the nerdle is passed through a portion of the edge of the gap to be closed and then through the terminal end of the suture (Fig -) In this way a slip knot is produced that forms an excellent anchor The suture is woven strongly into the edge with as many bites 25 seem necessary and passed backwards and forwards across the opening unul its whole length is used up Owing to the sippery character of the fascia it will be found useful to anchor the sutures at every second or thurd stitch by some form of knot (Fig 2) We usually combine a single loop-knot with transfixion When the first suture has been used up a second may be attached to it in the same stay as pieces of tensus gut are fastened together and the sewing conunucd in this way one suturs after another may be inserted until the opening is completely closed. The suture us finally ended by splitting its terminal portion into tho strands which are tied togethes about the suture with a tnple knot This knor should be made secure by transfixing it with a atgut ligature which will hold its loops in contact unul they become firmly healed together H-B ·TO HIERNIA Ogilne needles No 4 (left) and No s(nght) Gallie s needle (small) Pust Colt s cutting needle FULL 21 Ezt Gallic s necdle (large) Lane s fascial needles Fic I Needles used in hernia surgery There is of course no particular merit in the fibres of the uliotibial band beyond their length and number For limuced operations suitable aponeurotic strips may be cut from the tissues in the immediate neighbourhood of the operative field, such as the external oblique aponcurosis When only a single living suture of great strength is required, the plantans tendon is csen better than a fascial senp In summing up the place of fascial sutures in hemia surgery Ian only express a personal opinion based on considerable experience 1 ·GENERAL PRINCIPLTS or OPERATIVE REPAIR tlunk they have had their day as a ufus crsal method and they should now be reserved for problems that cannot be met in any other way To the saenufically trained theorist fascial sutures are ideal The material is an autogenous transplant u tuch retains its straigth and microscopic structure unimpaired, and sluch is woven into the tissues and becomes incorporated by living bands into their substance which when so incorporated becomes part of them and so shares their resistance to later infection To the practical surgeon who is forced to admit that even thc tcachings of cxpcnmental arunial surgery must be correlated with diucal experimce there are disadvantages Fasaal suture adds an operation on dic leg to onc on the hemia It adds its ume and ses crity and almost prohibius che usc of local anaeschesia The thigh inasion does not often 911c trouble but working men sometimes complain of pain and cakness In post-operative infection fasaal stnps will slough like any other suture material Perhaps the most obvious disadvantage is in the size of the sutures themselves thar excessive width and their inadequate length These strips which must be in. in diameter and the course needics required to carry chem, make a sorry mess of the delicate structures of the inguinal canal particularly Poupart s ligament which is casily separated thercby into disconnected longitudinal scrips They are too short to bridge Silk stitch Soto Threaded suture Start Joining Ending suture Mylene FIC 2 To llustrate the methods of fascial suturc ·I2 HIERNIA the zone of failure in a large direct hernia which extends from Pouparts ligament to the rectus sheath. In my own opinion fascial strips are unsuitable for the repair of inguinal hemia Recurrence is frequent and strangulation through a chink in the lattice of tendinous bands is not uncommon. Further the destruction of Poupart s ligament by the sutures makes any further repair very difficult indeed Fascial strips are excellent for the repair of tendons ligaments and the capsules of joints and of traumatic hemiae in the abdominal wall and diaphragm whose margins consist of tough scar tissue Unabsorbable suture material Because of the mechanical disadvantages of living sutures unabsorbable sutures are being used to an increasing extent today in hemia surgery The materials to be considered arc Mesh matenals Afonofilament matenals Silkworm gut Sulk Cotton Linen thread Braided nylon Nylon Wire-silver stainless steel tantalum I would first put forward some general observations on these substances based on my own experience and expressing my personal views In hernia surgery we must consider suture materials from tuo points of view Their ability to stimulate a fibroblastic reaction, and their liability to provoke infection The ability to stimulate a fibroblastic reaction is almost entirely a property of the minute structure of the material All unabsorbable materials are created by the body as foreign substances and walled off by fibroblasts The reaction against them is at first wolent and later when the process of encapsulation is complete it is limited to the immediate neighbourhood of the foreign body Monofilament sutures eventually come to be enclosed in a fine avascular connective tissue sheath in which they lie unattached like a tendon in its sheath. In this ability to lie unchanged and quet among the tissues is their valuc in neuro-and thoracic surgery Mesh suture material is invaded ·GINIRAL PRINCIPLES OF OPERATIVE REPAIR 13 by the young fibroblasts and a mesh suture is eventually incorporated in and becomes part of the structure into which it hias been inserted. The liability to provolc infecuon depends largely on the irritant nature of the foreign material In 2 000 000 000 years of solution the survival of any species has depended on three things on its ability to reproducc in sufficient numbers to keep pacc with wastage on its ability to secure food, and on its ability to overcome the attacks of cncnues The cncmues of the screebrates leave mostly been smaller members of the animal kingdom and the introduction into the tissuc of substances of arumal ongin is resented morc than clut of scgctable matter Catgut an animal protein provolos a brisk inflanimatory reaction which subsides only when the catgut has been broken up and absorbed by the leucocytes summoned to the fight Silk an animal exudate is resented more than cotton or linen which are vegetable fibres Wnting in 1936' when I was more influenced by the writings of Halsecad than by personal experience I recommended Pearsalls No 4 Chinese tivist sulk' for hemia surgery I said Silk is morc pliablc and more than twice as strong as calgut of the same diameter silk again is received by the tissues much more kindly than caigut producing no apprcaablc reaction Should infection supervene silk does not aggrasate it but merely prevents the healing of the wound. Once an operung has appeared it settles down to a small sinus with nonc of the signs of inflammaton and through this chc silk is quietly and painlessly extruded, having in the meantimc donc the work for which it was inserted I have since abandoned silk entirely for all purposes For one thung I have found it highly sinogenic In the Middle East sinuses round silk sutures and knots were so common that I had to forbid its use For another thing I have found Barbour s linen thread superior in cvery way to silk stronger for a given gauge and in my crperience never cxtruded. Couton appears to be received as kindly by the tissues as linen, but in comparison it is weak and unreliable material Monofilament materials have the advantages that their smooth surface does not cause trauma and their solid structure offers no crevices in which bactena can lodge or into which fibroblasts can penetrate. Of these nylon is the best Silkworm gut is merely monofilament silk, and for that reason is more foreign than nylon, which, being a synthetic "Maingots Postgraduate Su gery Vol. III Part XVIII ·14 HERNIA fibre is not regarded by the tissues as an enemy from the method of manufacture it is also less uniform in length and diameter, and less reliable in strength than nylon The metal wires have no advantage over nylon They damage gloves fingers and sassors when they are being put in and they fragment after a week or two The one exception is stainless steel wire which because of its strength, is the best material for the emergency resuture of a burst abdomen Nylon is an ideal suture for the skin, because it causes no sepsis and if sepsis is already present it does not increase it It is unsutable for hertua repair because though it is a strong material it adds nothing but its own strength to the repaired arca It is not incorporated in the tissues it does not provoke a fibroblastic reaction, and if it has been used to displace structures against tension that tension if it persists will re-displace them and leave the nylon bchend Re-operation on a failed nylon repair discloses the nylon lying just where it was put in free loops that have no attachment apart from the knots at the beginning and end of the suture line The worst material ever used in herra repair is floss silk which manages to combine in itself the disadvantages of every other suture material It has the diameter and therefore the disruptive qualities of fascial sutures it has the irritating properties of silk and a loose mesh structure that makes it a perfect shelter for bacteria against the attacks of the leucocytes When it causes infection it disintegrates into shreds that take months to extrude themselves and arc almost impossible to remove Materials for filling gaps There should be no gaps in hernua surgery for the material that filled the hole onginally has seldom been destroyed or removed but has merely been pushed aside Nevertheless the temptation to patch rather than to repair is always present The following materials have been used Sheets of fascia Any aponeurosis transmitting the pull of a muscle is strong only in the direction of that pull Its longitudinal fibres are held together by very few transscrsc ones and large patches csen when they are securely anchored all round are unfitted to take a strain applied equally to all their margins ·CENERAL PRINCIPLES OF OPERATIVE REPAIR IS Derma In the derma thc body possesses a connectic tissue sheet of tough interlaang fibres cqually strong in all directions Many surgcons, of whom Rchin of Freiburg was probably the first have seen the possibiliues of derma in repair work The method has failed to secure a permanent place in surgical technique because unfortunately too many surgeons have seen the results in sepsis frequent sinuses and occasional dermoid cysts Shects of derma however carefully taken always include cpithelial renunants sweat and sebaccous glands hair and hair follicles and bacteria and they settle down to make a satisfactory membrane only after the whole of the orginal transplant has been replaced by the fibroblasts of the neighbourhood Silver wire filigree Thus can be made in any size or strength required and is usually woven by the surgeon humself to fit a particular defect It is casily stenlized and in the absence of infection it is well tolerated by the tissues in time it becomes incorporated in a dense web of fibrous tissuc of which it forms the framework. Like all unabsorbable materials silver wire will in the presence of infection, whether present when it was inserted or arriving later by the blood strcam keep up the infection indefinitely Whereas silk under such arcumstances can be discharged piecemcal through a very small sinus a silver wire filigree can only come out as a whole In my opiruon the perfection of modern methods of hernua repair has left no place for the wire filigree but the surgeons who followed Launc Macgavin at the Seamen s Hospital are very satisfied with it today Many of their patients carrying double filigrees arc carrying out the strenuous work of a merchant scaman over the seven scas of the world Nylon netting Nylon woven into an openwork mesh like mosquito netting has been introduced fairly recently and I have no personal experience of its use It can be sterilized by heat and unlike monofilament nylon It should because of its many interstices become incorporated with the tassues ·HERNYA 16 Tantalam wire ganze Tantalum is a metal that produces no reaction in the tissues Tantalum wire gauze is obramable in sheets up to 8 in square wbuch can be cut to any shape with sessors bent to any curve and sutured in position with cantalum wire or thread. It soon becomes fragmented by the movements of the body, but the pieces semain in posipon. (Fig 3) FIC 3 Tantalum gauze ·LU CHAPTER 3 INGUINAL HORNIA The inguinal canal The accounts of the inguinal canal in textbooks are largely traditional They perpetuate the names of long dead worthies and they refer to structures whose appcarance in the living does not always tally with the description in the book The conjoined tendon the cromasterc fascia thc transt crsalis fasaa when we meet them in the course of an operation, are often very unlike what we have been led to expect What are they and what do they do: In the inguinal region nature has faced the difficult problem of allowing the energence from the abdominal cavity without loss of security of the pou crful group of flexor muscles of the thigh together with the vessels and nerves of the lower limb The general arrangement of the muscles is simular in all limbed scrtebrates in all there are flexors of the shugh that take ongin from the vertebral column where it forms the postcnor wall of the abdominal cavity in all the abdominal wall consists anteriorly of two rectus muscles runnung vertically on either side of the mud-linc attached below to the pelvic girdle and above to the thorax and laterally of three layers of muscles (some of which may be further divided) running at an angle to cach other but on the whole set transversely to the long axis of the body These lateral muscles are attached directly or indırcaly to the vertebral column behind, to the thorax above and to the rectus sheath in front Below they end in a firm fibrous band that arches over the psoas and the vessels and nerves to the hind limb and blend with the fascia covering them We can imagine the ancestral reptile that gave rise to the mammals thus equipped, with an abdominal wall whose lateral muscles the extemal oblique intemal oblique and transversalts all ended below in a common fibrous band that bndged over the flexor muscles and the neurovascular bundle was firmly blended with their sheaths and the septa between them and gained attachment through them to the pubic part of the limb girdle 17 ·18 HERNIA Then came the mammalian revolution One particular reptilian stock discovered the advantage of being independent of climate and time of year of being able to conduct all the chemical processes of metabolism at a uniform temperature This new method of life demanded fundamental changes of structure More heat must be produced This demanded an increased food intake a better digesti c system and increased combustion which in turn involved discarding the nuclei of the red cells to make them pure orygen carriers sending the blood round more effectively by means of a four chambered heart and super-charging the orygen intake by the more efficient bellows of a diaphragm The increased heat must be conserved by a skin covering that could vary heat retention at will yet could also dissipate heat when, owing to muscular exercise or heated surroundings it threatened to become excessive One function alonc refused to be regimented that of reproduction. All creatures tend by migration or by selecting the season to breed under certain conditions of temperature and under these only The newly formed mammals experimenting with living at a much higher temperature than their ancestors had known found it necessary to extrude the male gonads (and possibly the female also at that remote period) from the abdomen into an annexe where they could be maintained at a constant yet temperature than that of the rest of the body The inguinal canal is the track of thus prehistonc cxpulsion It is in fact a physiological hernia an extrusion of all the layers of the abdominal wall by the tests as it thrusts its way through. The key to rajonal hernia surgery therefore lies in an examination of the measures whereby that physiological hemia is kept from beconung pathological and in an attempt to retain that mechanusm where possible The emerging testicle as it passes down the posterior abdominal wall, is brought to a stop by the fibrous barrier of the arch psoas and the neurovascular bundle and it is forced to traverse the lateral abdominal muscles just above this arch (Fig 4) The layers at pushes in front of it are fibrous and muscular The first is the transversalis layer which is herc a tough fibrous shect named by anatomists the transversalis fascia or fascia of Astley Cooper for he first ponted out its significance Elsewhere thin, this fascia is a tough sheet where it forms the posterior wall of the ingunal canal It seems clear houder that here it is not merely an investing membrane as as the rest of the so-called transversales fasaz, bur that it represents the tendon of lower spanning the ·INCUINAL STRNIA 19 Transversalls fiscla Testicle Peritoneum Transversalis m Internal obl External obl mn Rectus m Cremaster m FIC 4 The cruption of the testis insertion of the transscrsalis muscle into the fibrous arch common to the latcral muscle group This transversalis layer transmits the cord through an opening with almost cendinous margins whose edges are prolonged uprtards as fan-like extensions on the deep aspect of the muscular fibres of the transversalis (Fig s) It is carried on the cord as a thin invesung Layer the infundibuliform fascia The remainder of the transversalis layer making the posterior wall of the canal is thickened where it blends with Pouparts Ligament The muscular layers consist of the lower edges of the intemal oblique and transversalts which are separate where they anse from Poupart s ligament and blended where they are inserted as the conjoined tendon into the pubis and of the cremaster muscle which represents their extruded lower fibres and springs from the whole ning through wluch the testide emerged and which then svraps round the cord and extends in loops to surround the testicle itself (Fig 6) These muscular layers are really one The intemal oblique and the transversalis muscles thrust aside by the bow-12%e of this biological ·20 HERNIA Cord Internal illac artery and vein Poupart s ligament FIG 3 Schema of the internal ring from behind (after Lytle) FIG 6 The conjoined and cremaster muscles projectile are fused to form the so-called conjomcd tendon The sanie muscles where they lie directly in the track are thinned out and curved downwards their fibres being spread all round the tests and cord There is no boundary where the conjoined tendon ends and the cremaster begins There is no cremasteric fascia The cremaster in a healthy man is a muscular sheet in thick an integral part of the ingwnal mechanism The postenor wall of the inguinal canal consists of the thunned tendon of the transversalis muscle covered by the posterior fibres of the cremaster muscle The most external layer the aponcurosis of the extemal oblique is pierced near its insertion by the cord the main fibres being thrust aside to form the pillars of the external ring but some continuing over the cord as a thin investing layer Poupart s ligament which is conveniently descnbed as the uptumed lower edge of the external obliquc aponeurosis is really the representative of the fibrous arch that bridges the flexor muscles in reptiles and amphubia It contains contributions from all the lateral abdominal muscles and from the fascia over the iliacus and is continued into the fascia linung the pelvis and the fascia lata of the thigh. The sap between the pillars of the ring is usually visible right up to the muscular part of the external obliquc which extends horizontally inwards from the anterior superior spinc Thus gap is bridged by w cak transscrse fibres but it is widened by the presence of a hernia in the canal For this rcason methods of approach to the inguinal canal that make a point of leaving the external ring untouched arc unsound ·INCUINAL IERNIA 21 Opening of the ring by dividing the intercolumnar fibres and cxtending the cut in the aponcurotic sap is necessary not only for atraumatic reflection of thic creimaster afterwards but also to allow the stretched ring to be sutured back to its normal size Medully the external obliquc aponeurosis joins clic anterior rectus sheath but it does so a full inclı inside the lateral border of the rcctus muscle so that for this width the shcath is fornied by contributions of the intemal obliquc and transicrsalis only These anatomical points arc all of importance when we conic to consider the normal defences of the inguinal canal and the principles of repair when they beconic cffetc Ang subdivision of the posterior wall is valueless and Hesselbach s triangle should be one of the first pieces of uscless vcrbiage to be scrapped Such redundant descriptions do more than or crload the students memory they suggest that the ingunal canal is a mechanical defence meclianism whosc sccurity depends upon fibrous planes an oblique course and two operungs placed some distance from cach other in short upon a salvular mechanism. The value is a device not cnployed in the body cxccpt in the arculatory system There is no cardiac valve no pylonic valve no ilo-accal valic and no ureteric valsc Studiсd by the anatomy of the living the observation of structures when they are working the inguinal canal is seen to be a muscular sphincter The inguinal muscles work with the abdonunal muscula- (ure of which they form a part and whose innervation they share When thc abdomunal pressure is raised tending to force thc cord farther out of the abdomen or a pouch of peritoneum beside it the extemal oblıquc aponcurosis becomes a rigid sheet supporting the deeper layers and fixing the rectus sheath The cromaster pulls the testicle and cord up against the extruding force and towards the internal Iring (As can be seen in any young boy when he is asked to cough) The conjoined muscles straighten out the arch of their lower fibres intersposing a thick muscular band that prevents thc fibrous posterior wall from bulging The transversalis muscle as it contracts pulls the internal ring with the enclosed cord upwards and outwards behind the muscular shect The mechanisms that defend the inguinal canal against abdominal pressure are thus muscular rather than fibrous (Fig 7) When they are healthy the cord with its abundant and varying blood supply can pass through undamaged but nothing else can pass beside it ·22 HERNIA ABDOMINAL Sanssjud CREMALE FC 7 A cartoon by Anna Zinkersent emphasizing the bes that the defences of the inginal casal against mura abdominal pressure are muscular rather than fibrous opening us lateral Types of inguinal hernia There are two main types of inguinal hernia the obligue or indirect and the direct in oblique inguinal hernia the hemial to the deep epigastnc artery in direct bemiz the opening us medias to the artcry Both indirect and direct hernize may be congenal or acquired but whereas the grext majority of obleque hemilac arc congenital al except a very few skrece heruse are acquired (Fig 8) The oblique hemis accompanies the cord. It bas the same fascal covering and is led by it along the inguinal canal through the external abdominal ring into the scrotum, and finally to the testis -The direct herrua pushes through the abdominal wall belund and not in any particular relationship to the cord, which is merely 2n1 anterior relation and may lie abovest below it or over its summus It has thus the same intescolumnar and cremasteric coserings as an oblique hehu but not the fascial Layer while in adduon it us cosered by the layers of the abdominal wall that lie behind the cord. As it marges its spread is limited by the accachment of these layers to Poupart s ligament and the aliopccuncal line Bang a bulging of the postenor wall of the angunal canal i swel} conanue to bulgelt ia centrafugal manner being lurused ·23 PORT INGUINAL HERNIA only by the sclanıcstrength of the structures it encounters l'oupart sligament and the outer border of the rectus musce near its insertion, here reinforced by the pyra- CONGENITAL nudales are almost unyielding so that an cnlarging direct fiertua tends to push upwards and outwards ci entually stretching the muscles far beyond the confines of the inguinal anal bur hardly cver entering the scrotum. The zonc of failure in the inguinal canal as thus AQUIRED ODLIQUE 1 V sich the body of the pubis as its apex and Poupart s ligament and the rectus sheath as its limbs DIRECT Congenital oblique inguinal hernia The testis is formed in the lumbar region. At the third month the Wolffian duct that will form the epididymus) and the genital gland (that will form the corpus testis) project into the coclomic cavity on separate mesenterics with a common attachment. During the fourth to the sixth month theyslide down the posterior abdominal wall, while the epididymis is formed The two mesenterics become FIG & Types of inguinal herosa Rectus m Poupart 3 Ilgament Zone of fallure FIC 9 ·24 HERNIA blended as the mesorchium and the testis assunies its final shape By the seventh month it reaches the internal ring Meanwhile there is a rapid growth of muscular tissue in the mesorchium Thus muscular mass the gubemaculum pushes its way into the scrotum in advance of the testes, carrying with it all layers of the abdominal wall she peritoneum the transversalis fascia the internal obliquc and transversalis muscular layers the external oblique layer and the deep layer of the superfical fascia of the groun During the seventh month the tests also passes through the abdominal wall sliding down the back of the pentoncal tube dragged from the iliac fossa by the gubernaculum In the aghth month it lies at the external ring At birth it has reached the bottom of the scrotum A congenital obliquc hernia The common kind is due to persistence in whole or in part of the funicular process the evagination of the peritoneum thar preceded the testis in its descent The disposition of the sac may follow onc of four cypes the vaginal the furicular the retrofunicular or the intrafunicular (Fig 10) The vaginal type of sac often named the congenital is clearly a persistence of the whole funicular process including that part which normally remains as the tunica vaginalis The funicular type is almost as certainly due to the persistence of the upper part of the process with obliteration of the lumen at the upper polc of the testis where the sac does not go right down into the scrotum the obliterated segment can usually be traced as a fibrous band uruang the fundus of the sac to the summit of the tunica vaginalis The retro-funicular and intra-funucular herruse grouped together under the term infantile arc of more uncertain ongin. Thie explanation that is usually given in textbooks and almost certainly the wrong one is that the funicular process is closed at the internal ring remaining patent distally and that an acquired sac us later pushed down in front of it behind it or into its lumen Excry stage intermediate between the funicular and retrofunicular varletics is met with the tunica vagualis extending up into the inguinal canal for varying distances in front of the sac so that it seems probable that the infantile varieties are due to irrcgularities in the descent or obliteration of the funicular process and have no acquired element The distinction is of academic interest only and affects neither the diagnosis nor the treatment of ·INGUINAL IFRNIA 25 2 & FIG to Developmental abnormalities arising in the funicular process The funicular process just before birth • Normal closure of the furucular process « Congezutal hernia persistence of the condition seen in a d Furicular hernua ( Hernia magna Bilocular hydrocele Retro-funucular hernia h Intro-funicular herria these herniac Only the possible confusion of an inexperienced surgeon on finding two cavities wherс he expected to find one justifies thus discussion The sac of a congenital ficmia lies in front of the cord or rather surrounds it in front above and below so that in transserse section it shows as a horse-shoc shaped slit into which the cord is invaginated much as the testis appears to be pushed into the tunica vaginalis The sac is intimately bound to the structures of the cord, particularly to the vas deferens from which it can be separated only with difficulty In hemiae associated with imperfectly descended testes the pentoncum 15 50 thin and the sheathing of the cord by the sac so intimate that the separation and closure of the peritoneal process a matter of real difficulty The sac bears funher traces of its congential ongin in numerous II-C ·26 HERNIA and in bands of fibrous muscular and nerve tissue which streak its outer surface and in the presence of small rests of adrenal cortex in its walls In most cases the process of peritoncum forming the sac is a simple cube Occasionally the distal part is divided by septa into a series of compartments which may be distended with flud Incomplete sepua and diverticula from the main channel are also found These itegularities are probably of developmental ongin, but some of them may be the result of pressure by a truss The extra-peritoneal fat usually ceases at the internal ring the operation for hertua its appearance 15 usually an indication that the ring has been reached The fat may however invade the cord particularly in the inguinal canal of adults Two conditions are seen in one the fat extends down the cord, distinct from the vessels and sac but in the same fascial envelope as a lobular finger-like process carrying an obvious blood vessel with itThe appearance suggests that the fat had descended with and at the same time as the testis In the other type the far is invaginated into the neck of the sac and bears when viewed from the inside of the cavity a very striking resemblance to a loop of small intestine protruding through the operung An acquired oblique hornja This is far more common than the textbooks admur Most sliding herniac are of this nature When a normal inguinal canal is laid open in the dissecting room or during life as in the operation for the radical cure of femoral hemus by the inguinal route at spill be found that a moderate pull on the cord brings down a rounded pouch of panctal pentoneum through the opening in the transversalis fascia An acquired obliquc hernua probably has its ongin in such a prolapse of the cord, due to the combined influence of poor muscles and repeated strauung Thc diverticulum once formed, is further stretched by efforts of straining or coughing and becomes a fully developed hertua The acquired origin of any oblique hernu can never be proved beyond doubt but it is typical of such a hernia that the sac us inimedeately visible among the other structures of the cord, that it is thick walled and broad in proportion to its length that its fundus 15 rounded and not continued by any fibrous bands into the scrotum thar 103 walls are desunct and separable without dissection from the vas and formi plexus and that its neck is wide and surrounds the emerging cord pampins ·INCUINAL HERNIA 27 on all sides except the inferior instead of lying lateral to it as does the neck of a congenital sac. Direct hernia A direct hemia is mcrcly a bulging of the posterior wall of the inguinal canal Anatomy books have in the past described this part as Hesselbach s triangle a tnangle bounded by Poupart s bgament below the decp cpigastric artery laterally and the outer border of the rectus muscle medially and further have subdivided this triangle into outer and inner portions marked by the obliterated hypogastric artery Such names are mcarungless and such subdivisions are without significance They are best forgotten. Thic portion which yields first is that which is formed by the transversalis fascia alone that is the part medial to the deep epigastnc artery below the arched fibres of the conjoined muscle and lateral to their insertion into the lilio-pectincal line The bulge is a general one rougluy hemisphencal in shape and the sac which hardly ments such a name has no neck. It is covered by fascia throughout. As the hernia enlarges it spreads upwards and outwards The epigastric artery becomes stretched over it and in a large hernua may appear to divide the swelling into two lobes The lower fibres of the conjoined muscle and cremaster become stretched and their fibres separated. The external oblique aponeurosis become thunned. A direct hemia does not come through the external nng in the sense that an indirect one does but as it increases in sizc it meets with less resistance in the intercolumnar fibres than in the more fully developed parts of the aponcurosis that lic laterally and it may bulge through the stretched external nng Such a hernia shows the most prominent swelling and gives the most obvious impulse on coughing at the extemal ning but it does not like the indirect hernua become inguino-scrotal The sac of any ingunal hemia, as it cnlarges tends to drag down further peritoneum from that lining the abdominal parieties and with it any intra-abdominal mobile structures which the pertoncum clothes Thus the bladder may be drawn into the neck of the sac on the inner side the caccum into the posterior wall of a nght hernia and the iliac colon into a left onc A congenital direct hernia A case was descnbed by me in 1935 and occasional cxamples harc since been reported by other surgeons ·28 HERNIA it is The opening is in the conjoined tendon just lateral to where inserted into the sheath of rectus and pyramudalis a part that is really tendinous (Fig 11) The onfice is ngid, arcular and usually smallfrom to u in diameter The sac is long narrow and tubular It does not accompany the cord but may extend through the extemal ring There is no general yielding of the postenor wall of the canal Erc i Congenital direct hemu It is difficult to explain the ongin of these uncommon hernuae but they are probably due to some aberrant gubernacular mechanism The long tubular sac and the small ngıd opening suggest a traction diverticulum rather than one due to pulsion The diagnosis of inguinal hernia Inspection is important for a small hernia can often be better scen than felt This is particularly true of a bubonocclc in women and small children, in whom the oscrlying fat often obscures the impulse on coughing in a small sac Inspection too is often the most certain means of distinguishung between the common condition of bulging groin seen in fccble and sedentary men and a definite herria. The distinction between an oblique and a direct hertua is often difficult and sometimes impossible le is unimportant for the type of ·INCUINAL ISERNIA 29 large wide-mouthed hernia in which differentiation is hard usually needs an operation in olving reconstruction of tlıc inguinal canal and the exact relations of the swelling will become apparent whicn the tissues are exposed. Diccct hcmuac are usually seen in men oser forty they are bilateral and synınıctrical in size and position A heria which appears as soon as the patient stands without any straining effort and wluch disappears as soon as he lies down without the application of any pressure or one sluch lien reduced reappears inmediately is probably direct One whose length crceeds its breadth which comes anyu here belou Poupart s ligament or medial co thc pubic spine or onc which when it is made to reappear by coughing is seen to fill obliquely rather than to come straight forward is probably oblique The differential diagnosis between inguinal hernia and other inguino-scrotal swellings is seldom difficult Common sense should serve to distinguish swellings that are superfiaal to the abdominal wall such as an abscess or suiclling of the inguinal lymph nodes and those deep to it lying in the psoas of liac vessels from sucllings in the anguinal canal proper Swellings in the inguinal canal must anse from some structure in the spermatic cord and arc cither tumours lipoma or fibromamor varicoceles or abnormalities in the mechanism of tesacular descent retained testes or hydroccles of the cord A lipoma is softer than a hertua and gives no impulse on coughing but unless accompared by a sac, it rarely attains suffiacnt size or gives enough trouble to attract the attention of thc patient A fibroma is a firm rounded swelling which can be distinguished with certainty from an encysted hydrocclc only by the absence of translucency A vancocele can never be mistaken for anything else unless onc of the varices has ruptured An encysted hydrocele of the cord is often diagnosed but seldom seen after puberty A truc cncysted hydrocele is a small rounded translucent swelling sharply demarcated above and below The majority of rounded translucent swellings seen in the inguinal canal of adults are ency sted hydroceles of a hemial sac, the neck of which is blocked by a plug of omentum Their truc nature is revealed by examination of the neighbourhood of the internal ring when the cord will be found to be thickened ·CHAPTER 4 GENERAL PRINCIPLES IN OPERATIONS ON THE INGUINAL CANAL The incision The skin in the ingunal region is smooth over the outer part, harry towards the pubis and at the level of the pubic spine it has the rugosc surface and the large sebaceous glands of the scrotum and labium majus The superficial fascia shows the two layers fatty and fibrous of Camper and Scarpa The latter which is continued into the scrotum and labrum and is attached just below Poupart s ligament to the fascia lata of the thigh must be divided with the knife before the femoral opening can be explored through an inguinal incision The standard inosion for the operation for the repair of inguinal hernia is an inch above and parallel to Poupart s ligament This incision has the advantage of direct access and for that reason at may be preferred by the surgeon working short handed but it is not a good one It leaves a scar that is always obvious sometimes keloid and occasionally painful These drawbacks are duc in part to the encroachment of the incision at its lower end on skin that is sterilized with difficulty in part to its lying across lines of tension The position of rest of the trunk is with the lumbar spine and the hips flexed. To this position the skin adapts rself and ficxion of the trunk and thighs leaves a constant crease in the inguinal region shown in Albrecht Durer s drawings Inguinal & le moral and known by the older anatomists as the linc of Venus Saphenous tigature (Fig 12) This linc crosses the mudline about 11 in FIC 12 The flexaon areases in the abdominal wall and their uses in homia surgery above the pubis and on cach 30 Umbilical hernia berntae ·OPERATIONS ON TIE INGUINAL CANAL 31 side it cun es upwards as it passes outwards crossing the line of Pouparts ligament in iis outer fourth and fading away on the outct side of the thugh just below the anterior superior spina This crease is the best site for an inasion for inguinal or femoral lierrua It us a line of skin rest and the stitches can safely be removed in four or five days Thic scar is comfortable and almost inssible and it lases very little scar tissue in the subcutancous layers so that further operation in the samc region should it be required later is easy in cluldren at luas the further advantage clut it removes the surches and dressings a further in from the arca of probablc soiling Local anaesthesia for operations on the inguinal canal Operations for inguinal hemmua niust often be undertaken urgently in patients whose age or gencral condinon would prohibir such a step were it not for the even greater danger of sonic threatened complication The risks are largely eliminated by the use of local anacsthesia Modem local anaesthesia depends on blocking man nerve trunks outside the area of the proposed operanon rather than on infiltration of the ussues in that area The nerses that must be blocked for an operacon on the inguinal canal are many The skin of the groun is supplied by branches of the 12th dorsal ist lumbar lateral cutancous and genito-crural nerves The skin of the scrotum is supplied by the ilio inguinal nerve by scrotal branches from the internal pudic and by the long pudendal nerve from the small saatic The abdominal muscles and pentoncum are innervated by thc ilio-inguinal and iho-hypogastric nerves The cord and testis receive their sensation from the spermatic ficrves accompanying the vessels in the cord These nerves can all be reached through three subcutanc heals one a fingers breadth medul to the anterior superior spinc one over the saphenous operung and onc over the supra-pubic skin crease in the mud lint (Fig 13) The secret of successful local anaesthesia is twofold firstly the administration of sufficient sedative an hour before the operation to render the pacient drowsy during its performance and secondly a pause of at least fifteen minutes between the injection of the anaesthetic and the start of the operation. The solution recommended is one of } per cent vylocaine to which one drop of 1/ooo adrenalin solution to every 10 cc has been added. The three subcutaneous wheals are first raised with a fine hypodermic needle A in needle is used for the remaisung injections

·32
IIERNIA
6C
10cc.
20cc
트
U
vo
10ce.
50.
o
20cc.
25cc
(d)
U
FIC 13 Local anaesthesia for unguinal herriu (see Icxt)
a The cutaneous whesis 6 Deep rijections through the first what Deep
injections through the second wheal d Decp injections through the third wheal
Curcum-ınjection on the subcutancous layer through all three wheals

·OPERATIONS ON TUE INCUINAL CANAL 33 Thic needle is first inscrted through the first wheal that just Inedial to the antenor superior spine) at right angles to the skin and pushed slowly down all its point strikes the bone of the iliac fossa (Fig 136) Occ. of solution ss then injected slowly into the niuscle to block the ilo-incuinal llo-hy pogastric and last dorsal nerves The needle is then withdrawn from the musculat layer and pushed again through the extemal oblique aponcurosis about it in medial to the anterior superior spine and a further 10 cc of soluuon us injected between the aponeurosis and the internal obliquc layer in a direction horizontally inwards The needle is next inserted through the second whcal (that over the saphenous opcrung) and .0 cc of solution are injected honzontally across the base of the scrotum which is held up in order to block the scrotal nerves (Fig 134) Withdrawn slightly its point is then pushed upwards and inwards all 1e strikes the pubic spinc and sc.c of solution are injected there Through the third sshcal (that is the mid-line) a plane of soluson (ncc in all) us laid down in the nud planc of the scrotum by passing the needle round the root of the peruus into the upper part of the scrotum (injecting as it is advanced) and then fecding the tissues in the mid-linc of the scrotum on to the point of the needle in tum (Fig 13d) Sall using the same shcal 10 CC of solution are injected into the fascial cnvelope of the cord which is held up at the external ring for thus purpose Lastly using all three whcals a continuous line of subcutancous injection, using about 40 cc. in all is placed around the wholc arca uniting all three wheals and a further line along the skin arcase which will be used for the incision If the surgcon completes the injections before he puts on his gown and gloves for the operation, anaesthesia should be complete by the aime he is ready to start General principles of operation upon inguinal hernia What is the operative treatment of ingunal herria: It is only necessary to put the question in this way to raise a laugh The operations that have been advised and practised arc legion. Each 15 somebody s darling and I have not the temerity to criticise or select from among them I shall therefore give my own vicws the operations that I have now practised for twenty years and have found successful In a later chapter I shall give the outline of other operations that have been ·34 HERNIA ing them 4 widely recommended and my reasons for avoiding them or abandon- Two general statements will I think be accepted by all First that permanent cures can be obtained by operation cven in large and old standing hemiae provided that the patient is fit enough to allow an operation appropriate to his particular defect to be done Cures should therefore be all the more certain in the simple cases A cure rate of 100 per cent should be obtainable provided that an operation of the correct type has been done, and well done The inguinal canal is the recognized practice ground for the man who likes to do a spot of surgery just as he likes to play a spot of golf Secondly in any particular group of patients submitted to similar operations the proportion of cures vanes with the type of hernua The following results may be looked upon as average or a little better than average 1 Inguinal hemia in chuldhood and oblique inguinal herua of recent appearance in healthy young adults 100 per cent Oblique inguinal hemia in older patients when the history is short and the inguinal canal apparently sound 95 per cent 3 Old oblique hemiae and direct herniac 90 per cent It is said that sepsis is the commonest cause of recurrence Tlus does not agree with the lessons of experience Sepsis enforces a long rest and it calls forth an abundant reaction of repair Induced sepsis was the basis of the medieval cure of hernua by blistering and an inflammatory reaction is the probable modus operandi of the injection treatment and of the insertion of dermal transplants Could sepsis be regulated it would be the reparative surgeons best friend in any case it is conmon experience that a majority of recurrences are found under beauaful linear scars The usual cause of recurrence is thar the first operation has been donc by the wrong surgcon or by the song method. During the Second World War recurrence after hernia operations in healthy young men was a riajor headache both in the Army and in the Air Force The following excerpt is from a memorandum arculated by the department of statistical research of the Army Medical Services * The overwhelming majority of such recurring cases are the result of an operation for the performance of which a relatively modest level of professional skill is deemed to suffice ·TIIC STANDARD OPERATION 35 Hemia operations are rarcly considered important They are lightly undertaken by men who are not surgeons at all and who refrain from attempting any other abdonunal procedures In hospitals they are often regarded as introductory cxcrascs for the novice and are left by the chief to his assistant when he has finushed the more interesting part of his list The three groups outlined above with their varying prospects of curc correspond cry approximately to thrcc degrees of pathological change demanding in cach casc an operation of a different type In the first the inguinal canal :s normal for an unfilled hermal sac is a potential space only in the second the internal ring has become dilaced that is the fibrous defences have been weakened but the muscular defences are intact in the third the posterior wall luas given way and the muscles have also becomic weak, that is the inguinal mechanisn has failed. In the first group removal of the sac will remove the only abnormality and, provided that it has been accomplished without damage to thc incernal ring or the muscles this simplc opcration will Icad to lasting curc In the second group the muscles cannot be cxpected to maintain the integrity of the canal unless the stretched internal ring has been restored to its ongunal size and strength in the third group the failed inguinal canal must be reconstructed I THE STANDARD OPERATION (a) The skın incision After identification of the skin crcase three or four lines are marked across it with a pen, brush or throat swab dipped in Bonncy s bluc to ensure accurate spaang of the flaps when they are subsequently sutured (Fig 14) The cut made with a continuous sweep of the knife while the skin is put on the stretch with the finger and thumb of the Icft hand extends in the creasc from the front where it crosses Pouparts ligament nearly to the mudline Two or three branches of the superfical femoral vessels which are seen running in the fatty layer at nght angles to the incision are divided been een artery forceps and ligatured with No go linen thread. The incision is then deepened down to the external oblique The surgeon then grasps the whole thickness of the lower flap with toothed dissecting forceps and lifts ·36 HERNIA FIC 14 Standard operation for ingwnal hernia The incision it away from the abdominal wall while che assistant docs the same with the upper flap A few bold sweeps with the knufe in the arcolar plane between Colles fascia and the external oblique aponeurosis followed by gentle pressure with a swab will separate the fatty layers from the aponeurosis upwards and outwards as far as the muscular Fic 15 Standard operation Reflection of the superfical flaps ·TIIT STANDARD OPERATION 37 fibres downwards as far as Poupart s ligament and inwards to the extemal ning and the emerging cord (Fig 1s) Poupart s ligament should be laid bare at thus stage down to its inscrtion in order to faalitate subsequent suture of the pillars (b) Reflection of the external oblique aponeurosis The extemal oblique should be inased towards the external ning and not from it as thus method carries a risk of injury to the cremaster muscle or the illo-inguinal nen c A cut fin. long as made with a knufc in the line of the pillars and about ? in from the point where they diverge The upper leaf is held up with dissecting forceps and the cut 15 crtended with Mayo sassors into the external nng and carcfully beyond it into the inter-columnar fascia The cut is then extended outwards in the line of the fibres to a point i in lacral to the internal The upper leaf is then reflected off the underlying structures which are gently detached from its decp surface with suceping strokes of thc closed Mayo scissors working from without inwards in the line of the arched fibres of the internal oblique Separation is continued till the outer border of the rectus slıcath is cxposed (Fig 16) ring Fic 16 Standard operation Reflection of the cremaster muscle from the cord ·38 HERNIA The lower leaf is treated in a simular manner till the inner surface of Poupart s ligament is cleared as far as its insertion into the pubic bone The fibres of the cremaster will be separated from the deep surface of the aponeurosis with which they lie in contact, but their origin from Poupart s ligament must on no account be disturbed. When this stage is complete the cord will be seen completely clothed in the fibres of the cremaster muscle on whose surface lies the illo inguinal nerve (c) Opening the sub-cremasteric space The surgeon picks up the cremaster muscle # in below the lion inguinal nerve directs his assistant to do the same just below it and divides it boldly in the line of its fibres downwards to the centre of the external ring and upwards to within in of the point where the thickened arching fibres indicate the lower end of the internal oblique He now releases the lower leaf of the crorizaster and picking up the cord with toothed forceps he frecs it by a few gentic touches of the closed Mayo scissors from the upper leaf of the muscle which is sull held by his assistant (Fig 17) The assistant then releases this leaf and takes the cord from the surgeon who picks up the lower muscular sheet and frees it in a similar manner The cord is now free and can be Fig 17 Opening of the sub-cremasteric space and isolation of the cord in its fascual sheath ·TIIE STANDARD OPERATION 32 hooked up on the forcfinger of the left hand while the cromaster at Its fuo cxtremities is pushed off it with a gauze swab The cord lying on the finger is covered with infundibuliform fascia only through wluch all its constitucits normal or abnormal can be clearly seen (d) Isolation and ligature of the hernial sac The cord still lying on the index finger of the left hand is inased longitudinally for about is in by a gentle strolc of the knife that divides the investing fascia only The sac, which has already been seen lyang antenorly now prolapses through this cut completely denuded on its superficial aspect It is picked up with a pair of hacmostars which are then fired by the thumb of the left hand and is thus held firmly on the pulp of the left index finger With a pair of non-toothed dissecting forceps all structures adhering to the sac are gently separated from it working transiersely to sts long axis (Fig 18) As succeeding parts of the sac arc laid bare they are gathered up with the left thumb bringing a fresh portion into view for clearance Finally the point of commencement is reached and the index finger will be seen in a space that separates the sac from the cord FIC 18 Isolation of the sac from the cord bundle ·40 HERNIA If the plane of dissection has been kept close to the wall of the sac there is no danger of injury to the vas but the surgeon should always assure himself at this stage by feeling the separated cord, that the vas is actually with the vessels and not with the sac This dissection, once begun, must be pursued methodically in a plane transverse to the axis of the cord till two separate bundles emerge the sac on one hand and the normal constituents of the cord on the other The left thumb must not relax its grp on the sac and the temptation to wander up or down the cord must be resisted. The structures of the cord are kept together by endosing them in the loop of a Lane s tissue forceps, and the separation of the sac is continued towards the fundus The sac is spread out and fixed by the left hand, while the structures of the cord are peeled off it with blunt dissecting forceps This separation may be difficult at the fundus Thc turuca vaginalis is often adherent over a wide arca to the expanded fundus of the sac The veins increasing in size as the testicle is reached may also be adherent to it, and the vas may lie in a loop on its walls Many of the bands are so tough that they must be cut with the knufc By holding the cord on the stretch and pushing its constituents off the sac with a gauze swab or closed sassors and by using the knife only for strands that stand out between structures already isolated the separation can be effected cleanly and bloodlessly When the fundus is free the surgeon gets hus assistant to put thc cord on the stretch by drawing it downwards and inwards while hc clears the neck of the sac The fascial sheath which in an unstretched inguinal canal is almost tendinous at the internal ring must be treated with great respect for on its integrity the success of the operation depends When well marked it may be separated from the penitoncum of the sac by a arcular cut with a knife or supped with sassors close to the sac It must not be tom apart in an undulated sac the site of the neck can be recognized casily by a sudden expansion in diameter where it becomes the thin parietal peritoneum by a congue of extra-peritoneal fat that appears beside it and by the deep epigastric sessels on its inner side Except in those sacs thun cnough for the contents to be seen through them the fundus should now be cut and held open with thrcc hacmo- Stats The interior of the sac is inspected any abdominal contents sail in it are returned and a blunt instrument is passed into the peritoneal cavity to prove that no contents are adherent at the neck. The fundus ·TIIT STANDARD OSTRATION is then grasped in a hatmosfat and assisted til the sumns reach the internal ring (Fig 19) This mancuyre insures that no loop of gut or tag of omentum c31) fc-enter the sac a thic lase moment and be pierced during transfixion of the sac and it provides a narrow pedicle for ligaturc FIG 19 Standard operation Legature of the sac at its neck The sac us held up while the twisted neck ss picsced by a round needle carrying No I catgut and ned first on one side then on the other and finally all round in the groove made by the first two knots The ligature ss cut and the sac es divided t in beyond it The stump recedes into the aperture in the transversalis fasaa and disappears from VICW (e) Repair of the inguinal canal and closure of the wound If the internal nng has not been stretched by the hertil or damaged during the dissection, and then only the layers are closed in sequence The cord is pushed down into the scrotum talst lics led with the floor of the canal The cur edges of the cremaster are picked up near the internal ring and wuted with a continuous suturc of oo catgut (Fig 20) The musclc fibres have not been cut across so that only the lightest HD ·42 HERNIA Fic 20 Standard operation Repair of the cremaster muscle tension is needed to approximate the edges Carc must be taken that the illo-inguinal nerve is not caught up The external oblique aponeurosis is sutured with No i catgut starting at the lateral end of the wound (Fig 21) As the medial and is approached it is important to make sure that each stitch takes a firm bite of the pillars of the ring and not merely of the thin inter-columnar fascia The suture should be continued medially all the ring is reduced to a size that will just transmit the cord-that is to the diameter of the last joint of the little finger The last search should be held right and the diameter of the ring should be tested before it is died. Accurate closure of the subcutancous as well as of the cutaneous layers of the incision is an important step in the crcase inasion for herrua Four or five sutures of very fine nylon on a Colts cutang needle are passed in the following way The necdic is entered in. outside the wound edge and passed vertically through the superficial fascia to appear in the plane between Campers fasea and the cxtcral oblique it is then passed outwards through the same layers on the other side to emerge at a simular distance from the sound edge (Fig 22) The sutures are placed at even distances guded by the blue marks on the skin and thar ends are held in hacmostars. The skin cdges are then joined by Michel Clips placed dosely the blue lines on ·TJIE STANDARD OPERA UN petellit FIC 21 Standard operation Repair of external oblique aponeurosis opposite sides being matched exactly Finally the nylon sutures arc ued over a cylinder of gauze i en in diameter taking the tension off the skin cdges and preventing any oozing in the decper layers A single layer of gauze is laid over the pressure dressing to keep the strapping from adhering to the stitches and the dressing is fixed with a length of porous Elastikon strapping (f) After treatment A crease incision lies in a plane of no movement and clips and sutures are no more than approximating devices. The satches should be removed on the third day but the gauze cylinder that they held should be left in position till the fifth day when the clips should be removed I formerly advised chrec wecks recumbency after a hernia operation I now advise carly movement Ambulation on the first day is foolish but free movement in bed should be encouraged as soon as the patient is round from the anaesthetic (which with a good anaesthetist is as soon as he gets back to bed) On the second day he should be encouraged, but not driven to get out of bed and he should be allowed

·44
HIERNIA
-
2
W
b
FIC -- Standard operation Closure of the skin nasion
(6) Nylon anchor sutures inserted Approximation by Michel clips has been
starred
(b) Nylon sutures tied or et gauzc roll

·THE STANDARD OPERATION 45 to do morc cach day Harmful strain of recently divided tissues us presented by reflex inhibition The only strains likely to damage a hemua repair are those of coughing and constipation, and both are more likely in a bed-confined than in an ambulant patient () Special points in the isolation and ligature of the hemial uc (1) The separation of a scry thu u alled sac In some inguinal herniac particularly the congenital herniae of chuldren that extend into the tunica vaginalis and those associated with non-descent of the testes the walls of the sac are very thin and adherent to an unusual degree to the structures of the cord. In spite of the greatest gentleness the peritoncum is often tom when an attempt is made to separate the vas and the vessels from it The margins of the car should then be seized with finc forceps and the attempt to free the whole arcumference of the sac should be continued. If further tcars appear the opening may be allowed to gape and, guided by vision through the transparent peritoneum, the point of a blune dissector or one blade of a dissecting forceps is gently worked across between the sac and the vessels behind it in infants cien this manquvre will often fail In such cases I lay the thin sac night open with scissors on its anterior aspect to within 1 in. of the neck and get my assistant to hold the margins open with forceps while he the cord on the stretch By this mancurrc the neck of the sac us seen from within as a small funnel The peritoneum just beyond thus opening is carefully cut from within, using a small rounded knufc (No is blade) the traction on the cord causing the cut to gape When the cut has been extended nght round the neck, che proximal edges are tcased free and picked up by three or four mosquito forceps The neck of the sac thus isolated and held up is further freed from the stretched cord by a few strokes of the closed scissors and acd off The rest of the sac should be laid open and the anterior part should be cut away leaving the posterior part still clothing the cord (11) The treatment of the sumica vaginalis in congenital hernia In congenuital herrua the sac has no fundus that can be removed in continuity with the body The surgcon may either carry hus separation of the sac down to the upper polc of the testis and then divide it closing the distal opening with a ligature or purse-string suture or he may carry his dissection into the scrotum, and remove the parietal layers of the puts ·HERNIA tunica vaginalis in continuity with the sac thus combining a radical cure of hydrocele with that of heria The choice is a manter of personal preference The tunica vaginalis is a normal structure and must serve some purpose but there is no evidence that its removal brings any disability On the other hand hydrocele is slightly commoner after a hernia operation than it is in the general population I personally reconstruct the tunica vaginalis in a child and obliterate it in an adult (11) The removal of liponata Any lipomata lying in the inguinal canal must be removed as part of the operation of curc of thc hertua They stretch the muscles interfere with the action of the inguinal sphincter, and when springing from the extra-peritoneal fat they can undoubtedly cause a recurrence after removal of the sac by dragging down a fresh pouch of peritoneum Any obvious lipomato encountered in the sub-cremasterc space should be removed before the sac is disa turbed. They can then be seen clearly and removed completely whereas later when they are stained with blood, their outlines are less distinct Pedunculated lipomara has come through the internal ning with the sac should be pulled down crushed at their neck and ligatured before they are divided (h) Inguinal hernia in the female The inguinal canal of the female is surprisingly like that of the male suggesting that the first mammalian prototypes experimenting with temperature control of the gonads extruded the ovaries as well as the testicles from the abdominal cavity The round ligament that takes the place of the cord, is strualler and less sascular and is not subjected to the same movements and alterations in diameter The channel 15 therefore smaller the cremaster less well developed and the conjoined muscle forms a less obvious arch but runs close above and almost parallel to Poupart s ligament Inguinal hernia in the female is nearly always oblique duc to the persistence of a congenital sac that lies in front of the round ligament and accompanies it into the labium majus To separate this sac from the round ligament without damage to either structure is a difficult and cedious matter and in the opinion of most surgeons unnecessary The round ligament curtailed at the internal ning can apparently arry out its suspensory funcuons just as well as When it extends into the labium The steps of the operanon arc the same as those of the standard ·- OPIRATION FOR LARGER IERNIAE operation in the male down to the point when the cromaster is reflected from the round higament. The sac and round ligament are nou picked up and pulled gently wlule thesr distal extensions are cleared by blunt dissection from the tissues in the labium When the fundus of the sac has been exposed, any strands of tissuc remaining distally including the termination of the round ligament may be crushed, ued, and cut across The round ligament and sac are now held up and deared as far as the internal ning The sc is usually so thin that it can be seen whether It is empty but if there ss any doubt it must be opcried and explored. Thus point settled, che sac-found-ligament bundic is crushed at the neck, transfixed, ued with catgut, and cut across 11 beyond the ligacure Since the canul 15 now empty it can be obliterated with three satches of No i algut passed through the conjoined and crcmaster muscles and Poupare s ligament and tied aghtly enough to approximate the muscles but not to cut into them. 2 THE OPERATION FOR LARGER HERNIAE OF THE ODLIQUE TYPE The standard operation described aborc offers the best chance of permanent curc in an early oblique hermua in a young person that is a hernua in which the posterior wall of the canal us sound, the internal ring is unstretched, and the muscular defences are intact Some cases are encountered however in which the internal ring has become damaged, but the muscular sphincterc mechansın of the anal remains apparenely sound. The neck of a congcrutal hernia bes above and to the outer side of the cord Whion contains no bowel it is a potential space only that docs not dilate the fibrous collar of the internal ming With the repeated entry of abdominal contents into the sac the neck becomes dilated and the ring becomes stretched to accommodate it At first only that part of the accumference occupied by the sac is stretched, that is the upper and outer segment and the inner border of the ring is not displaced. Later the whole ning becomes dilated, the inner border and with at the deep epigastric artery is displaced medially and the border instead of being a tough fibrous sing loses its defiruuon The cord, rhough sall bearing the same rclauon to the neck of the sac and the ·48 HERNIA ring is artery leaves the posterior wall nearer the mid-line than is normally the case An estimation of the size and displacement of the ring and of the strength of its borders is necessary to the decision whether the inguinal canal can still be retained as a functional sphincter A normal the diameter of the cord when engorged with blood, roughly the diameter of a lead pencil Its margins arc well defined, almost tendinous Such a ring needs no repair If the surgeon finds that the site where he has tied and cut off the sac appears as a weak arca lying lateral to the cord, but that the cord is not displaced medially the inner margin of the ring is firm and the deep epigastric artery runs a straight course he will be content with some simple approximation of this defect over the stump of the sac. If on the other hand he finds that the ring as a whole is dilated, the cord displaced, and the artery shufted, he can restore normal relatons only by moving the cord outwards to that part of the occupied by the neck of the sac and by repairing the weak arca to its medial side ring formerly (a) Incision reflection of the external oblique aponcurosis and the cremaster, isolation and ligature of the hernual sac These steps are the same as in the standard operation. The frecing of the neck of the peritoneal sac from the fibrous layer that surrounds st without damage to the latter is particularly important for if the stretched ring is further damaged any attempt to reconstruct a functional sphincteric mechanusm is bound to fail (b) Repair of the defect in the internal ring The weak area is cxposed by drawing the cremaster and internal obliquc muscles strongly upwards with a small retractor thus bringing into view the transversalis fascia lateral to the cord the stump of the divided sac and the defect around it The integrity and strength of the margins of the stretched ning are demonstrated by drawing the cord upwards and laterally and holding up the infero-medial margin of the ring on a blunt hook. Unless these margins are strong repair of the ning is misplaced conservatism I advocated reconstruction of the intemal ning in 1936 Lytle published his method of rcduong the ring while seraining its mobility in 1945 I have since ampufied Lytle s operation by combining sath it ·OrTRATION FOR LARGER HERNIAE the transplantanon of an active fasaal strip a further method that I had advocated in 1936 (F18 23A) The cord is displaced to the outer and upper part of the stretched ring and held there by a small retractor which at the same amo keeps back the muscles and exposes the inner part of thc defect The 49 INTERIOR VIEW B FIC 23 The Levator Annuli Interni operation operation for repair of a moderately stretched internal ning (A) Suture of the stretched rig medial to the cord (B) Support of the repaired ning by a musculo-fascual sling margins of the defect are approximated by inserting a small blunt hook under its mcdial cdge and drawing it firmly towards the pubis The defect is now closed by interrupted sutures of No 60 linen thread the first inserted at the hook, which is now taken out and the tied suture left long is used to continue the traction. The margins are approximated by further interrupted sutures working ourwards till the ring is reduced to a diameter of 1 cm snugly enclosing the emerging cord.

·so HERNIA strip 15 A strip of external oblique } in. wide carrying its own ncr c and blood supply is now mobilized from the upper leaf of the aponcurosis The aponeurosis is slit with a knufe and the she is continued with sassors in the line of the fibres night down to the pubis where it is cut across close to the bonc The muscular part of the external oblique is now exposed by retracting the skin, and the separanon of the continued for 1 in into the muscular part the fibres being separated by gentle blunt dissection (Fig 23B) The distal end of the strip is now threaded on a Gallic needlc and passed ablıquely through the muscular layers in latcral to the ring to emerge in the plane between transversalis and fasaa just below the cord The needle and strip are then damned in and our through the repared posterior wall | 11. outside the margins of the ring as far as its upper margin, and then back through the muscular layers to emerge wherс they went in. The strip is then sutured to itself with a few interrupted stitches of No 60 linen thread, and any excess is cut off The effect of thus operation is to construct a fascial loop or sling surrounding and framing the intemal ring and pulling up the ning under the muscular layers when the muscles contract just as the normal fibrous sling described by Lytle appears to do (9) Closure of the wound The cremaster is carefully sutured over the cord and the external obliquc and superficial layers are closed in the same way as in the standard operation I have performed this operation perhaps n'enty times in the last ten years I know of no recurrence but any surgeon will know how little that means The operation springs from an admiration of the inguinal canal as one of Nature s greatest masterpieces and a wish to preserve that wonderful mechiusm intact It has the fundamental weakness of all action based on emotional rather than factual season, that it muay be used in cases for which it is not suitable There are certainly cases in which a stretched internal ring can be repared, leaving an inguinal canal as good as ever and as proof against recurrence A more practical view one to which I find myself Icaning increasingly, 15 that inguinal canals like eggs are good or bad few are 'excellent in parts The good ones should be left undamaged the bad one should be reconstructed rather than repaired.

·RECONSTRUCTION OF INGUINAL CANAL $1 3 RECONSTRUCTION OF THE INGUINAL CANAL The first two operations are intended to preserve or restore the normai inguinal mechanism When this mechanism is beyond repair something much morc claborate is required the replacement of Naturc s handwork by that of man Thc dcasion that such reconstruction is necessary is therefore onc of considerable importance The defences of the inguinal region are based on a system common to the whole locomotor apparatus of the body--a fibrous framework protected by a muscular guard, much as a frontier is defended by mechanical forufications manned by living troops Under repeated attacks the forts may be damaged, but the garrison may remain cffccave ready to take over as soon as the forts are repaired or forts and garnison may be overwhelmed together. But it is unlikcly that the troops will be put out of action while the fortifications remain undamaged. Even so in the ingunal region the fibrous planes alonc may suffer the muscles may atrophy with or after the fibrous planes but the muscles cannot give way alone leaving thc fibrous tissues intact. Reconstruction is necessary when the fibrous planes have yielded to an extent that renders repair impossible without cncroaching on the muscles or when, with a lesser degree of fibrous tissuc damage the muscles are also inefficent Any yielding of the posterior wall itself that is of the part medial to the deep epigastric artery is an absolute indication for reconstruction Enlargement of the eng lateral to the deep epigastric artery is remcdiable if the stretching is moderate and the margins of the defect are firm but beyond a certain point which may for practical purposes be taken as a diameter of an inch the clarging ring encroaches so much on the posterior wall that the falure becomes a general one of the fibrous planes of the canal An estimation of the conditions of the muscles is therefore of decisive importance only in those cases in which the fibrous defect is considered to be reparable provided the muscles can play their part that is cases considered suitable for the second operation Replacement of the cremaster muscle by fibrous tissue or far thunnung or bulging of the conjoined muscle or a pale flabby appearance of its fibres will determine the surgeon to reconstruct rather than restore A direct heria always demands reconstruction The reconstruction of a faled inguinal canal would be relatively ·S2 HERNIA surgeons like simple were the surgeon free to close the whole defect as he can in the female inguinal canal after excision of the round ligament with the sac In most cases he has the more difficult task of effecting sound repair while allowing free passage to the spermaac cord with its variable blood supply Castration is seldom permissible The device of reduang the diameter of the cord by crasing most of the pampuuform venous plexus as in the original Halsted operation, is followed too often by pain hydrocele, or atrophy of the cestes to be recommended The majority of reconstruction operations fall into two groupsthe operations of repair anterior to the cord and those of postcrior repair The surgeon himself must deadc which type is the more rational and he should be guded in his choice by basic principles rather than by the catch words" with which priests and politicians seek to suggest the answer by the way they put the question Thus the advocates of anterior repair seck to justify their choice by saying that the cord is not dislocated from its bed The same surgeons never speak of dislocating themselves or their patients from their beds in the morning nor do they'dislocate' a shirt from the drawer when they dress They use a word suggesting volent rupture from natural bonds because they have alrcady deaded tluar they do not wish to reach the posterior wall of the cana? In my opinion the deading factor is that an efficient and durable reconstruction depends on the production of firm fibrous tissues and that to be secure a fibrous channel transmutting a bundic of blood vessels must be long and obliquc An efficiently performed posterior repair will transmit the cord through two openings cach ngid and of the sequired diameter placed far apart in strong posterior and anterior walls An anterior repair which takes no notice of the posterior wall may make a rampart cqually strong but the channel that it leaves for the cord will eventually become a direct one lying close to the pubic spine (Fig 24) The following description is of the form of posterior repair that I have myself found satisfactory It is a des clopment of the operation that I first descnbed in 1936 as Silk Lattice Repair , but I have modified it considerably since I returned to anl practice in 1945 I have abandoned strong silk (No 4 Chinese Twist) for fine thread (No 60 Barbour s linen thread) I no longer use a double lattice but I make a single one span the whole zone of failure and extend lateral to the internal ring and I do not attempt to inase the ring ·- RECONSTRUCTION OR INCUINAL CANAL 53 MORMAL INGUINAL CANAL 0 FAILED INGUINAL CANAL POSTERIOR RECONSTRUCTION ANTERIOR RECONSTRUCTION FIC 24 Alternative methods of reconstructing a failed inguinal canal (a) Exposure of the defect The skin inasion and the reflection of the external oblıquc aponeurosis and of the cremaster are donc in the same manner as in the standard operation and the modified standard operation The skin crease incision is particularly advisable in the operation of reconstruction because where thread is used, the carly removal of the skin sutures and the divergence between the plane of the inasion in the subcutaneous layers and that of the musculo-aponeurotic structures provide further safeguards against chancc infection from without If the hernia is an oblique one the cord is lifted from its bed the sac is separated in the usual way isolated to its neck ligaturcd and cut off if the hemia is direct the sac should on no account be opened ·56 HERNIA to che enough to lift the patient off the table of the catgue could stand the strain The stitch is trebly tied, and a second stitch 15 taken through Astley Cooper's ligament and the rectus sheath in more laterally After this second stitch Astley Cooper s ligament should no longer be used as an anchorage since the illo-pectincal line runs backwards and belongs properly to the lateral wall of the pelvis and not to che abdominal wall The suture is continued outwards in a lateral direction each stitch taking below a bite of the very tough layer that lies below Poupart s ligament and is compounded of the thickened edge of transversalis fascia and the lower origin of the cromaster and above the conjoined muscle The upper bite should include quite a fair amount of tissue as much as can be brought down to Poupart sligament with only gentle tension The suture is continued outwards about four stitches to the inch point of emergence of the cord At this point the cord is held strongly outwards, so that the last stitch can be acd behind the cord unuting the conjoined muscle to the para-Poupart fibrous layer and allowing only just room for the emerging cord While thus suture is being inserted the surgcon should make sure that the detached cremaster muscle is lying snugly behind the sutured layers for the whole length of the canal I consider it important that the statches in thus continuous catgut suture should cake their bite in the tough layer that lies deep to Poupart leaving a virgin and completely undamaged Poupare for che thrcad lattice that follows (c) The thrcad lattice Thc purpose of the thrcad layer as I now use it is not to add any considerable mecharucal strength to the new posterior wall but to anchor all the layers in their new position ufule they become blended and to provide a permanent fibrous matrix for this important barrier The upper margin of the zone of failure is first displayed by rctracting the upper leaf of the external obliquc aponeurosis to the line Khere it becomes blended on the sectus sheath An 78 in suture of No 60 linen thread of a No s nccdie is used Tlic first stitch is taken through the rectus sheath just outside the point where the external oblique blends with it but a good inch inside the outcr border of the muscle (Fig 27) It should be at least an inch latcral to the emergence of the cord and is tied there it is then passed downwards to pick up Poupart s ligament about an inch latcral so the emergence point of ·RECONSTRUCTION OF INGUINAL CANAL 57 of the cord back again to pick up the rectus sheath down again to Poupart s ligancut aill at the third or fourth stitch the point of cmergence of the cord is rcached Each loop on its downward joumey is anchored by short passes through the muscles and cach bite of Poupart s ligament picks up the ultimate uptumcd cdge FIC 27 Second layet (thread) of reconstruction of the postenor wall At the emergence of the cord which will become the new internal ning the thread is anchored by a single loop knot on Poupart s ligament then again just above and lateral to the cord, above and medial and finally again on Poupart s ligament just mcdial to the cord so that the new ring is surrounded and reinforced by a square of thread From the medial side of the ring the thread is carried back to the rectus sheath and down again Poupart s ligament and so on at intervals of 1 in the loops spanning the whole zone of failure till the last is knotted at the pubis where the catgut suture started. Finally the cord is laid back on the new posterior wall which is lightly dusted with penicillin powder The external oblique and skin are closed as in the former operations The after treatment is the same H-E ·CHAPTERS SPECIAL PROBLEMS IN INGUINAL HERNIA Interstitial herna An interstitial hernia is an obliquc inguinal hemia in which the direction of the sac and its relation to the spermatic cord differs from the norma) arrangement of the funicular process Sometimes the whole sac may be ectopic More often a second sac is found that is a deserticulum from the inain one there being a single opening at the internal ring communicating with the abdominal cavity Such a diverticulum may be congenital due to some abnormality in the mechanism of testicular descent in which case it is assocated with late or imperfect descent of the testis or it may be acquired, due to distension by abdominal pressure of a sac that is obstructed distally by adhesioris or by the pressure of a truss Threc varieties of interstigal hernua are described 1 The Properitoneal The sac extends within the abdominal cavity between the peritoneum and the transversalis fasaa It may extend inwards towards the bladder upwards towards the umbilicus or ourwards parallel to Poupart s ligament 2 The Intra-muscular The sac lies ben een the externul oblique aponeurosis and the internal oblique muscular layer Thus hernia too may spread in any direction, but its ink ard extension is limited by the fusion of the extemal oblique with the rectus sheath. 3 The Superficial The sac after leaving the extenul nng curns back over the abdominal wall instead of extending into the scrotum Of the three varieties the first can seldom be recognuzed on physical signs and it can be a source of diagnostic difficulty in the case of scranges lation The second presents as a swelling with the main characteristics of inguinal hernia, but it can often be recognized because the outline of the swelling is obscured when the patient contracts the external 58 ·SPECIAL PROBLEMS IN INGUINAL HIERNIA 59 oblique Thc superficial type is sometimes nustaken for a femoral hernia These intersntial hcmiac arc of little more than academic interest and a trained surgcon will have no difficulty in recognizing the condiuon at operation and in dealing with it Only in the case of strangulation, when an obstructed loop may be concealed in such a diverticulum may they cause confusion. Congenital direct bernia (Sec page 27) This hernia is usually cncountered as a surprisc and its nature is not sccogized until the external oblique layer has been reflected The sac should be exposed with as little trauma as possible usually by indsug any overlying muscular layer in the line of its fibres The peritoncal layer is exposed and mobilized without difficulty and then it is held up while the opening in the aponcuroric layer through which the sac has protruded is defined and cleaned By traction and a few stups with blunt scissors thc peritoncal neck is defined After opening thc sac to nuake sure it is empty the neck is tied cut beyond the ligature and allowed to drop back The margins of the aponcuronic hole arc overlapped in the line of pull of the conjoined tendon with two or threc sutures of No 60 linen thrcad. Sliding hernia These herniac are I believe always of the acquired oblique type (sce page 26) The sac is wide-mouthed, rounded, thin-walled, and though it is lateral to the cord and has got into the same fasaal layer It is quite distinct from vas and veins A sliding herria can present a very trying even a dangerous problem to the inexperienced surgeon The diagnosis of oblique inguinal hertua has been made with confidence and the operator after reflecting the external obliquc and opening the sub-cremasteric space is pleased to find that the diagnosis is correct He then picks up the sac in front and proceeds to work round it carefully stnpping off all adherent structures Half way round the arcumference he comes on veins that will not strip These are the posterior caecal veins and if he does not then recognize that he is dealing with a sliding hernua he will proceed with increasing vigour and determination until he is faced with copious haemorrhage or a ragged hole in the back of the caecum or pelvic colon ·60 HERNIA As soon as he knows that he is dealing with a sliding hemia he must realize that the sac is a matter of no importance It must be cleaned but this can be done in a few moments with a dry sabor blunt scissors It need not often be opened and it should never be excised. If the empty part of the sac where its wall is not formed by a slıdıng viscus is roomy that part should be erased and the edge should by sewn up again to make a smaller sac but usually it is wisest to push the unopened sac and its contents back into the abdomen, clear the cord from its cremasteric coverings and reconstruct the inguinal canal The security of such a repair depends entirely on the soundness of the reconstruction, and not at all on the removal of the sac. Very large herniae An inguinal hernia which has stretched both inguinal rings and become uncontrollable by a truss will grow rapidly and often attain an enormous size within a year or two The skin is stretched and often ulcerated over it and the petus entirely buried the urine passing through a small slit and adding to the soreness of the skin the contents are adherent and irreducible and often too bulky to be accommodated in the abdomen could they be reduced The patient suffers from the immobility enforced upon him and from absorption of toxins in his obstructed coils he is fat emphysematous and has poor heart muscle Such cases present a very difficult problem The patients are unable to work alınost unable to get about On the other hand strangulation is much less likely than in smaller and more reducible old hernuac, and their operanse risk taking into consideration the magnitude and difficulty of the task and the condition of the subject is almost prohibitive The only apparatus that can be provided is a bag truss but with thus the increase in size as arrested and a certain amount of activity is possible Operation should be undertaken only if there is some special reason to commend it and after the risks have been pointed out By using local anaesthesia by stopping the operauon at any time on the apa pearance of collapse and completing it if necessary in two or three stages it is usually possible to alleviate all but the worst cases The amount of tissue to be replaced in the abdomen is very matonally reduced by exauung ali omentum that lies in the sac These operations are definitely not cures but they will allow the patient to get about afterwards wickassell ficced truss and to improrchus health by exercise ·SPECIAL PROBLEMS IN INGUINAL JIERNIA 01 Recurrent hornac A herus appearing in an ingunal canal that has already had a licrual repair is not necessarily a rccurrence A direct licmia is so common in older men that it must be expected that many of these will occur in inguinal canals in which an obliquc herra has already been successfully repaired if the second hcmua appears five years or more after thic first it should be regarded as a fresh onc Apart from the incvitable fallibility of the inguinal region with advanang cars which means that a certain number of hermal repairs will fail cvcntually however well they have been performed, the causes of recurrence may be attributed to the surgeon, or to the method It is unfortunate that in many Medical Schools the repair of herniac is regarded as a matter of minor importance Senior surgcons seldom perform the operation themscives nor do they often demonstrate che steps to their juniors or supervise them when they do it for the first time in the Review by the Statistical Department of the Army Medical Service to which I have referred previously (page 34) it was reported that in a series of nineteen operations for recurrent hernia in fifteen failure to excise the original sac was the cause for recurrence Thc sccond cause of recurrence which is often combined with faulty performance is the usc of the wrong method to say that any method is wrong is after all no more than a personal opinion I will therefore cnumerate the causes of recurrence roughly in the order of their frequency in the cases that have come to me for a secondary repair The most frequent finding has been the recurrence of an oblique hemia within a few weeks or months of an operation for the curc of oblique hemia Usually the sac has not been identified or removed and It lies in its normal position undisturbed Often the sac has been dissected out but not removed up to its neck and the remnant left behind has dilated again Sometimes the sac has been tied off at its neck, but the stretched internal ring has not been repaired and a fresh oblique hemia often of the sliding type has come down through the weak area The second commonest cause of recurrence in my experience has been the performance of the classical Bassin operation The sutures pull the muscles out of their normal line of action and if tied tightly strangulate them in any case sutures alone however placed and ·62 HERNIA however tied, cannot perpetuate the displacement and the muscles tend to leave Poupart's ligament and retum much damaged, to their original position The result is a direct hernia Next to Bassini in my experience has been the reconstruction of the inguinal canal by a nylon latace Nylon appeals to many surgeons because it is strong produces no reaction and is not extruded even in the presence of sepsis But it takes no part in repair, and tissues sutured under tension with nylon return to their original site leaving the nylon where it was put A nylon damed hema fails, not because the nylon has done any harm but because it has done no good Finally hernia repairs fail because the method of repur has damaged the delicate tissues of the inguinal canal and particularly Pouparts ligament the key to the inguinal region Fascial strips and Aoss silk sutures are both wreckers of Poupart s ligament Fascial sutures semain alive and are incorporated by living fibroblasts in the tissues into which they are woven But they tear Poupart s ligament into longitudinal strips and they are too short to bridge the zone of failure effectively They are wosen into the internal oblique layer which is capable of further yielding and they cannot be spaced close enough to form a secure barrier Direct herniae may force their way through the rigid openings which are left between the strands Floss sulk is as destructive to Poupart s ligament as fasaa but it as more irritating and in the presence of sepsis it must be removed piecemcal an interminable task THE OPERATION FOR RECURRENT HERNIA The repair of a recurrent herrua necessarily requres a reconstruction of the inguinal canal The incision is dictated by that previously used, which is in most cases the conventional one parallel to Pouparts ligament The incision The skin is first marked with three or four lines drawn in skin ink at night angles to the previous scar The saar is outhned by tro cuts which meet at the ends and are continued at the outer end for } in. for it is here that the decper planes can be identified in undisturbed tissues The cuts are decpened to the external oblique layer and the ·THE OPERATION FOR RECURRENT IFRNIA 63 dissection is continued between fat and aponeurosis towards elic scar of the incision The scar with the clipse of fat is removed and the deeper layer of fat is trimmed with scissors all the scar in the external obliquc is laid barc Care is necded at the inner end to avoid damage to the emerging cord and it is wisc at this point to identify thc cord well bcyond the scar of thc previous operation and to hold it up with the fingers wlulc it is freed. Reconstituting the canal The external oblique aponcurosis is incised just lateral to the previous scar and the cut is continued in the same line through the scar tissue The two edges of this cut arc held in toothed forceps and the surgcon frees the upper flap with a knife working on thc deep surface of the external oblique aponeurosis in the linc of its fibres and parallel to its planc Thc night plane is easily established to the outer end of the incision where the internal obliquc layers have not been disturbed by the previous opcration but more medially it may be difficult particularly if fascial strips or unabsorbable materials have been used. Towards the external ning the dissection requires carc as the structures of the cord are often adherent to the aponcurotic layer that overlies them, and the veins and still more the vas may be casily The lower leaf is dissected in the same way until the lower edge of Pouparts ligament is displayed down to its insertion in the pubic spine Once again the correct plane is casily established towards the outer end of the inasion where the layers have not been disturbed previously but from the internal ning to the pubic spine they may be almost unrecogruzable if fascial strips from the thigh or the external oblique or sulk or nylon sutures have been used to dam Poupart s ligament Nevertheless the whole length of Poupart s ligament must be displayed or a satisfactory reconstruction will be impossible This step implies slow and patient dissection with a sharp knife working parallel to the surviving fibres of the ligament where they can be recognized and dividing the darning material whatever its naturc Sutures of foreign material should be removed as they are cut but fascial sutures can be left to play their part in the new fibrous posterior wall that will be reconstructed Having reflected the external oblique medially as far as the point where it blends with the sectus sheath and laterally to Poupart s cut ·HERNIA 6.4 ligament the surgeon must nox free the cord as far as the internal ring The cremasteric layer has probably been removed, destroyed, or incorporated in the previous repair but the cord must be dissected frec from any structures whatever their nature that overlic or underlie it by sharp dissection while it is held up and drawn medially with finger and thumb till the point where it comes out of the transversalis layer and under cover of the internal oblique layer is reached Reconstruction of the posterior wall This is effected by a thread lattice repair as described in Chapter 4 page si but the material available is very variable If the previous operation was an inadequate herniotomy for obligue hemia the operation is straightforward If some reconstruction has been done the cremaster has almost certainly gone and the internal oblique has probably been damaged On the other hand the total matenal available is probably adequate and viable and it may even be better than usual owing to the incorporation of fascial strips It is brought down as described previously to the tough para-Poupart layer of fibrous tissue that lies immediately deep to the aponeurotic fibres of the ligament by a continuous suture of No o catgut that extends from the pubic spine to the internal ring This continuous fibro-muscular shcet lying behind the cord is kept in place and reinforced by a lattice of No 60 linen thread woven from the rectus sheath to Poupart s ligament cxtending onc inch lateral to the emerging cord and enclosing this point of emergence by a square of thread stitches knotted at each comez The previous repair has sometimes so damaged the distal parts of the cromaster and conjoined tendon, that not enough material is available to make a strong posterior wall to the all-important inner end of the canal Thus difficulty is 01 crcome by a vertical relaxing incision in the inner end of the rectus sheath decp to the cxtcrrial oblique (Fig 28) This inasion need not be more than an inch long but It allows the outer edge of the rectus sheath and with it any intemal oblique fibres remaining to be approximated without tension to the inner & in. of Astley Cooper s ligament After reconstruction of the posterior wall the canal is dusted with peruallin powder and the extemal obliquc is closed with a confinuous suture of No i catgut The skin and subcutaneous layers 250 doscd carefully by a series of fine nylon sutures tied over a gauze roll ·TIF OPERATION FOR RECURRINT NICANIA 65 FIC 28 Operation for recurrent hemia The relaxing incision in the rectus sheath (The cord has been omitted from the figure) after the skin cdges have been accurately approximated with Michel clips Meticulous skin closure is essential after the repair of a recurrent herrua because carly first-intention hcaling is the suresc safeguard against infcction of the decper layers of the sound Castration The inguinal canal is the rent in the abdominal parietes caused by the emergence of the cestis and with the removal of the testis it becoines no more than a gap in the muscular layer that can be repaired with the same case and the same certainty as any other ventral hemia In any difficult repair particularly in a hernua that has rccurred several times the advisability of removing the testis should be considered, and the consent of the patient to such a step of considered advisable should be obtained. To castrate a patient without permission is dangerous Most men s cgo is to some extent linked with their virility or its memory and they would look on the removal of any part of their extemal genitalia as an intolerable affront Actual removal of the testis is not absolutely necessary Where a patient has refused such a course I have on several occasions obtained the same secunty by dividing and ligaturing the cord at the internal ·66 HERNIA ing ning and, after repairing the hemia, attaching the stump to the external oblique aponeurosis near the dosed external mng The testis is, of course dead, but if the sound is clean it remains umunfected and atrophies only slowly remaining in the scrotum as a symbol. Only once have ! known it to slough The empty inguinal canal is dosed by stitches of stout atgut, bringthe muscular layers down to Poupart s ligament without tension. A further latace of No 60 thread may be addedıf considered advisable Reconstruction of Poupart s ligament Poupart s ligament is the representative in man of the fibrous banner found in all quadrupeds where the anterior abdominal wall meets and blends with the flexor muscles of the thigh. It us infinitely older than the inguinal canal, and it depends for its secunty on bang aed by and to every fascial plane in the neighbourhood-the fascia of the muscles the fascial envelope of the thigh, the fasaal sheaths of the vessels and the fascial septa that dip between the muscles and get attachment to the bones of the pelvis and the capsule of the hip joint The ligament is not merely invaluable it is irreplaceable. The advice given by some surgcons that it may be divided to help the reduction of a strangulared femoral berma, or that the lower attachments of the ligament to the fasaa Lata of the thigh may be cut to help the repur of an inguinal herrua is unsound and dangerous When Poupart s ligament has been cut across detached from i deep connouons or lacerated by fascial or floss silk sutures secure repair of an inguinal canal that still transmits the cord us impossible The tesacle should be removed, or the cord should be removed from the inguinal canal by division at the internal ring The anterior abdominal wall can then be re-attached to the fexor muscles of the thigh by a series of stitches picking up the remains of Poupart s bgament Astley Cooper s ligament medial to the femoral vein, the psoas fascia lateral to the external liac artery in fua any structure fibrous cough to give a secure hold. Something more as needed when the recurrent bertua is a femoral one In such a case a stap of fascia lata may be passed through a doll hole in the body of the pubs and attached Laterally to the remains of Poupart s igament (w buch alsays surties in its outer half) A fasaal dan berteen thus sop and Astley Cooper s ligamear medul to the che femoral san completes the barriet retaming peritoneur ·TIIT OPERATION TOR UNDESCENDED TESTIS 67 THE OPERATION TOR UNDESCENDID TESTIS A fully scrotal tests as unusual in a new-born infant During infancy testos arc normally highly retractile and under the stimulus of cold or skin contacts they are drawn up into a subcutaneous pouch overlying the pubus It is therefore important to distinguish between a retractile testicle and a blocked testicle Tlie retractile testicle will descend into the scrotum at or shortly beforc puberty the blocked ecstide wall neser descend Hormone therapy luas no place in the treatment of undescended testes If the testes are merely retractile the adminustranon of hormones may Lasten their inevitable descent by a few months or cien y cars but at the expense of precocious cnlargement of the external gcrutalia and irreparablc psychological damage of the testes are blocked hormone treatment is equally harmful but quite useless The distinction between non-descent and blockage is casily made If the testis is merely retractile it can be persuaded to come down momentanly into the scrotum by repeated genelc stroking in the line of the inguinal canal with the finger while the child lics related and warm if it is blocked no amount of stroking will bring it below the pubis A retractile testis (and indeed a blocked rescis) is doing no harm and suffering no harm all the onset of speriatogenesis Any treatment therefore should be postponed till the age of ten or later if normal descent seems to has started then. The incision As in all operations on the inguinal region, the crease incision is to be preferred. The cut after ligature of the superfiaal vessels is deepened to the plane between Colles fascia and the extemal oblique aponeurosis and dissection is extended in thus arcolar plane with small ball su abs until the whole external ang is displayed down to thc pubes The tests will then be seen cither drawn up to the external ring or lying within it covered by the intercolumnar fascia The external oblique is split in the line of the pillars of the the inner and outer leaf are turned back as far as the rectus sheath and Pouparts ligament exposing the muscular lazers The cremaster is picked up between toothed forceps and incised in the line of its fibres and the sub-cremasteric space is opened up The cord and testis are almost certainly lying in a congenital heral sac of very thin pentoneum and they should be mobilized as a whole by carrying the ring and ·68 HERNIA reflexion of the cremasteric flaps back till the cord is free Still kceping the sac unopened the testis is drawn up by trachon with finger and thumb and freed by dissection with non-toothed forceps from its attachments in the scrotum This dissection is difficult The undescended testus is usually imperfectly finushed and the epididymus is a long structure loosely attached to the corpus testis In drawing the tests out of the scrotum the epididymus lags behind and must be progressively freed Finally a point is reached when the tissue being drawn up is clearly fibrous and not secretory that is it represents gubernaculum and not epididymis Thus fibrous band is divided between hacmostats The distal scump is ligatured and allowed to drop into the scrorum and the path into the scrotum is defined by passing curved Mayo scissors down into it and opening them gently and repeatedly The hernual sac is now opened The difficulties mentioned on page 45 will be encountered but it is only necessary to remove the anterior wall of the sac in its distal part, and, while drawing the testicle downwards to mobilize the peritoneum where it forms the intemal ring dissect it free from the constituents of the cord, ligaturc it and drop ir back It is now necessary to make sure the testis can reach the scrotum The vessels of the cord and the vas are seldom short and the barrier to reposition is a number of fine fibrous bands that can be divided after they have been identified and put on the stretch Provided that the testis can be placed and maintained in the scrorum without trauma the cord will stretch afterwards to the required length The absence of trauma is the one essential for it is fucile co replace in thic scrotum a tests that has been destroyed by the method of replacement The operation commonly advocated that of Thorck whereby the testis is held down by stitches to the fascia of the thigh is an example of inexcusable trauma and it is unlikely that any testis subjected to such treatment will survive to function The method of trans-scrotal reposition of Philip Tumer that retains the testis by an elastic pull that slowly elongates the cord, as preferable To retain the testis the closed lucmostat holding the gubernaculum is pushed down into the scrotum and 3cross the mid hne to present on the opposite side (rig -92) The presenting point is cut on to with 2 krufe and thrust through the skin. The jaws 350 opened, the crushed gubernaculum is seized by a second pur of haemostats and the first pair is withdrawn. While the gubemaculum is drawn down, the ·TIE OPERATION FOR UNDESCENDEN TESTIS small mason in the scrotum is charged with a knufc to a diameter of an inch and closed sassors are inserted on cach side bet cen the skin and the median septum and opened to nuke a pocket for the transposed testis Further traction on the gubemaculum nos brings into vw the hole in the septum through which it cmerges Whule the gubemaculum as pulled down sath care the septum is pushed back over b YA yyy . 2 FIC 29 Tumer s operation of transsctoral reposition 6. the testicular complex by a non-coothed forceps held in the other till qurte suddenly the whole pops through and is held from retuming by the elastic grip of the septal tissues Thc testis is tucked into the scrotal pocket and the edges of the small Incision in the scrotum are brought together by interrupted stitches of the finest nylon The wound is dressed with Mastisol or Whiteheads varrush and the stitches are removed in a weck ·70 HERNIA Returning to the inguinal wound, the nasion in thc crcmaster muscle and that in the extemal oblique are closed by continuous sutuses of catgut and the superficial layers are closed, as in other inguinal operations by a pressure dressing and Michel clips OPERATIONS FOR INGUINAL HERNIA IN INFANTS Operations on the inguinal canals of small babies should be avoided if possible The subcutaneous tissue in the region is fat and deep and landmarks are hard to identify The aponeurotic layers reach their full development only as the result of continuous muscular action, and at birth the external oblıquc aponeurosis and Pouparts ligament are barely identifiable sheets of thin transparent fascia The cromaster is a thick muscle, but the underlying hernual sac can barely be handled without tearing At the same time the child except in rare cases is in far greater need of the nutritional and psychological care of the mother than of the professional care of the surgeon, whose efforts he as prone to treat without regard to the necds of asepsis Inguinal herniac in infancy are rarely uncontrollable and cven more rarely dangerous and operation can usually be postponed till u caring is accomplished and the early infectious crises are over-say till the age of 2 or preferably 4 ·CHAPTER 6 INGUINAL HERNIA-STANDARD OPERATIONS TIIAT ARE NOT RECOMMENDED, AND WHY I DASSINI S OPERATION As in all classical operations the conventional anasion is used onc placed an inch above and parallel to l'oupart s ligament and extending from Just above the external ring to just abose and lateral to the intemal nng The external obliquc is inased throughout the length of the canal The cord is freed from the crenzastoric fibres and the herual sac is scparated from the other constituents of the cord as far as the internal ring ligatured and divided 2 Fig Jo Bassini s operation The isolated cord is now held up and the internal oblique and conjoined tendon the cremaster and the transversalis fascia are united behind it to the inner shelving margin of Poupart s ligament to make a new floor to the inguinal canal (Fig 30) Bassını himself made a point of detaching the transversailis fascia from Poupart s ligament and separating it from the underlying extraperitoneal fat but this step is not followed by most surgeons Bassını again first made the new floor 71 ·72 HERNIA by a continuous suture starting at the internal ring but later he used interrupted sutures starting at the inner end of the canal and furushing at the internal ring He also used silk, but later surgeons have for the most part used stout catgut Each stitch takes a good bite 2 to 3 cm from the edge of conjoined tendon cremaster and transversalis fascia, and then picks up the inner shelving edge of Poupart's ligament The first stitch is placed close to the pubic spine and the last one about 1 cm lateral to the position of the internal ring Four to six stitches are usually required, and all are inserted before any one is tied The stitches are tied behind the cord which is then laid back on its new bed The external oblique aponeurosis and the skin arc closed u turn Bassini was a pioneer He was the first surgeon' to make a rational attempt to repair inguinal hernia by insisting on isolation and ligature of the sac at its neck and the construction of a new posterior wall to the inguinal canal behind the cord His operation introduced a new epoch and all successful operations since his day are founded upon hus work Nevertheless the classical Bassını operation should not be done today Its place like that of all pioneer efforts is in the historical The inguinal canal is a physiological mechanusm, a sphincter. If the muscles are still good they should be preserved if they have fuled they cannot be relied upon to make a strong wall The failures of the Bassını operation vary from none to so per cent according to the length of the follow up and whether it has been conducted by the surgeon who did the operation or by an independent observer museum. 2 THE WILLYS ANDREWS OPERATION Bassinu s operation was first performed in Padua in 1884 and first described by him in 1888 and published in 1890 Willys Andrews imbrication operation which was the first attempt to overcome the fundamental seakness of the Bassini method was published in 1895 The skin incision and the exposure of the ettemal oblique arc made in the usual manner but the pulars of the ning are carefully defined 'He was preceded by Marcy of Boston who however did not convince his contemporrics.

·OPERATIONS NOT RECOMMENDED 73 and the subcutancous fascia is cleared from the aponcurotic layer for an inch belon l'oupart s ligament The inasion in the extemal obliquc is also made in the usual manner but it is placed at least 3 or 4 cm above Poupart s ligament so that the lower flap is suffraently wide to cover the cord at the end of the operation The aponeurotic flaps are reflected the cremaster is incised the cord as Lifted from its bed and the hertual sac is dissected out and ligatured at its neck as in Bassiru s operation. The essential part of the operation is that a strong fibro-muscular posterior wall is made to the canal from conjoined tendon, Cremaster and upper leaf of the external obliquc aponeurosis (Fig 31A) Thus Aap is brought down to Poupart s ligament by a number of W stitches Each stitch is passed first from the fasaa of the thigh below Pouparts ligament into the inguinal canal whilc thc femoral vein is guarded by a finger then through the cremaster and conjoined tendon from within outwards then back through the recurved edge of Poupart s ligament then through the upper leaf of the extemal oblique aponeurosis and lastly back through the lower half of the external oblique close to Poupart s ligament (Fig 313) The effect of this stitch when ccd on the other surface of the aponeurosis is to bring the upper aponeurotic flap and the conjoined muscular sheet down above and below the shelf of Poupart s ligament which projects between them The first stitch is at the medial end of the canal and should pick up Gimbernat s ligament the last should be just mcdial to the point of emergence of the cord. Each stitch, when it has been inserted should be caught with artery forceps and none should be tied till the series are in place Willys Andrews himself used a small number of stout W sutures of Kangaroo tendon, but a larger number of stitches of good catgut more closely spaced is better When all the stitches have been tied the cord 15 laid back on the new posterior wall just above Poupart s ligament and the lower leaf of the external oblique is sutured over it to make a roof for the canal The suture is started at the lateral end and continued inwards all the external ring is reduced to the size of the tip of the little finger The Willys Andrews operation has maintained its place as a sound method of reconstruction in those cases in which the aponeurotic layers are sufficiently good to permit imbrication Unfortunately in many cases in which it is most needed the extemal oblique layer is so thinned by the hertua and the pressure of a truss that it is of little value as repau material I have abandoned it because it has not been H-F

·74
HERNIA
Ext. ObL
muscle
Poup
1
Co joined
tendon
Cord
B
FIC 31 The Willys Andrews operation
(a) Details of the W stitch which draws the conjoused tendon and the upper
leaf of the external oblique aponeurosis down to Poupart s ligament
(b) Suture of the lower leaf of the external obliquc aponeurosis in front of the
cord
available in the cases in which I needed it most because the aponcurotic
overlap at cach cnd of the canal tends to constrict the vessels of the
cord, and because it had no advantage over the thread lattice (page 51)
which is applicable in every case
3 SCHMIEDEN'S OPERATION
Schınıcden s operation was based on the observation that closure of
an empty inguinal canal after removal of the testicle nearly always
leads to cure of a hernia

·OPERATIONS NOT RECOMMENDED 75 After isolation and ligature of the sac in the usual manner, Schimicden pulled the testis into thc inguinal canal and dissected it free of its scrotal connexions He then burrowed between the transversalis fascia and the conjoined tendon and made a split in the internal oblique and transcrsalis muscles in the line of their fibres about an inch above the intemal ring (Fig 32) Hc drew the testis through this opening wluch he then closed round the cord with one or two catgut scitches He completely obliterated the now empty inguinal canal by suturing the conjoined tendon to Pouparts ligament throughout its length He replaced the testide in the scrotum and repaired the extemal obliquc over the cord FIG 32 Schmieden s operation Schmieden s operation is attractive in that the cord, instead of passing through a ring already stretched by the hernia as led through a fresh opening in healthy muscle and the new inguinal canal is longer and more oblique than the one it replaces I have not tried it because the Brandon operation which was published in 1946 seemed to offer the same or greater advantages 4 BRANDON S OPERATION OF LATERALIZATION OF THE CORD Brandon, reviewing contemporary practice of hemia surgery agrees that for congenital hernua with good muscles removal of the sac alone is the surest safeguard against recurrence He considers that in larger oblique hemiae treated by operations of the Bassını type IW J M. Brandon, Lancet 1945 I 167 ·76 KERNIA recurrence is due to one factor alone that the true internal ning is overlapped completely by the lower border of the internal oblique muscle In consequence closure of the so-called internal nng at the operation does not occur at the true internal ring but at a point i to * in. lower down the cord' He proposed to scrap the stretched and weakened internal ring entirely, and construct a new one The operation The steps of the standard operation are followed up to the point where the cremaster has been incised and the cord has been isolated The internal oblique and transversalis muscles are nos divided dosc to their origins from Poupart s ligament in the line of the inguinal canal for a distance of 1 to it in (FIS 33) The sac is thesi isolated FIG 33 Brandon s operation ligatured at its neck and excised Two small retractors are inserted and the cut ends of the muscles gently separated This gives an unimpeded view of the stretched internal ring and allows a comparatively casy closure of the stretched or com transversalis fasoa Once this has been accomplished the cord is brought well up into the V of the incision, and held with slight tension whilc the two arms of the V are sutured with two or threc interrupted catgut of silk sutures thus reconstituting the cut muscles round the cord which nos emerges through a scll-fitting aperture placed 3 ell out 19 a. lateral position The conjoined tendon is then sutured to Poupart s ligament by a scries of interrupted catgut or silk sutures thus closing the old intemal ring and the entirc inguinal canal The extemal oblique is repaired over the cord and the skin incision closed in the usual nuanner ·1 OPERATIONS NOT RECOMMENDED 77 The operation in this form is a modificd Bassini with the following advantages 1 The cord now emerges through a neuly constructed and wellfitting muscular intemal ring well away from the danger arca' 11 Thic now canal is longer and more oblique than the one it replaces * The repaired outlet for the cord through the transversalis fascia now abuts directly against the newly constructed muscular ring allowing no lccway for the forination of a new sac The article in which Brandon propounded this operation, hus assessment of the causes of failure of the older procedures and the reasons that led him to design this new operation of lateralization, arc a finc example of surgical thinking Impressed by hus reasoning and knowing his excellent record as a star surgeon I adopted his operation with enthusiasm and combined it with a silk lattice rc-enforcement in the treatment of the failed inguinal canals that I encountered in a hospital that has the reputation of attracting the failures of surgery elsen here After a series of successful results I had two or three recurrences of 1 type now to me a direct hernia at the internal ning of the type that is common after the purely posterior repair opcrations It is possible that I had not repared the stretched opening in the transversalis fascia with the care on which Brandon insists but I attributed the failure to the fact that the new ring is made through purely muscular tissue with no fibrous component The origin of the internal oblique and transversalis muscles from Poupart s ligament where they arch over the emerging cord is almost tendinous and the new opchung constructed in the Bassını type of posterior repair though it does not correspond cractly to the deeper opening in the transversalis fascia is nevertheless ngid and fibrous The Brandon lateralization cut divides these tendinous fibres and then cuts soft fleshy muscles across their fibres Such muscles however carefully sutured after division, are not matenal to form good fibrous tissue 5 GALLIE S OPERATION OF FASCIAL REPAIR The preparatory steps of the operation the mobilization of the cord and the isolation and ligature of the hertual sac at its neck, differ in no ·78 JIERNIA essential details from other methods of hemial repair The essential technique of fascial suture may be quoted from Gallie s article. The first suture of fascia lata a quarter of an inch wide is anchored securely into the rectus sheath closc to its attachment to the pubic bone The needle is now passed behind the spermatic cord to pierce Pouparts ligament at its insertion into the pubic spine (Fig 342) If possible it should be made to pick up the periosteum to make the security of its fixation more certain. When the suture is drawn taur the weakest spot in the abdominal wall namely that which lies behind the external abdominal ring is filled with a tough aponeurotic tusue which effectively prevents any bulging through the ring The sewing us continued in an outward direction drawing the intemal oblique muscle to the reflected portion of Poupart s ligament behind the cord, until the position of the internal ring is reached Herc the suture is locked and then carried to the outer side of the ning where a supporting stitch is inserted. In this way the cord, at the point where it disap pcars through the abdominal wall is surrounded by a fibrous ring which will effectively prevent the development of a hemia at thus point By locking cach stitch at this stage the possibility of unduc constriction of the cord is prevented The sewing of the internal oblique muscle to Poupart s ligament in this manner as a detail of the operation which in our opinion is of very little value in preventing recurrence of the hernua it is of value however in permanently covering the pentoncum with a thick layer of muscle which will prevent the protrusion of peritoneum through the chunks of the next layer of sutures which is the important one in the prevention of recurrence (Fig 34b) This layer commences as a continuation of the first at the outer side of the internal ring The needle takes a sold bite of the abdominal aponcurosis at its point of fusion with the external obliquc and is then passed behind the cord to pick up Poupart s ligament The suture is carried backwards and forwards across the space with frequent lock-stitches until the sheath of the rectus is reached, and thus also is woven to Poupart s ligament unnl the whole space is filled with fascia down to the pubic spine No attempt is made with the second rou of sutures to drag the abdominal aponcurosis and the rectus shcath out of their normal positions No grcater tension is cxerted on the sutures than is sufficient to make them lie flar The shole idea of the operation is to fill the weak spot in the abdomunal wall with what IW E. Gallae and AB le Mesurser Bm Journ Sute 1944 12.45 115 19 ·OPERATIONS NOT RECOMMENDED 79 TIG 34 Posterior repair of inguinal canal by fascial suture may be called a filigree of living aponeurosis and to depend on the strength of this filigree and on its gnp on the surrounding tissues for the cure of the herria What onc docs with the external oblique is of relatively bale importance Usually in direct hernia it is too weak to be of any value to the surgeon. In our carlier operations we closed it down to the external ring with a narrow strip of fascia but in the last four years we have simply sewn it up with catgut This operation, which I supported strongly in 1936 I have now abandoned because though it is based on excellent research work it damages Poupart s ligament the key structure of the inguinal canal irreparably If it falls it leaves a bad headache for the surgeon who comes after 6 MACARTHUR S OPERATION MacArthur advocated a method of daming by fascial strips similar to that of Gallie but he used strips cut from the upper and lower flaps of the external oblique aponeurosis The strips are left attached at the pubic.snd wherс they form part of the pillars of the extemal ning and are attached to the pubic bone They are divided at the lateral end where the aponeurosis joins the muscular fibres Each strip is threaded on a fascial needle and is used, as in the Gallie operation to dam the conjoined tendon to Poupart s ligament ·80 HERNIA The advantage of the MacArthur procedure is that the operation is shortened no second inasıon is required in the thigh and the first anchoring stitch is unnecessary as the strips are already attached to the bone On the other hand, the fascial material is almost necessarily limited to two strips and in a large hernia these may be of poor quality With this amount it is difficult to reinforce the internal ning with a double ring of fascia as Gallie recommends The diameter of the strips renders this operation open to the same objections as Gallic s that they wreck Poupart s ligament 7 THE MCGAVIN SILVER FILIGREE OPERATION Thus operation differs from all others in that the strength of the repaired inguinal canal depends on the presence of a rigid unstretchable plaque and not on stitching or the mobilization of tissues Thc dcscription is quoted from the author 1 The prinaples which underlic the operation are the removal of the saç the approximation of the conjoined tendon to Pouparts ligament and the rendering absolutely unstretchablc of the whole operative cicatrix by the introduction of a scaffolding of silver wire known as filigree When an aseptic filigree of silver wire is intro duced into the tissues of the inguinal canal there follows crudation of lymph which rapidly organuzes about the filigree and in a very short time new vessels and young fibrous tissue are produced, and entangle themselves among the wire of the filigree to such an extent that a solid plaque is formed that converts thc inguinal canal into a sound, resistant area which will neither stretch nor bulge the muscles pentoneum and aponeurosis being welded together by the filigrcc The method of constructing filigrees given in the above chapter is not repeated but it can be followed from the illustrations The filigree being made by the surgeon is tailored to the particular hernia (Fig 35) Afethod of implantation The filgrees should be placed in cther for five minutes to remove all grease from them, and should be left in the sterilizer in the centre of the most actisely boiling arca until the moment of implantation Lawt McGavin, Choyce a System of Surgery 2nd Edition Vol 2 page 52% Casxli & Co Ltd, 1933 ·OPERATIONS NOT RECOMMENDED 81 The operation is at first conducted exactly as in performing an ordinary Bassint s closure after the sac has been removed, by a little blunt dissection a bed is made between peritoncum and conjoint tendon and thc pubic section of the filigree is laid fiat in it cho conjoint tendon is then scwn to Poupart s ligament with a row of sutures placed in front of the filigree The sliac section of the filigree is now taken from the sterilizer and placed besicath the aponcurosis in such a way - O 75 4 175 Pubic section OS FIC 35 (a) Construction of wire filigree (b) Filigree ready for insertion (a) Pubic section () Iliac section Dac section ning and upon the that its inner end lies over the internal abdominal cord for a space of t in the outer end being carried out ards and lud upon the surface of the internal oblique muscle one or two sutures holding it in place (Fig 36) If the muscular wall lateral co the internal ning is weak it is divided from the ring outwards towards the sliac spine for about an inch and is separated from the peritoncum by the handle of a scalpel upon this peritoneum the outer end of the illac section is land being lightly sutured in place and the muscles are brought together again over it the inner end lying as already described. Finally the aponeurosis is sutured in place and the wound closed. It will be seen that the cord comes to be sandwiched between two layers of filigree in the canal the natural relations of which are ·82 HERNIA hardly altered, and further that the area outside the intemal abdominal nng is fortified by a filigree which may be made of any size that may be deemed necessary Granted a primary union of the wound the hernial gap will be found to become as impermeable and unstretchable as a pad of leather There will be neither pain nor discomfort afterwards there is no interference with the cord or with the functions of the testis and the necessity for any form of truss is done away with permanently b FIC 36 Filigree in position (6) As normally placed (6) Alternative position in large herniac McGavin s operation has an excellent reputation Like John Brown its author is in the grave but his soul goes marching on His successors at the Scamen s Hospital Greenwich to shuch merchant samen from all the seven scas come to have their hernias repaired look on it as the only method that can guarantee a permanent curc of rcally large scrotal heruac in heavy labourers The disadvantages are mainly theoretical Silver sales may occasionally give a brown discoloration of the skin oser the operation arca and if sepsis appears the filigrec cannot be crtruded and must be removed ·OPERATIONS NOT RECOMMENDED 83 8 THE TANNER SLIDE OPERATION Tanner, Scott and del Oro have used thc device of a vertical relaxing inasion in the anterior rcctus sheath decp to the external oblique aponeurosis to allow thc conjoined tendon to be brought down without tension to Poupart s ligament Tanner guards against subscqucnt u cakness of the outer part of thic rectus sheath by attaching the outer leaf of the nasion in the sheath to the underlying muscles by a fess interrupted sutches I use a short relaxing inasion, not more than an inch long in the lower end of the rectus sheath to facilitate closure of the canal at its pubic end in old standing direct homic whicre the material at this point is inadequate I do not like larger relaxing incisions nor do I like detachung the new posterior wall from its normal anchorage on the medial side Robbing Peter to pay Paul is normal practice in finance and politics but it is seldom profitable in surgery 9 THE MCVAY PRINCIPLE Astley Cooper s ligament is a tough fibrous structure on the ilio poctineal line lc is compounded of many tissues of the periostcum of the innominate bonc of the pectincus fascia thickened at the ongin of the muscle of fibres from Gimbernat s ligament the insertion of the conjoined tendon and the insertion of the psoas parvus and of the transa versalis fascia lining the pelvis It holds stitches well and McVay has recommended it as secure anchorage for the conjoined tendon and the transı ersalis fascia in reconstruction of the posterior wall of the Ingunal canal Astley Cooper s ligament belongs properly to the inguinal canal only in its medial inch, for the distance that the conjoined tendon is inserted into the ilio-pectincal linc Lateral to this point it sweeps backwards as well as outwards and leaves the inguinal region to form the lateral boundary of the truc pelvis At the point where the external iliac vein crosses at the ligament is a good inch deep to Poupart s Ligament The inner end of Astley Cooper S ligament may nghely be used to give a secure anchorage to the inner end of a reconstructed posterior wall to the canal Lateral to this point the internal oblique cremaster ·HIERNIA 8. and transversalis fascia can be attached to the ligament only by pulling them right out of their proper plane under considerable tension, and If the suture line is continued out as far as the internal ning the displaced muscles are forced down on the cord like a chopper For the anchorage of free transplants of skin or fascia or of sheets of foreign material such as nylon net or tantalum gauze where it is desired to fix without tension a secure rampart to defend the abdonunal and of an enlarged femoral canal Astley Cooper s ligament gives a secure hold IO BLOODGOOD S FLAP OPERATION The rectus sheath flap is often referred to as Bloodgood s contribution to the Hopkins operation for repair of the inguinal canal antenor to the cord published by Halstead in 1903 The same flap has been used as part of an operauon of repair posterior to the cord by Bloodgood, and also by Downes and by Keynes In some illustrations of the operation as performed by Bloodgood himselt the rectus muscle fibres as well as the sheath are shown as sutured to Poupart s ligament FIC 37 Bloodgood s operation The posterior Bloodgood operation is a reinforced Bassını type of repare (Fig 37) Tro criticisms are suggested the basic one of Gillies cxperiments that a sheet transplant of fascia sutured by its edge does not gain a secure atrachment and the practical one that the detachment of the anterior sheath of the recrus lcases a weak area at the outer border of the muscle protected only by transversalis fascia and sude sider by the pull of the sutured Aap "W SIŁalstead John Hykias Hose Bully 1903 14 20$ ·85 OPERATIONS NOT RECOMMENDED The use of the rectus muscle itself las nothing to reconincnd it A soluntary musclc pulled out of its normal linc tends to atrophy and to make icry poor fibrous tissue 11 TURNER'S TLAP OPERATION Philip Turner of Guys Hospital devised an operation to repair 2. stretched intcmal sing medial to the cord, by tuming up a flap of fasaa from the hip His account of the operation is as follows The essential fcature is that a pedicled flap of fasaa lata with its basc at Poupart s ligainent is used for the purpose of dimunushing the size of FIC 38 Turier s operation the operung and strengthening the fasaal boundary of the canal The flap is tumedupwards bencath Poupart sligament into the inguinal canal and is sutured to the margins of the gap which have been carefully defined at an earlier stage The orginal deep surface of the flap which was in contact with the muscles of the thigh looks forward, while the onginal superficial surface in relation with the fatty assues of the thigh is now in contact with the extra-peritoncal fatty tissues at the back of the ingwnal canal The essential features of Tumer s operation are shown in Fig 38 'Guys Hosprial Reports 1933 13 2 233 ·86 HERNIA Twenty years ago I cited Turner s operation as a permissible method in difficult cises Twenty years have taught me the interdependence of all the fibrous planes of the body, and I look on any injury to or rough treatment of Poupart s ligament regrettable and any severance of its deep attachments as reprehensible Ever since the first vertebrate to get out of the water developed limbs to paddle through the slime limbed creatures have used a fibrous scal to close the gap where the abdominal muscles and the thigh muscles mect The secunty of this band which in man is Poupart s ligament scenis to depend on little but faith and fibrous tissue I shall refer to this point again in discussing femoral hernia Mcanwhile I would discourage any operation that interferes with the deep attachments of the ligament I should disapprove even more strongly of operations such as thac of Henri Fruchaud of Aleppo in which he detaches the whole lower part of the extemal oblique aponicurosis and turns it up as a flap I2 METHODS OF REPAIR ANTERIOR TO THE CORD HALSTED S OPERATION The skin and external oblique aponcurosis are inased in the line of the inguinal canal and the flaps are dissected back widely to demonstrate the muscular layers The cremaster is incised in the line of its fibres and the cord is exposed but not lifted from its bed. The sac us identified dissected free from the other structures in the cord that lie behind it cleared up to the internal ting transfixed ligatured at its neck cut across and allowed to drop back. The muscular layers are then imbricated in front of the cord. The lower flap of the cremaster is first drawn up under the internal oblique and conjoined tendon by a series of matress sutures of finc catgut that pick up the edge of the cremaster and then pass through the intemal oblique from wiclun ouestards about an inch from its free border (Fig 39(a and b) These are tied The conjoined tendon is then sutured to Poup art s ligament by interrupted stitches of catgut Finally the incision in the external oblique aponeurosis is overlapped in a simular manner to the deeper layers the lower leaf being drain under the upper one by a senes of matress sutures (Fig 40) Fruchaud Tenues de l'Ane G Doi & Cue Paris, 1957 ·OPERATIONS NOT RECOMMENDED (6) FIG 39 Halsted s operation Imbrication of the muscular layers in front of the cord (a) The louet flap of the cremaster is being drawn under the internal oblique by a series of sutures %) The conjowed tendon is sutured to Poupart s ligament by interrupted satches The operation is sometimes modified by Incising the rectus shcath vertically to allow thc conjoined tendon to be brought to Pouparts ligament without tension or by cutting a fiap of the rectus sheath in the manner associated with the name of Bloodgood and stitching that also to Poupart s ligament in front of the cord. Foster s operation is a simpler form of the Halsted the conjoined tendon being brought down to Poupart s ligament as in Bassitu s operation, but in front of the cord Ferguson s operation is also similar to the Halsted, but hc believed that in herrua there was a deficiency in the ongin of the internal oblique ·88 HERNIA FIC 40 Halsted s operation Imbrication of external oblique aponçurpsis and transversalis muscles from Poupart s ligament for this season hc started hus suture of the muscular layers to Poupart s ligament lateral to the point of emergence of the cord, and conanued this surure two thurds of the way to the pubic spine but no farther Babcock s operation was simular It seems clear that antenor repair is wrong in primaple In any but an early oblique hernia, the internal nng is stretched, and the cord is displaced inwards carrying the fibrous margin of the nng and the deep epigastric artery with it Anterior repair docs nothing to restore the obliquity of the cord or to prevent its further displacement and the end result is a direct hemia passing through all layers of the ab dominal wall close to the pubic spinc 13 METHODS OF POSTERIOR REPAIR IN WHICH ALL LAYERS ARE USED IN THE REPAIR, AND THE CORD IS PLACED SUBCUTANEOUSLY The best known example of such a mcthod is the niodified Willys Andress operation descnbed by Dewitt Steturn After suture of the upper end of the external oblique aponeurosis to Poupart s ligament the cord is brought out subcutancously and the losser leaf is also sutured behind it to the upper leaf ·OPERATIONS NOT RECOMMENDED 89 Tus operation produces not a licnus but a short direct passage for the cord through u luch hertua will almost successarily follow The great bulk of the cord consists of large veins chat vary in diameter from time to time, and it is impossible to construct a straighe channel that will fit it so snugly that herruation is impossible yet in which obstrucaon of the bloodhou, leading to hydrocclc or atrophy of the testicle is unlikely 14 REPAIR OF INGUINAL CANAL THROUGH AN ABDOMINAL APPROACH (s) Intrapentoneal in the carly days of abdominal surgery Annandale and Lawson Tant advocated an approach to the angunal canal chrough laparoroniy nasion. Later G P la Roquc advised opening che abdomual cavity by a muscle splırang masion through the internal oblique and transsersalis muscles about an inch above sheir lower margus after exposing the sac is the inguinal canal' Hc mm crted the sac into the peritoneal cavity divided it, and sutured the Perconcum scl above the neck. (b) Extra-pontonesl Lenthal Cheatles and A X Henry advocated 211 extra-peritoneal approach through a muid-linc inasion. The back of the ingunal canal and the internal ring can be reached with remarkable case by gentle stripping of the peritoncum from the transuersalis fascia Removal of the sac from the neck downwards without damage to the other structures of the cord is a very different mattes Most surgeons who arc familiar with the long and difficult dissection that is necessary to separate the sac from the veins and the vas by the inguinal approach would say that it is impossible Professor Henry has contributed more of value to the study of anatomical approach in operative surgery than any living man, but hus advocacy has nos ensured any wide acceptance of thus method It is Very difficult to see any advantage on indeed to find any excuse for blind extraction of a herual sac. The intemal ning the fibrous gateway to the mgumal canal must be stretched if not tom, by dragging the whole of the sac through it Surg Gym G Okt 1919 XXIX, 507 *Bni Aled Jourt 1921 3 1035 Lancet 1936 53 ·CHAPTER 7 HERNIA BELOW POUPARTS LIGAMENT The first vertebrate to crawl out of the sea must have been a fish-like creature possibly allied to the Coelacanth, with paddles rather than limbs But the sinuous movements that drove the fish through the water were useless in the new clement. The paddles became limbs and because propulsion is more efficent than traction, the hind Limbs became dominant in locomotion. Antero posterior movements of the spine took the place of the lateral movements of the fish. The creature progressed by a series of leaps flexion of the trunk and the limbs bringing the hunder end forward on the ground extension transmitted this gain to che rest of the body The flexors of spine and hip worked together and had a common attachment to the front of the vertebral column. The scaling of the gap bernseen the anterior abdominal wall and the Aexor muscles of the thigh is the basic anatomical problem of all quadrupeds It is solved by a blending of the lower edge of the abdominal muscular sheet with the fasaal sheath of the thigh flexors In most creatures the contrast between the planes of the two muscular groups is less obvious than it is in human beings In repales and amphsbla the lower fibres of the transversus muscle arise from the fascia over the iliacus and sweep downwards and inwards to gain a wide insertion into the sheath of the flexors and adductors of the thigh. In many monkeys a simular arrangement is seen. Poupart s ligament like the peroneus tertius in the foot is a typically human structure. It represents the fibrous scal that all quadrupeds have but the broad human pelvic girdic places it more nearly in the honzontal plane that it is in other anumals So distinct us it from the flexors that come out from under it that anatomusts have described it as made by the loner folded edge of the external oblique aponeurosis. It is nothing of the sort All layers of the abdominal wall contbute to Poupart s ligament and in its outer third it receives a considerable contnbution from the fascia iliaca. 90 ·or HERNIA BELOW POUPART S LIGAMENT In terms of conventional surgical anatomy Poupart s ligament is a ligament that bndges a shallow trough through wluch the flexor muscles of the tlugh the iliacus psoas and pcctuncus and the neurovascular bundle of the lower limb emerge from the abdomen (Fig 41) It is anchored to the two margins of the trough to the anterior superior spine of the lium and the spine of the pubis The inner anchorage is continued by Gimbernat s ligament which is merely the deeper fibres of Poupart s ligament fanned out along the allo-pectincal linc for more secure attachment Gimbemats ligament is thus a trangular sheet Ileopeclineal line Pectineus - an Gimbernat s Lig Poupart Ilg Conjoined tendon - Rectus m FIG 41 hose apex is at the pubic spine one of whose sides is continuous with Poupart s ligament and the other is attached along the inner end of the Iho-pectincal line and whose base is a free margin faang towards the sub-Poupart trough. On the illo-pectincal line the attachment of Gimbernats ligament lies between the insertion of the conjoined tendon medially and the tendinous origin of the pectineus (Astley Cooper s ligament) Laterally Poupart s ligament is securely attached at the two ends Above it is blended with the abdominal musculature Below it is continuous with the fascia lata of the thigh, and is held by this attachment in a slight curve convex downwards Behind it depends for its security which is for practical purposes absolute on fibrous anchorages The fasaa lining ·IIERNIA 92 the abdomen is a continuous sheer that gains attachment to Poupart s ligament as it passes behind it The same fasaa is continued into the thigh as the sheath of the iliacus and psoas so that Poupart s ligament is fixed to these muscles as they pass behind it The aorta and inferior vena cava are in front of the vertebral bodies and their branches, the iliac vessels lie in front of the fascia covering the posterior muscles When they reach the point where they pass under Poupart s ligament to become the conmon femoral artery and vein, they meet the aliacus fascia sweeping up to join the transversalis fascia and they carry a prolongation of it with them as the femoral sheath The femoral sheath is attached also to the pubic fascia behind and thus fascia, dipping down in the interval between the psoas muscles is fixed to the liopectineal eminence and to the apsule of the hup joint. Thus a strong fascial band embracing the femoral vessels anchors the mid-point of Poupart s ligament to the framework of the pelvis behind (Fig 42) While the moorings of the ligament are indefinite they are romarkably secure and the only sub-Poupart hernua cliat is encountered except as a great rarity is one through the crural canal-that is a femoral hernua The textbook description of the crural canal is that it is the innermost of three compartments of the femoral sheath the arterial the venous and the crural canal It is said to be {to in long to have an pectincus and the Fic 4. The fibrous attachments of Poupant s ligament to the pelvis ·HERNIA BELOR POUPART S LICAMENT 93 opening abosc bounded by Gimbernat s ligament medially Pouparts ligament in front the ongin of the pectincus bclund, and the femoral en laterally to be closed above by a fibrous washer in the sub-peritoncal fat-the scptum crural--to be closed below by the fusion of its medial wall with the femoral sheath to contain fat and a lymph gland, the gland of Cloquet and to transmut a lymphatic channel running from the deep femoral to the external liac Group of glands To the consacntious dissector thc crural canal is an anatomical fairy tale In the dead body che femoral vein is collapsed and a blunt instrument can casily be pushed to its inact side to make a channel In fe the icin is full and during activity the flow it is required to transmut zay be increased up to tu enty ames Room must be allowed under the sid sub-Poupart canyon, and is provided by thus mythical canal for clan to increase its CTOSS-section to carry thus augmented flow Certain anatomical facts must be reiterated since they have a bearing on the surgery of femoral herruae First the canal of a femoral hernia begins and the neck of a femoral herrual sac lies at the free edge of Gimberiat s ligament This level is * in. above Poupart s ligament and it in above the saphenous opening The sac cannot therefore bc controlled up to its neck by any form of truss The junction of the neck of the sac with the parietal peritoncum cannot be reached from below without gross trauma nor can the crural opening be closed securely by any method of suture from the thugh Sccondly Poupart s ligament depends for its sccunity on a wide system of fascial anchorages Any damage to those anchorages such as that caused by dragging a femoral sac from the thigh to the abdomen Is apt co leave a wcakness for which subscquent repair cannot adequately atonc Thirdly Poupart s ligament is a long tendinous span anchored to bone at both ends Depression at one end will depress the whole and compress the vascular channels that pass under it Thereforc any method of closing the channel of a femoral hernia from above by fixing the inner end of the ligament to the pubic bone by staple or suture is unsound. Aetiology of femoral hernua Femoral hernia is the classical example of an acquired hernja Hamilton Russell who established the congenital nature of oblique ·94 HERNIA 1 inguinal hernua, thought that femoral hernia was also congerucal 1 Embryological research dissections in the foetus and operations on the new born do not support such a view Two causes seem to be iniportant repeated strain and adiposity Fat and fascia in the body arc alternative aspects of the same tissue and mutually exclusive Femoral hernia is six times as common in women as in ment, but it is certainly not as is sometimes stated the commonest hera in women Inguinal hernia is twice as common In men one femoral hernia is found to twenty ingunal in women one to three The difference is accounted for entirely by the strain of child bearing The incidence in childless women is about the same as in men Femoral hernia is rare in childhood but it has a similar inadence in both sexes Femoral hernua then is a labour casualey It is commoner in women? of cıvılızed races because bear their chuldren in bed after a period of recumbency that is with the venous compartment of the femoral sheath comparatively empty and because parturition is with them a more strenuous affair than it is with savages or animals Diagnosis of femoral hernia In theory a femoral hernia is covered by nine layers of which every alternate one is fat-skin, subcutaneous fat cubriform fascia fat in the saphenous opening femoral sheath fat in the crural canal septum crurate extra-peritoneal fat and peritoneum. It is well to retail thus useless information because it emphasizes to important practical points that a femoral hernia is never reduable and that at operation a surprising number of layers must be divided in turn before the truc sac is reached The bulk of a femoral heria consists of coverings rather than sac I though it is sometimes (but not oftcn) possible to reduce the contents of the sac into the abdomen by nran pulanon the Jump in the saphenous opcrung remains almost unchanged The size of the lump tends to increase with the duration of the heraua The neck of the sac which lies in a rigid channel tends to remain a tube of small diameter but the fundus dilates as more contents enter it and repeated obstruction to their blood suppls leads to repeated crudation of Auid. A large femoral sac comes to resemblc a balloon on 2 stalk. The coverings increase in thickness as the sac enlarges A femoral hernia appears at the saphenous opening in the deep Surg Gym Ort 1926 43 147 ·TIERNIA BELOW POUPART S LIGAMENT 95 fasaa and as it cnlarges tends to remain there If it migrates it tends to extend upwards over the inner end of Pouparts liganıcıt The probable explanation of thus tendency is thac the hernia is forced by its surroundings into a course first downwards and then forsvards and cach further protrusion follows the same curved course The differential diagnosis of a femoral lıcmnia will depend on whether It is reduciblc or not The common femoral kiertua is irreduablc but symptomless The sac contains nothing but a cag of adherent omentum and the outer coverings are fat laden and bulky There is no impulso on coughing Such a swelling is merely a rounded classic tumour in the inner half of Scarpa s triangle that must be distinguished from an enlarged lymph gland and a lipoma the only conditions wluch it resembles The distinctive feature of the hernia is that it has a neck and the neck passes backwards below Poupart s ligament and medial to the femoral vessels When the lump is moved about thus deep attachment becomes obvious A lymphatic gland lies in the planc of the superficial fascia and in that plane it can be moved to an approximately equal cxtent in all directions A single cnlarged inguinal gland is in any case unusual A lipoma is in the subcutancous fat and can be lifted off the deep fascia A femoral hernia can be moved in arcles within the range allowed by its stalk like the joy-stick of an aeroplane in most cases the stalk can be traced to Poupart s ligament A reduable femoral hernia may be quite clearly a hernia that is it is reduced by manipulation and returns not immediately but after coughing or straining Reduction and reappearance are accompanied by the gurgle of intestine and the swelling is resonant to percussion, The only difficulty in such a case is the distinction between a femoral hernua lying over the external ring and an inguinal hertua The destinction between femoral and inguinal hernia rests on two points on the relation of the swelling to the pubic spine and whether the swelling after reduction reappears above or below Pouparts ligament An inguinal hema that has reached the extemal ring overlies the pubic spine but the spine can be felt by putting a finger below and lateral to the swelling and displacing it inwards In femoral hernia the public spine can be felt only by a finger placed above and medial to the swelling After reduction of a hertua whose nature is in doubt a finger should be kept on the inner end of Poupart s ligament while the patient coughs It can then be determined whether the swelling ·96 HERNIA reappears from below the ligament that is from the crural cana) above it from the ingunal canal Two reducible stellings in Scarpa s triangle saphenous vanx anpsoas abscess may be mistaken for femoral hernia by the inexperience or over confident Both are reduable swellings belou Poupart ligament but neither has the true characters of a herniz Both appca in the erect position and disappear on recumbency and neither ha the firm rounded outline of a hernia gives a gurgle when handled o is resonant to percussion Saphenous vanx a venous swelling large enough to resemble = femoral hernia gives a bluish colouring to the overlying skin I rarely exceeds the size of a half walnut and it reduces so castly that its outline cannot be felt It disappears not merely with finger pressure but spontaneously on lying down On coughing a fluid thrill can be felt over the swelling It may sound ludicrous to suggest that a psoas abscess can be mistaken for a femoral hernua but the nustake has bech made repeatedly in the past by surgeons of considerable experience and it is being made even more often today when psoas abscess-indecd any form of cold abscess--is rarely seen by the student The patients who are seen with these dissecting psoas abscesses are not the textbook cases of Ports discase-children or young adults with pale wasted faces and a hunch back--but old men and women suffering from the periostcal form of thus desease affecting many vertebrae but destroying none They complain of pain and stiffness in the back that are no worse than the common senile sheumatism due to ostco-arthritis They come to hospital to report a swelling in the groun that has appeared in the last few weeks and they do not mention their backachic The careful surgeon an are of the saying chat spot diagnosis is the quckest way of reaching a wrong decision will notice that though the suelling is obviously below Poupart s ligament ut lacks that sharp definition that is typical of a femoral hernia A femoral hernia looks and feels like a rubber ball under the skin A psoas abscess cannot be defined. If it is small the only kind that resembles a femoral hernia in any way it lies lateral to the femoral artery if it is large enough to have ruptured the psoas fascia and to point medial to the sessels it is slack and diffuse and feels like a cold abscess and nota herria A second stelling can be seen and felt in the iliac fossa and fluctuation can be demonstrated berscen thus swelling and that in the groin. a ·HERNIA BELOH POUTARTS LICAMENT 97 or THE OPERATIVE TREATMENT OF FEMORAL HERNIA The operations for femoral herria are usually classified as high low that is abovc or below Poupart s ligament The low opcrations are as old as surgery itself for man s fatural instinct is to tackle any problem in the most direct and simple manner and only later to scck improvements. The only variants arc in the inasion and in the means adopted to closc thc canal and these are all minor modifications of the same basic approach The high operations imply an approach through the inguinal canal The principle is at any rate as old as antiseptic surgery It has been des cribed in nuany countrics by many surgeons of whom the first appears to have been Annandale of Edunburgh The inguinal operation in its modern form is usually given the names of Gordon and Lotheissen It has on the wholc been remarkably successful but there has been a tendency in recent y cars to decry it owing to occasional recurrence and to return to the los operation Being old enough to remember as a student the time when the hugh operation was just conung in, and the low one owing to its numerous recurrences was fast going out I have no patience with the attempt to rehabilitate the anatomically unsound and practically unsuccessful operation from the groin. Recurrences after the Locheissen operation are uncommon, but they are not unknown. They can hou ever be traced to tuo errors that can and should be avoided firstly to the dislocation of Pouparts ligament by dragging a bulky sac under it leading to a femoral recurrence secondly to the division and imperfect repair of the transversalis fascia where it forms the posterior wall of the inguinal canal leading to a direct inguinal hernia in place of a femoral onc Since thc Sccond World War the extra-peritoneal approach to the femoral canal first proposed by A K Henry in 1936 has gained increasing acceptance In my opinion it should now become the standard method replacing the approach through the inguinal canal Henry' used a mud-line incision. His first case was the unusual one of bilateral femoral hernia and the approach gave equally ready access to both femoral canals He stripped thc unopened peritoneum from the "Lancet 1936 1 331 ·98 HERNIA sides of the bladder and from the pelvic wall and obtained a view of both sacs wluch stood out from the peritoneum as he describes it like homs from a snail MacEyedy used an approach from the outer border of the rectus which gives even more direct access to the neck of a femoral sac From a general consideration of the anatomy and actiology of femoral hernia it should be clear that both the high and the low operations have faults The high operation gives a direct access to the neck of the sac and the commencement of the canal but not to the fundus or its coverings The reverse is true of the low operation A combined approach is essential I THE STANDARD OPERATION (Modified MacEvedy) MacEvedy used a vertical approach near the outer border of the rectus at its lower end. A vertical incision through the skin is unsightly A vertical inasion through the rectus sheath has the mechanical defect of dividing aponeurotic layers across their line of stress I have modified the operation by using a crease incision for the skin and a muscle splitting approach for the deeper layers The skin incision The incision is made in the skin creasc above the groun, as in the standard operation for inguinal hernia but it should cxtend from the muid-line to the point where the crcase crosses Poupart s ligament in its outer third After division and ligature of the small vessels in the superfiaal fat the inasion is decpened to the extemal oblique aponeurosis Dissection is continued in this layer till a wide area of the aponeurosus down to Poupart s ligament is cxposed. Exposure of the sac The lower flap of the inasion is held up with two Lane s tissue forceps that take all layers an inch away from the edge The bulge of che hernia will be seen under the fibrous layer of the deep fascia immediately belov Poupart s ligament and a stroke with the krufc dividing thus layer over the swelling allows it to crrrude (Fig 43) The Ann R. Coll. Surg 1950 7 484 ·MODIFIED MACELEDY OPERATION suelling wluch consists largely of fatey coverings is scized with toothed dissecting forceps and cleared with a few strokes of the closed Mayo sassors from the superfical fusaa that surrounds it back to the point where it disappears under Poupart's ligament 99 Tic 43 Modified McEvedy operation Exposure of the sac An assistant holds the other side of the fatty swelling with roothed forceps and the surgcon cuts boldly into it with scissors all he reaches the sac, whuch is usually quite small in relation to its coverings The coverings are stripped off the sac down to Poupart s ligament They cannot be idenuficd seriatım, but all of them come out of the femoral canal and they should on no account be dragged back through it They are cut off with scissors round the neck of the sac A few small vessels will require ligature The sac is now opened and its interior inspected. The usual content e fringe of omentum that has become fibrous and adherent from long residence and repeated vascular obstruction. The omentum is pulled down further ligatured and cut off and the stump is pushed back into the abdomen The sac is clamped Rush with Poupart s ligament cut off and the neck is ligatured with No 30 linen thread the ligature being IS 2 left long Abdominal exposure of the neck of the sac The external oblique aponeurosis is split in the line of the pillars and the upper leaf only of the aponcurosis is cleared by blunt dissection ·100 HERNIA from the underlying internal oblique muscle to the point where the two fuse about an inch medial to the outer border of the rectus The deep layer of the rectus sheath thus exposed, is incised in the line of its tendinous fibres which are here scen to run almost transversely The cut will extend 1 in to it in before it reaches the muscular fibres of the internal oblique and it will expose the underlying rectus muscle (Fig 44) The cut is now carried outwards for another inch through the internal oblique separating rather than cutting its fibres, and is deepened in the same line through the transversalis which is here purely tendinous A tenuous layer of transversales fasaa only covers the extra-peritoneal fat FIC 44 Modified McEvedy operation Division of rectus sheath n The rectus muscle is displaced medially and the extra-peritoneal fat is thus exposed for a width of 2 in to 21 in immediately above the opening of the femoral canal A few touches with a finger or a small swab will expose the neck of the sac disappearing into the canal (rig 45) If the neck is not inmediately obvious a gentle pull on the ligature in the saphenous opening will immediately roycal it The neck carrying the ligature is drawn into the abdomen and inspected. If there is any doubt about the complete reduction of the contents of the sac the neck can now be opened as widely as is neces sary and closed again by ligature In most cases where a ligature is used in surgery the surgeon is carcful to include as little as possible 1 16 grasp since all tissues distal to the ligaturc die and are converted into fibrous tissue In ligaturing the neck of a femoral herruz, this is just what the surgcon desires He to the neck flush with the peritoneum and removes the temporary thread ligature applied in the groin but ·101 MODIFIED MACHIEDY OPERATION he does not cut off the redundent (issuc A good blob of fibrous tissue lying betw con tlic pentoncum and the femoral canal is a consummatron devoutly to be wished Vas deferens Cord AH Epigastric vessels Neck of sac Astley Cooper's ligament FIC 45 Modified McEvedy operation Exposure of the neck of the sac The empty femoral canal is further prorected at its abdominal end by a few sutures bringing the conjoined tendon down to the liopectincal linc (Astley Cooper s ligament) as far as the external liac vein. By the MacEvody approach thus can be done casily, safely and without injuring the fascal posterior wall of the inguinal canal Closure of the wound The peritoneum is allowed to fall into place and the rectus muscle is allowed to resume its line The incision in the rectus sheath is closed with interrupted sutures of catgut and the outer part is simularly closed a few separate stitches being inserted into the transversalis layer before the intemal oblique layer is sutured the external oblique aponeurosis is approximated with a continuous catgut suture If the herrua was a large one its removal has left a gap in Scarpa s triangle This should be obliterated by a few storches of fine catgut drawing the fatty fascia together The main ingsion is closed as in ingunal hernia by fine nylon ·102 HERNIA sutures through all layers of skin and superficial fasaa aed over an anchor dressing after the skin edges have been approximated with Michel clips Alternative treatment of the femoral ring The ideal treatment of a femoral hernia is the closure of the femoral canal without disturbing in any way the normal moorings of Pouparts ligament In an early femoral hernia the crural canal is occupied by a peritoneal tube and its coverings the structures that having escaped into Scarpa s triangle expand into the familiar hernial swelling but that in the canal fit the inner compartment snugly, in fact make the ideal living plug In such a hernia the peritoneum can be opened just above the femoral opening and the neck of the sac can be inspected from within. If the contents have been reduced the peritoneum can be cut round the femoral opening leaving the neck in situ and the opening into the peritoneal cavity can be closed by an enarcling ligature that leaves a fibrous plug as a further protection against recurrence In such a case there is no need to suture the conjoined tendon or to disturb the inguinal canal 2 THE INGUINAL OPERATION The operation as originally described by Lotheissen, who recorded twelve cases repaired by this method in 18981 has been modified since only in unimportant details The incision usually recommended is one parallel with the Poupart s ligament but a little lower than the usual inguinal one in order to provide ready access to the sac in Scarpa s triangle The sac is first identificd stripped of its coverings emptied and ligatured at its neck as in the standard operation. The inguinal canal is next opened by an incision in the crternal oblique aponeurosis extending into the external ring The flaps are turned back, the cremaster is inased and the cord or rotind ligament is lifted from its bed to crpose the posterior wall of the canal This wall which consists clucfly of transversalis fasaa in the middle tlurd of the canal 15 incised with the knife abosc and parallel to Poupan s 'G Lotheussen Zentralbl Сhir 189$ 35. 343 ·INCUINAL OPERATION TOR ICMORAL FICRNIA 103 ligament taking care to avoid the decp epigastric vessels laterally and their pubic branches that run along the ligament The extra-periconcal fat cxposed by this masion 1 pushed upwards away from Poupart s ligament with a small gauze swab till it is tied by the neck of the sac entering the femoral canal Thus peritoncal neck is defined by blunt dissection, and carefully worked out of the canal into the inguinal inasion. When free it is pulled up into the wound, inspected at its inner side for adherent bladder opened and cleared of any omentum still adherent Firually it is ligatured flush with the peritoneum and cut away (Fig 46) Pouparts Astley Cooper's ligament ligament TIG 46 The ingunal approach for femoral hernus (Lotheissen) The weak spot under Poupart s ligament from Gimbernat s ligament to the external ilac vein, is protected from within by broadening the insertion of the conjoined tendon to the illo-pectincal line in a lateral direction, that is by attaching it to Astley Cooper s ligament by interrupted catgut sutures While an assistant with a flat spatula retracts the conjoined tendon and peritoneum cogether the surgeon places the index finger of his left hand firmly on the illo-pectineal line and slides it outwards laying barc Cooper s ligament as a glisterung tendon and pushing the illac vein out of harm s way Three or four stitches of No I catgut on a snuall stout curved needlc are inserted through the conjoined tendon # in from its free margin and through Cooper s ligament The first should be next to Gimbernat s ligament ·HERNIA 104 the last just medial to the femoral vein, and the assistant must remorc the spatula to give access to the conjoined tendon and re-insert it to expose Cooper S ligament All the stitches are put in before any are bed. The posterior wall of the inguinal canal having been damaged by the operation the internal oblique and transversalis fascia should be sutured to Poupart s ligament as in Bassini's operation. The external oblique and skin are closed in the usual manner Modifications in the case of large herniac In old standing femoral herniae or in those that have rccurred after repair the weak area under Poupart s ligament medial to the femoral vein may be so large that suture of the conjoined tendon to the 1l1cpectineal lune behind the aperture cannot offer sufficient security against recurrence Those who share with me the view that Poupart's ligament should not be loosened or displaced have the choice of several alternatives Owing to the proximity of the femoral vein the use of metal or any rigid structure is inadmissible (a) Fascial suture The plantaris tendon or one or more fascial strips taken from the thugh or the extemal oblique aponcurosis are damned backwards and forwards from Poupart s ligament to Astley Cooper s ligament the darn starting at the pubic spine and continuing outwards till no more than sufficient room is left for the femoral vein The method implics not the drawing down of Pouparts igament to the pubic crest but the construction of a stronger and wider Gimbernat s ligament (6) Renforcement of the conjoined tendon by an aponeurotic layer · The Willys Andrews method The upper leaf of the criernal oblique aponcurosis may be sutured with the conjoined tendon to Cooper s ligament behind the cord. u The Bloodgood rectus sheath flap (see page 84) The flap is sutured to Cooper s ligament as far as the point where it is crossed by the vein, in much the same way as it is sutured to Poupart s ligament in the Halsted operation (c) Reinforcement by free transplants of living material derma or fasaal sheets or of inert fabrics such as nylon or orlon mesh or gelaune sponge ·LOW OPERATION 105 (4) Plugging the canal 1 By the sac, turned inside out and flattened over the abdominal aspect of the canal like the head of a river u By auto transplants of fat or muscle 3 THE LOW OPERATION While the low operation is traditional rather than scientific it semains the choice of the inexpenenced surgeon who is forced to operate without assistance It is sometimes advisable when speed and minimum interi ence are important and it may be the best operation in some cases of strangulation The skin inCISION An inasion directly over the swelling has many advantages but the vertical inasion described in many textbooks should be abandoned The crcase inasion advised for inguinal hemia and for the high operation for femoral hernia is entirely satisfactory but one below Poupart s ligament and lying in the crcase that is made by flexion of the hip joint is better (Fig 12) Isolation and ligature of the sac The steps are similar to those described in the standard operation, but in the low operation the sac itself is dissected as high as possible by pulling on it while the layers round it are dissected off with Mayo scissors and pushed back with their closed points When it appears that the actual neck has been reached, the sac is opened and empued the neck is tied as near as possible flush with the peritoneum, and the scump is allowed to retract into the abdomen. Closure of the femoral canal Many methods have been recommended but none are entirely satisfactory Most rely on the suture of Poupart s ligament or of Poupart s ligament and the falaform ligament to the pectineus fascia Marcy the real father of hernia surgery used a simple purse-string starting at the inner end of Poupart s ligament picking up Gimbernat s Saunders Melville Brit Aled Joum 1935 I 467 H-X

·106
JERNIA
ligament the pectineus fascia and as much of the femoral shcath as
appeared to be safe and emerging through Poupart s ligament near to
its point of entry (see Fig 47) Bassin used interrupted sutures the
first two or three passing from Poupart s ligament to the perineus
fascia others from the falciform ligament to the same fascia (see Fig 48)
Falciform
process
Poupart s lig
Pectineal
lascia
Femoral v
Saphenous v
FIC 47 Closure of femoral canal from below Marcy s method
FIC 48 Closure of femoral canal from below Basunis method

·PRPVASCULAR BERNIA 107 Lockwood using a curved hema needle on a handle and protecting the vein with a finger in the canal inserted stitches wing the inner end of Poupart s ligament to Astley Cooper's ligament Other surgcons attempted to anchor Poupant s ligament discctly to bone by a metal staple (Raux) or by sutures passed through dnil holes in the pubic ramus (Nichol) It will be realized that the low operations have no place except as emergency procedures The sac can never be cleared from below suffiantly high to leave a smooth undimpled perroncal surface after Ligature All methods of repair of the canal from the thigh fail to Construct an adequate protection of the hernial passage at its commencement and most of them compress the femoral vein. The more attempt to reach Astley Coopers and Gimbernat s ligaments through the femoral opening involves a damage to the fibrous attachments of Poupart's ligament chat is quite inexcusable PREVASCULAR HERNIA (Naraths Hernia) Apart from femoral hemua the only hemuz encountered below Poupart s ligament is the prevascular hemia a lesion due to the rupture or stretchung of the fascial bands that normally anchor Poupart s ligament to the structures that lie behind st. Through the nucak arca that results the peritoncum bulges into the thigh berween the ligament in front and the femoral vessels and flexor muscles befund. The hernia was first described by Professor A Narath of Utrecht in 1899* Prevascular hemia is usually a result of congenital dislocation of the hep but it occasionally follows a traumatic dislocation. The upper ond of the femur displaced from the acetabulum, carries the insertion of the flexor muscles backwards and away from the ingunal ligament that overlies them Apart from its associadon with dislocation of the hup prcvascular herna is seen in the aged ssck where repeated coughing has slowly forced a passage between Poupart s ligament and the wasted muscles behind if I have encountered it once in a young and healthy man, in whom the cause of the weakness was quite inexplicable He was a hospital official and he refused to wear a truss and insisted on operatron. 11 Narath Asthan Chr 1899 59 35 ·108 HERNIA The prevascular hernia is a wide bulge without a neck Strangulauon is unlikely and control by a truss is satisfactory Operative treatment of prevascular hernia An attempt to re-attach Poupart's ligament by artifical means to the tissues from whuch it has come adnft is unlikely to succeed A sounder plan is to substitute a tough and unstretchable sheet for the continuous layer of fasaa iliaca and transversalis that normally lines the bottom of the abdominal cavity outside the pentoneum. In the case mentioned the only one that I have myself repaired, I approached the abdomen through the usual crease incision. I split the external oblique aponeurosis in the line of the ingunal canal and tumed back the flaps I then divided the internal oblique and transversalis muscles in the line of the fibres of the former roughly parallel to Pouparts ligament and above and parallel to the alio-inguinal nerve Having exposed the extra-pentoncal fat I pulled the extruded pouch from under Poupart s ligament and without operung * cleared the peritoneum from the abdominal muscles in front and from the lacus and psoas muscles and from the external illac and spermatic Tessels behind I took a square of skin 4 in by 3 in cut like a Wolff graft from the abdominal wall and laid it with the superficial surface faang the extra-peritoneal fat on the defect The skin square was folded on itself about an inch from the long edge The fold was laid along Pouparts ligament the wider flap covering the liac fossa the narrow flap lving bencath the abdominal wall The posterior flap was tacked with a few catgut stitches at the edges and corners to the fascia covering the iliacus and where it hung over the rim of the pelvis to the obturator fasa: The antenor flap was tacked in a simular way to the back of the transversalis muscle The inasion in the deeper muscles was closed with interrupted catgut and the external oblique with a continuous suture Healing was unci entful and the patient at any rate svas satisfied with the result Had I the same operation to do again I should use nylon net instead of skin, as I have seen too many complications chucfly afective-following the use of dermal Implants in the inguinal canal sutures of ·CHAPTER 8 HERNIAE IN TIC RECTUS SIIEATI The rectus sheath is the tendon of insertion of the lateral muscles of the abdomen, and all three contribute to it The external oblique aponcurosis passes in front of the rectus muscle throughout its length and joins the deeper layers a short distance medial to its outer border The internal oblique and transversalis muscles fuse at the outer border of the rectus in a common tendon. From the costal margin to a point half way between the umbilicus and thc pubis thus fused tendon splits into two layers half of it going in front of the rectus muscle the other half bchind Below this level all the combined internal oblique and transversalis tendon passes in front of the rectus Thus the posterior sheath of the rectus in so far as it is tondinous ends at this level in a cresentic fold, the fold of Douglas below it the posterior sheath 18 formed of transversalis fascia only Thc pull of the lateral muscles being transversc thc tendinous fibres in the rectus sheath are arranged for the most part transversely with few interlacing fibres to bind them together Incasions made transversely in the rectus shcath are almost self-approximating after suture whule vertical ones hold stitches badly Only where the fibres of the internal oblique and transversalis arc blended at the outer border of the rectus and where those of the two sides mect in the mid-line 15 there an interlacing that forms a tough feltwork The linea semulunaris and the linea alba are the two strongest parts of the antenor abdominal wall The unbilicus marks the centre and the transitional point of the rectus sheath Above it the rectus muscle is divided by three tendinous intersections that are attached firmly to the sheath in front but hardly at all behind The muscles are separated in the mud-line by a gap varying from a { in to } in. wide a gap bndged by felted aponeurotic strands running from one sheath to the other Below the umbilicus the reca are in contact separated only by a thin fibrous septum. 109 ·IIO HERNIA On the posterior surface of the anterior abdominal wall the umbilicus marks the meeting point of three pentoneal folds drawn out by the fibrous cords representing the obliterated placental vessels as they are left behind in the process of growth. The obliterated umbilicalien becomes the round ligament of the liver that runs from the umbilicus upwards and backwards slightly to the night of the mid-line to enter the porta hepatis of the liver The round ligament drags back a cresenuc fold of peritoneum the falaform ligament that partly divides the epigastric compartment of the peritoneal cavity into two The to obliterated hypogastric arteries (the remains of the umbilical arteries) form less prominent folds on either side of the mid-line running from the side of the bladder to the umbilicus These three folds are often loaded with fat At the umbilicus itself the peritoneum is firmly fixed to the abdominal wall The umbilicus is the scar left by the sloughing of the umbilical cord after birth It marks the spot where a series of remarkable changes have taken place during the development of the foctus At about the seventh week the embryo which is then s mm long is attached by a short broad stalk to an 'umbilical hernia' larger than itself This hernia continuous with the abdominal cavity and lined with the same coelomuc membrane contains the yolk sac and the fundus of the bladder, known as the allantois At about the 10 mm. stage the mud-gur loop leaves the abdominal cavity to enter the umbilical annexe forced to some extent by the rapid development of the mesonephros that is taking place in the abdominal cavity at the ume While the mid-gut loop is in the extra-abdominal coelom the yolk sac emptes rapidly and the vitelline duct with which it communicated with the alimentary canal is reduced to a fibrous cord attached to the lower ulcum The gut increases in length and the division between small and large intestine is marked by the appearance of the caecum Towards the end of the third month when the cmbryo is between 35 to 40 mm, long the gut returns fairly rapidly to thc abdominal cavity between the tenth and eleventh wecks The extra abdominal coelom is scaled off and is absorbed together with the remains of the vitellinc duct and the allantou For the remainder of foctal life the umbilicus transmits only the placental vessels At birth the cord which contains the umbilical cin and the two umbilical arterios embedded in Wharton sjelly is covered by skin for about 1 in. After ligature the part outside the abdomen sloughs and ·UMBILICAL INCRNIA III the scar is rapidly covered by skin The vessels thrombosc as far as the next functional channel within the abdomen and the clot in their lunien is converted into fibrous tissuc by the ordinary process of repar During the first fortnight after birth the umbilical scar consists of a firm fibrous ring part of the rectus sheath surrounding a space filled by organızıng blood dot a substance that is by no means strong UMBILICAL HERNIA Threc varieties of hernia occur at the umbilicus--the congenital the infantile and the adult Of these only the second is truly umbilical The congenital herniae are not umbilical because they arisc bcforc the umbilicus is formed The adult heruac arc for the most part protrusions through the linca alba above the umbilicus that is they are para-umbilical I CONGENITAL UMBILICAL HERNIA (a) Complete Exomphalos This rare abnormality which is said to occur in about onc birth in 10 000 is due to the failure of the mud-gut loop to retum to the abdominal cavity in the tenth weck. It may be associated with other congerutal defects such as spina bifida Exomphalos is seen only in the newly born. Unless treated within the first few hours by surgery it is not compatible with life The abdominal wall appcars to be replaced by a grey translucent dome chrough which the underlying viscera can be dimly seen The cord is attached to the summit of the dome The true abdominal wall lies well back in the flanks at the side of the swelling and its edge 13 marked by the sudden transition from pink skin to grey Whartons Jelly The coverings of the swelling are amnion, Wharton s jelly and extra-coelomc peritoneum The contents are the parts derived from the mid-gut loop the small intestine and the proximal colon, together with structures derived from the fore gut and the hind gut that have been extruded later The greater part of the liver and portions of the stomach and pelvic colon are usually in the hernia and they are seldom normal The liver wluch has not been moulded dunng develop- ·112 HERNIA ment by the pressure of adjacent organs is a globular mass the mudgut loop is unrotated and unfixed, and a Meckels diverticulum is usually present The coverings of an exomphalos derive their blood supply from the umbilical cord they therefore die at the birth of the infant and slough shortly afterwards Unless the abdominal cavity can be closed with living tissue death from peritonitis is inevitable Fortunately the abdominal wall is not deficient but merely displaced Operation An incision is made all round the swelling exactly at the line where skın joins Wharton s jelly Every bit of skin must be preserved since the re-establishment of skin-cover is the essential part of the operation The skın edges are undercut and dissected back on cach side to expose the aponeurotic layers The abdominal avity is then opened and the hernual covenngs are rapidly separated with the fingers from the underlying viscera which are covered with warm moist swabs as they are exposed The edges of the living abdominal wall are defined on each side seized with a row of Allis forceps and pulled forward A series of tension sutures of stout nylon, guarded with an inch of fine rubber tubing are passed from one side to the other through skin and abdominal wall about an inch from the edge of the defect and their ends are clamped The edges of the aponeurotic defect are then approximated by closely spaced interrupted sucures of No i catgut if the child is er good condition the rectus sheath may be opened throughout its length on cach side so that the closure is in two layers If speed is important one layer will suffice The skin edges are approximated by fine nylon sutures and the tension sutures are tied By onc of those cunous connadences which are common in surgery the only two cases of cxomphalos that I have seen were admitted into the same ward at Guys Hospital within six hours of each other the one under Mr R. P Row lands the other under Mr Lancelot Branley The first was operated on by me as Surgical Registrat and was later shown at the Clinical Section of the Royal Soacty of Mediane' Ile developed a year later bilateral inguinal herniae which were also repaired In 1932 he was a healthy boy of 12 with a sound abdominal wall WH Ogive Proc Roy So Aled Dec 19 1 ·UMBILICAL HERNIA II3 The second case already had peritonitis on admission and died a few hours afterwards (b) Congenital hernia into the cord In this type of hernia the mud-gut loop has retumed to the abdomen in the normal way but the extra-cocloruc pouch of peritoneum has semained patent in whole or in part A peritoncal sac extends for a vanable distance from the abdomunal cavity into the root of the umbilical cord whuch may be of ncarly normal appearance or a little wider than normal The importance of this hermia lies in the risk that a loop of bowel in the sac muay be included in the ligature applied at birth. Even if the bow cl is not injured or if there is no boucl in the sac the coverings of the sac are not viable and when they slough the way will be open for infection to spread to the abdominal cavity Every case should be operated on as soon as the abnormality is detected The need as in cxomphalos is to close the opening into the abdominal cavity with viable tissucs According to the size of the defect the repur of the muscular layers may be vertical as in cromphalos or transverse as in the Mayo operation in adults 2 INFANTILE UMBILICAL HERNIA An infantile umbilical hernia is a defect acquired during the first few days of extra-uterinc life It is due to stretchung of the newly formed scar before it is consolidated and it is therefore not seen during the first few days after birth nor is it likely to appear after the second month Some factor causing an increase in abdominal pressure either constant or intermittent, is usually to blame Such causes as crying coughing constipation, tymparutis or phimosis are common in the new bom The fibrous ning formed by the rectus sheath is usually intact and unstretched and the hertual protrusion is a small knob that is empty when the child is lying down and not straining Infantile umbilical herniac rarely strangulate They can be retained by a simple pad and with thus treatment the majority are cured in a year or eighteen months Umbilical herniae are almost the rule in African anfants and quite uncommon in African adults Operation If the hemia is still obvious at the second year it us ·HERNIA 114 unlikely to close spontaneously and operation at some convenient time is advisable The incision To remove the umbilicus in a small child is anexcusable Children are cruel little savages ready to combine in mass attack on the timid and the defenceless They often see cach other naked and the child without an umbilicus is taunted unmerafully for psychological if not for surgical reasons the umbilical scar must be preserved The incision should be inade in the short transyerse crease that will be found crossing the epigastrium a short distance above the umbilicus The iflcision is carried down to the aponeurotic layer and the lower Alap is then dissected further in this plane In most cases the little sac will come out of the fatty layer, if it does not the dissection is carried across its neck and beyond to 1 in. or if in below the operung The sac is held up and the fibres that surround the neck are divided are fully with a sharp knife More sac comes out unul a good collar of peritoneum is free The sac is then opened, emptied, tied at its neck and cut off Closure of the ring The defect in the aponeuroticlayers is usuallya small one and it can be repared by simple suture A purse string suture of No i catgut is passed through the aponeurosis a few mullimeters outside the margins of the opening and died. This suture buries the stump of the saç and closes the hole The closure is further reinforced by three or four stuches placed in a vertical direction on each side of the hole so that when tied, they infold and bury thc previous suture in a transverse direction In the rare instances in which the hole in the aponeurosus cxceeds in in diameter it may be advisable to enlarge the opening in a transverse direction by cuts extending into the rectus sheath on either side and to overlap the opening by the Mayo method (sccp 116) The skin incision is closed by finc nylon suures tied over an anchor dressing after the skin edges have been approximated with Michel clips 3 THE UMBILICAL HERNIA OF ADULTS A few adult umbilical herniac arc truly umbilical the recurrence in later life of a hernia that seemed to have been cured in infancy but that has been forced open by the pressure of repeated pregtanacs or of asates The above the umgreat majority are through the linca alba just ·UMBILICAL JIERNIA IIS agc bilicus that is they arc para-umbilical They occur for the most part in women res are seen before the age of 23 and few appcar for the first time after the of so Thus age span corresponds to the childbearing period and there is no doubt that umbilical herniac can be dassed as a labour casualcy Most of the women havchad many children and in addition they arc usually very fat in men adiposity is almost the only cause Thc hemia appears to start as a transverse split in the linca alba just above the umbilicus possibly preceded by the cxtrusion of a lobule of extra-peritoncal fat between che tendinous fibres The sac at first is a simple pouch of peritoncum but as it cnlarges it is unable to draw out further peritoncum from that lining the abdomen as do enlarging inguinal and femoral lemise owing to the fivity of the peritoncum at the umbilicus The enlarging sac splits and gets blown out into des crticula lined by fibrous tissuc Any large umbilical hemia is loculated and its contents are adherent. Omentum is an invariable content but transverse colon is usually found as well and in large hemiae coils of jejunum. A small umbilical hertua is seldom scen because it is symptomless and buried in the subcutancous fat of the abdomunal wall A larger onc is a diffusc oval swelling sct transversely with the umbilical scar a little below its summut It is seldom reduable even in part As it cnlarges further the umbilicus gets deeper and narrower and its sccretions are apt to be retained and to become infected. Infection due to entertngo also develops in the deep groove that appears between the overhanging swelling and the abdominal wall below it Such herniac are dangerous but it is difficult to persuade the fat complacent grandmothers who possess them of the danger They cannot be controlled by a truss They increase steadily in size and the bigger they become the more likely are they to strangulate Strangulaaon in an umbilical hernia has a high mortality owing to the age and physical condition of the pacients the number of bands and the locul that are to be found in the sac and the frequency with which the strangulated loop is in the upper jejununi For these reasons repair by operation is usually advisable even though the patient is not an ideal subject for anaesthesia Local anaesthesia would be desirable but adequate field block is seldom possible owing to the abundant fat on the abdominal wall and layer by layer infiltration as the operation advances may be required ·116 HERNIA MAYO'S OPERATION The overlap method of repair of umbilical hemia introduced in 1893 by W ) Mayo is almost unique among surgical procedures in that it has remained unchallenged and unimproved since its introduction It is founded upon the observation that the pull on the aponeurotic structures in the mid-line of the abdomen is transverse so that an incision placed transversely lies in the plane of stress and is not exposed to disruption The skin incision The umbilicus should always be exased It is unsightly and septic and its loss in this age group will not lead to any complexes The incision should be a wide transverse ellipse including the umbilicus and as much skin in a vertical plane as will clearly be redundant and extending laterally at any rate as far as the rectus muscles (Fig 49) The incision is carried down to the aponeurotic layer, and the ellipse of skin and fat is dissected off this layer from all sides towards che umbilicus until the fibrous neck of the sac is reached A large vessel piercing the rectus sheath on each side will requre ligature SJC is Treatment of the sac The whole mass of skın, fat and hernia is held up in one hand sshue the neck is cut round with a sharp knife parallel to the abdominal wall and about ţin beyond it As the fibrous strands are divided, others are put on the stretch and divided in tum, till the peritoneal neck of the sac is free of its aponeurotic sheath. The peritoneum us opened cautiously at the same level for it is only at the neck that likely to be free from adhesions As soon as an opening has been made the points of a pair of Mayo scissors are introduced through it and worked round between the sac and its contents shipping cach part that has been shown to be free until the whole neck is divided The plane having been established, che operung is enlarged under direct YsION, and working from within, the contents are pulled out of the sac By working from free space to adhesions by ligaturng adherent omentum and dissecting adherent wall off intestinal loops that are stuck to it this clearance can be done safely and the contents can be replaced in the abdomen after complete haemostasis has been secured

·MAYO S OPERATION
117
If the opening in the peritoneum is not much more than an inch
across the peritoneal edges should be dissected free from the abdominal
wall on cach side and the hole should be closed with a continuous
aatgut suturc If the operung is larger or if it is necessary to completo
2
b
X*
*
FIG 49 The Mayo operation for umbilical hemia
(a) The skin incision
(b) and (c) The vest over pants overlap

·118 HERNIA the operation expeditiously peritoncum and rectus sheath may bc overlapped together Repair of the aponeurotic layer The opening remaining after removal of the sac is enlarged in a transverse direction by inasing the rectus sheath on cach side until the inner margins of the rectus muscles come into view thus converting a roughly circular opening into a transverse lozenge so that the opening when repaired, should be pulled together rather than apart by the lateral muscles the transverse length should be at least three times the vertical width. If extra width is needed when the muscles have been reached the anterior sheath only may be incised and included in the lateral part of the overlap The lower flap is drawn under the upper by a series of mattress sutures of No I catgut The first suture is passed through the upper flap from without inwards while a finger protects the structures behind, if in above the free edge and ; in from the mud-Inne It then passes through the edge of the lower flap from within outwards back through the same edge from without inwards in on the other side of the mid-line and out through the upper flap from within ourwards at the same distance from the edge and I m from its point of entry The ends of the stitch are held in hacmostats A further series of mattress sutures are placed in a similar manner on each side of the mid-line arca the mattresses being about 1 in apart and cach subsequent onc a lesser distance from the edge as the comers are approached When these sutures are tied the lower lap is drawn under the upper one in a broad tongue The frec edge of the upper flap is sutured under moderate tension to the aponeurosis below the opening by a continuous stitch of caigut The skin flaps are closed with a series of mattress sutures of stout nylon, the skın edges being approumated between them with stitches of fine nylon. If there has been oozing during the operation, or any sepsis beforehand a small corrugated drain should be led down to the aponcurotic layer between tho stitches and removed in forty-cache hours Very large bernuae Sometimes the hernia is a group of two three adjacent defects in the linca alba The Mayo di cilap still offers the best means of repairing ·EPIGASTRIC ISRNIA 119 such a ficriuia but the overlapped flaps are of poor quality In such cases strips of fasaa lata may be damned backwards and forwards across the repair in a vertical direction taking their anchorage in the rectus shcath whicre it is undoubtedly sound Prescrvation of the umbilicus Witlun the last two years I have been prescrving the umbilicus when thc herua is not really large and when the skin is ununfected The Incision as for the operation in infants is a transverse onc above the umbilicus and the skin of the umbilicus is kept in contact with the aponeurosis by a ball of wool applied under the dressing The cosmetic result is certainly better than the dented-in look of the abdomen in which an ellipse has been excised. EPIGASTRIC HERNIA Epigastric hernia resembles in many ways the umbılıcal hemia of adults but the clinical features are different It is commoner in men under 40 The patients are not necessanly overweight and the hernua has been noticed because of pain, cither in the lump itself or epigastric pain of the duodenal ulcer type associated with mcals and relieved by taking further food The hemia is usually snuall about half way between the umbilicus and the sophistcmum and it is often felt more easily than scen. Like the adult typc of umbilical hernia it protrudes through a chink in the linca alba It appears to be preceded by an extrusion of extraperitoneal fat and the various conditions that are found suggest such a development There may be a localized lipoma only coming froni the extra-peritoncal fat but containing no peritoneal sac a lipoma outside the aponeurosis with a small sac that does not protrude through it and a fully developed hemjal sac Few epigastric herniac impulsc on couglung or are reduable and they are recogruzed by the discovery in a patient complaining of epigastric pain of a tender fatty swelling in the mid-line At operation the sac is usually found to be empty or to contain a fringe of omentum only Two explanations have been advanced for the association of epigastric hernia with digestive disturbances the mechanical-that a tag of omentum caught in the hernia is dragged upon by the contractions of the pyloric antrum in the later stages of gastric digestion, and give an ·120 HERNIA the reflex---that a gastro-peritoneal reflex disturbs the neuro-muscular mechanism of digestion Operation An epigastric bernia is readily repaired by a transverse overlap operation of the Mayo type Since however, the patient has usually presented himself on account of the pain rather than in order to have a hernia repaired, the surgeon is usually anxious to combine the repair with a laparotomy For this reason a longitudinal reconstruction is usually preferred A 3-ın incision with the lump at its centre is made in the midline and deepened through the linca alba above and below the hernual orifice The peritoneum is opened, either by cxcising or incising the sac and the cut is extended to allow inspection and palpation of the abdominal contents The peritoneal layer is closed by a continuous everting stitch of No o catgut The rectus sheath on each side is then opened at its inner edge to a level 1 in above and below the mid-line cut and the two aponeurotic edges thus constructed are sewn together by continuous sutures of No i catgut to constitute an anterior and a posterior rectus sheath (Fig so) HERNIA IN THE LINEA SEMILUNARIS (SPIGELIAN HERNIA) Like epigastric hernia Spigelian hernia is often small and silent and remains unrecogruzed till it becomes painful or presents as a visible and palpable swelling The herual opening is in the aponeurotic layer where the internal oblique and transversalis muscles join at the outer border of the rectus The opening is small os to 2 cm in diameter and has ngid margins As in epigastric hernua an extrusion of extra-peritoneal fat seems to have preceded the pertoncal protrusion, and the sac is vanable in size It may be empty or may contain omentum small intestine and occasionally large intestine The herual swelling is covered by the criernal oblique aponeurosis Spigelian here are almost unknown above the umbilicus as the muscular fibres of the transversalis here extend behind the rectus muscle They are commonest at the level of the semilunar fold of Douglas ·SPEGELIAN HERNIA 12t that is half way between the umbilicus and thc pubis The herua that is described on page 28 as congenital direct inguinal hernia may be a variety of Spigelian hertua The cause of Spigelian hema is obscure They are probably not congcrutal They have been seen at the age of 10 but never in infants They are assocated with adiposity but not to any obvious extent with trauma and they are not like femoral and umbilical hemiae linked with repeated pregnancies The internal oblique and transversalis muscles where they become tendinous are seen to be arranged in little bundles between which chunks often appcar Such a chink is commonly encountered in the MacBurney approach to the appendix the commonest level for a Spigelian hernia to be found. It is probable that the growth of extra-peritoneal fat inco such a chunk may form the starting point of such a hcmua The diagnosis of or rather the search for a Spigelian hema is usually made on the history rather than the physical signs Strangulation may be the first indication, and the patient is presented as a case of obscure intestinal obstruction. More commonly the pain is localized to a point in the linca semulunaris and it is made worse by coughing or prolonged standing Often the patient himself has found the lump and he may have noticed that it varies in size sometimes even that he can reduce it with a gurgle On examination, a typical hemtua is sometimes found. It gives an impulse on coughing is reduable and when it is reduced the hole in thc parictes can be felt More often the diagnosis must be made on the finding of a rounded tender lump that is in and not deep to the abdominal wall A Spigelian heria never has the clear outline of an inguinal femoral or umbilical hernia because it is covered by the external oblique aponeurosis Treatment Operation is essential because the hernia cannot be controlled by a truss and owing to the rigid fasaal opening it is liable to strangulate The incision is a transverse one down to the aponeurosis The extemal oblique is split in the line of its fibres to expose the herrua The neck of the sac is dissected out of its coverings as in umbilical hernia the sac is emptied and the neck is ligatured and cut off The musculo-aponeurotic layers forming the opening are closed in a transverse direction with an overlap as in umbilical and epigastric hemiae R-I ·CHAPTER 9 INCISIONAL HERNIA An incision or wound in the abdominal wall is a solution of continuity in a musculo-aponeurotic structure exposed to constant and Auctuating stresses to the constant stress of muscle tone and the thrust of the intraabdominal pressure which that tonc maintains to the regularly recurring contractions of respiratory movements and to the irregular and sometimes violent contractions which it undergoes in work and play as the chief motor group of the trunk. At the time of repair the strength of the wound is merely that of the stitches that hold it together The gap is bridged by the normal mechanisms of the body with a speed that varies with the site of the wound the accuracy of apposition, the age and hcalth of the patient and the presence or absence of sepsis First dcad tissues are removed by phagocytosis and the gap :s filled by coagulated serum and blood clot then the clot becomes converted into granulation tissue by the invasion of fibroblasts and capillary loops then the granulation tissue is converted into connective tissue at first cellular and vascular later fibrous and avascular A sutured wound healing without sepsis has about 40 per cent of the strength of the tissues of the part after four days and about 90 per cent at ten days At ton days a scar that has healed by first intention will not be injured by normal use within the limits imposed by the normal inhibitory reflex of pain but it is not strong enough to stand maximal strains for about three months Herruation in the scar of an abdomunal inasion is due to stretching of the connective tissue binding the edges of the wound together while it is sull plastic that is wlule it still consists largely of fibroblasts rather than of adult connective tissue The causes are haemorrhage and sepsis shortly after repair by incrcasing the gap between the cdges of the wound and by interfering with the formation of healthy granulation tissue anaemia or malnutrition, by slowing down the process of repur tympanites or asates by subjecting the healog Hound 122 ·INCISIONAL HIERNIA 123 to stretchung and unskilled suture or the use of poor materials Hernation is particularly coninon after the usc of certain incisions All vertical inasions in the rectus sheath and particularly thc pararectal incisions such as Battles are liable to yield if there is any adversc factor during convalescence because they cut across aponeurotic plancs at right angles to the muain stresses Transversc incisions rarely give way in civil surgery particularly those in the lateral segments of the abdominal wall but transverse incisions used to approach the abdomunal injuries of warfarc vcre not successful The para-costal or Kocher s inasıon usually heals well The lateral oblique incision of Rutherford Morrison is particularly liablc to herniation because the internal oblique which at this level is the strongest layer consists of stout fleshy fibres that hold stitches badly when cut across The margins of an inasional hernia are a rim of tough felted fibrous tissue where the constituent layers have been fused in the process of repair The defect is bridged by a thin layer of stretched fibrous tissue covenng a layer of peritoneum to which the underlying viscera arc to some extent adherent The whole is covered by skin bearing the stretched and adherent scar of the operation. The characters and clinical features of an incisional hernia vary with its size If the whole incısıon has given way the hernua is a wide bulge that has no neck, is unlikely to strangulate and can usually be controlled by a simple belt or one with a pad corresponding to the defect 14 as little more than an extension of the abdominal cavity and does not cause symptoms If the inasıon has given way in part only the hernial opening is a rigid aperture in scar tissue through which the pentoneum bulges so that the herria overlaps its onfice and assumes a mushroom shape The stretched pentoneum tends to form pockets like those encountered in umbilical berria and strangulation is not unlikely A large inasional hernia presents no problem in diagnosis A small onc is often invisible being buried in subcutaneous fat and it is discovered because the patient complains of local pain in the scar or generalized colic The discovery of a rounded tender lump in the line of the inasion clinches the diagnosis Such a hernia is not often reducible owing to the disproportion between the size of the sac and the opening in the panictes An incisional hernia often contains nothing but omentum and is symptomless It resembles a lipoma but it is anchored deeply which a lipoma is not and it underlies a scar which a lipoma never does ·CHAPTER 9 INCISIONAL HERNIA An incision or wound in the abdominal wall is a solution of continuty in a musculo-aponeurotic structure exposed to constant and fluctuating stresses to the constant stress of muscle tone and the thrust of the intraabdominal pressure which that tone maintains to the regularly recurring contractions of respiratory movements and to the irregular and sometimes violent contractions whuch it undergoes in work and play as the chief motor group of the trunk At the time of repair the strength of the wound is merely that of the stitches that holdet together The Sap is bridged by the normal mechanisms of the body with a speed that varies with the site of the wound the accuracy of apposition the age and health of the patient and the presence or absence of sepsis First dead tissues are removed by phagocytosis and the gap is filled by coagulated serum and blood clot then the clot becomes converted into granulation tissue by the invasion of fibroblasts and capillary loops then the granulation tissue is converted into connective tissue at first cellular and vascular later fibrous and avascular A sucured wound healing without sepsis has about 40 per cent of the strength of the tissues of the part after four days and about 20 per cent at ten days At ten days a scar that has healed by first intention will not be injured by normal use within the limits imposed by the normal inhibitory reflex of pain but it is not strong enough to stand maximal strains for about three months Herniation in the scar of an abdomunal inasion is due to stretchung of the connective tissue binding the edges of the wound together hule it is sall plastic that is whule it still consises largely of fibroblasts rather than of adult connective tissue The causes are' hacmorrhage and sepsis shortly after repair by increasing the gap borucen the cdges of the wound and by interfering with the formauon of healthy granulation tissue anaemia or malnutrition, by slowing down the process of repair tympatutes or asates by subjecting the healing wound 122 ·INCISIONAL HERNIA segments of 123 to stretching and unskilled suturc or the use of poor materials Hertuation is particularly common after the use of certain nasions All vcrtical incisions in the rectus sheath and particularly the pararectal nasions such as Battles are liable to yield if there is any adverse factor during convalescence because they cut across aponeurotic plancs at night angles to the main stresses Transverse incisions rarely give way in avıl surgery particularly those in the lateral the abdominal wall but transicrse incisions used to approach the abdomunal injuries of warfare were not successful Thc para-costal or Kocher s incision usually heals well Thc lateral oblique incision of Rutherford Morrison is particularly liable to heruation because the intemal oblique which at this level is the strongest layer consists of stout fleshy fibres that hold stitches badly when cut across The margins of an inasional herna arc a nim of tough felted fibrous tissue where the constituent layers have been fused in the process of repair The defect is bridged by a thin layer of stretched fibrous tissue covering a layer of peritoneum to which the underlying visccra arc to some extent adherent The whole is covered by skin bearing the stretched and adherent scar of the operation. The characters and clirucal features of an incisional hernua vary with its size If the whole inasion has given way the hemia is a wide bulge that has no neck, is unlikely to strangulate and can usually bc controlled by a simple belt or one with a pad corresponding to the defect It is little more than an extension of the abdominal cavity and does not cause symptoms If the inasion has given way in part only thc herual opening is a ngid aperture in scar tissue through which the peritoneum bulges so that the hernia ov erlaps its orifice and assumes a mushroom shape Thc stretched peritoncum tends to form pockers like those encountered in umbilical hernia and strangulation is not unlikely A large incisional hernia presents no problem in diagnosis A small one is often invisible being buried in subcutancous fat and it is discovered because the patient complains of local pain in the scar or generalized colc. The discovery of a rounded tender lump in the line of the inçision clinches the diagnosis Such a hernia is not often reducible owing to the disproportion between the size of the sac and the opening in the parietes An ingsional hernia often contains nothing but omentum and is symptomless It resembles a lipoma but it is anchored deeply which a lipoma is not and it underlies a scar which a lipoma never does ·CHAPTER 9 INCISIONAL HERNIA An incision or wound in the abdominal wall is a solution of continuity in a musculo-aponeurotic structure exposed to constant and Auctuating stresses to the constant stress of muscle tone and the thrust of the intraabdominal pressure which that tone maintains to the regularly recturing contractions of respiratory movements and to the irregular and sometimes violent contractions which it undergoes it work and play as the chief motor group of the trunk At the time of repair the strength of the wound is merely that of the stitches that hold it together The gap is bridged by the normal mechanisms of the body with a specd that varies with the site of the wound the accuracy of apposition the age and health of the patient and the presence or absence of sepsis First dead tissues are removed by phagocytosis and the gap is filled by coagulated serum and blood clot then the clot becomes converted into granulation tissue by the invasion of fibroblasts and capillary loops then the granulation tissue is converted into connective tissue at first cellular and vascular later fibrous and avascular A sutured wound healing without sepsis has about 40 per cent of the strength of the tissues of the part after four days and about 90 per cent at ten days Atten? days a scar that has healed by first intention will not be injured by normal use within the limits imposed by the normal inhibitory reflex of pain but it is not strong enough to stand maxima) strains for about three months Hemation in the scar of an abdominal inasion is due to stretching of the connective tissue binding the edges of the wound together while it is still plastic that is whule it still consists largely of fibroblasts rather than of adult connective tissue The causes arc harmorrhage and sepsis shortly after repair by increasing thc 8P between the edges of the sound and by interfering with the formation of healthy granulation tissue anaemia or malnutnaon, by slowing down the process of repair tympanutes or asates by subjecang the healing sound ·INCISIONAL HERNIA 125 towards the sac all the margins of the defect arc clearly defined all round The sac is then opened and the redundant peritoneum is removed leaving a margunin. wide on each side for suture Adherent coils can casily be freed from within once the sac is open. The exact margins of the defect can be identified by palpation between 2 finger in the sac and a thumb outside it Beforc proceeding further the surgcon must deternunc by scizing the edges of the defect with Ochsner forceps and pulling them together the crision to which his repair will be subject if it is greater than sutures of No i catgut can be expected to withstand he will be Wisc to abandon the attempt to closc thc dcfect in layers and to rely on the ability of the tough fibrous edges to hold fascial sutures After suture of the peritoncum with catgut as a separate layer the edges of the gap arc approximated by a continuous suture of fascia lata strips closely spaced A second layer of fascial sutures is laced across the first taking a bitc of the aponeurosis in from the edge of the gap Layer reconstruction of the defect If the previous incasion was one through the rectus shcath a scries of tension sutures of stout silkworm gut or nylon cach guarded with an inch of finc rubber tubing are passed through all layers of the abdomunal wall across the gap an inch apart and an inch from the edge The ends of the sutures arc sccured with haemostats The edge of the defect is held between finger and thumb of the left hand and split with a sharp knife till the fibres of the rectus muscle arc exposed (Fig so) Sassors are inserted into the rectus sheath and the cut is extended up and down as close to the margin of the defect as the muscle fibres extend splitting the wall into two fibrous layers with the rectus muscle between them The opposite side of the defect is treated in the same way and the cuts are extended I in above and below the ends of the hemial defect into the rectus sheaths where they are normal The two inner margins of the cuts are then sutured across the gap with interrupted sutures of No i catgut and the outer layers are then sutured in the same way thus reconstituting a posterior and anterior rectus shcath Finally the tension sutures are tied thus taking all strain off the catgut sutures The skin edges are apposed and cvected between the tred tension sutures by interrupted stitches of finc nylon. The fine stitches are removed after six days The tension sutures remain for ten days ·124 HERNIA Treatment A large incisional hernia is not dangerous Whether it is inconi cruent or not depends on the personality and occupation of the patient Thc choice between a belt and operative repair is thereforc a matter for discussion. All nasional herniae can be repaired and most healthy and sensible patients would rather have an operation than be condemned to a lifetime in harness Small herniae are a real danger They cannot be controlled by apparatus and they are liable to strangulate Operation must be advised unless there is some cogent contra-indication, OPERATION The only satisfactory repair of an incisional hernia is by the sucurc of living tissues Nothing is missing and though the scar has stretched, healthy muscles lie on cach side of it and can be brought together Only when portions of the abdominal wall have actually been removed as in operations for cancer, is there any need to use implants of foreign material On the other hand most patients with incisional hernia arc fat often grossly so and it is fucile to attempt repair till they have by dicting been brought back to the average weight for their age und bud Fat increases the width of the defect and the bulk of abdominal contents that are thrusting against it It also infiltrates all fibrous planes including those that must be brought together and destroys ther ability to hold stitches The incision An elliptical inasion carcling the scar of the previous operacion is used The width of thc ellipse should be such that the skin edges meet after repair of the hernia without tension and without redundancy The incision is deepened till a cleavage planc is encountered between the sac and the subcutaneous fat and this plane is followed unul the aponeurotic layer is reached on each side The ellipse of skin and subcutaneous tissue is then cut away In dissecting the adherent scar from the underlying peritoncum care must be taken not to injure adherent bone) The dissection is now continued in the plane of the aponcurosis ·INCISIONAL HERNIA 127 REALLY LARGE DETECTS Occasionally chc hole is so large or the hernia has been present so long that repar by suture of living tissues seems to be impossible More often the difficulty is due to the removal of large sections of the abdominal sall that have been involved by a malignant tumour Ten years ago I was obliged to resect the whole nght lower quadrant of the abdominal wall for a cancer of the colon that had been fungating for three years but yet had not metastasized widely I bndged the huge gap with two layers of tantalum gzuze anchored to the normal tissues on each side with interrupted sutures of tantalum wire but covered only by skin and subcutaneous tissue and backed only by great omentum The tantalum gauze is seen in a film to have fragmented extensively but the repair seems to be as sound as ever and the patient became mayor of an important town ·126 HERNIA 2 FIG so Repair of incisional hernia in the rectus sheath (a) The margins of the defect arc incised (b) The inner margins of the incisions are sutured to each other above the closed peritoneum (c) The outer margins of the incisions are sutured to reconsutute an anterior rectus sheath In hemiae occurring in oblique or gndıron incisions the external oblique muscle which was divided in the line of its fibres is usually found to be stretched over the defect but not separated The planes should be identified outside the area of the hernua The external oblique fibres should be split in the line of the previous incision and separated from the intemal oblique layer and the separauon should be continued for the length of the inasion reflecting the external oblique inwards and outwards as flaps and exposing the herual defect in the deeper layers The internal obliquc and transversalis muscles will usually be found to be fused together by repair and they can be treated like the rectus sheath, being split into tuo fibrous layers which are separately repaired by interrupted sutures of catgut In the case of a gndron incision that was too large to start with and has given way widely difficulty may be found in dosing the inner end of the gap in the deeper muscles at the outer border of the rectus Here a short dam with fasaal sutures or strips taken from the cremal oblique will usually proude the requisite security ·OBTURATOR IIERNIA 129 by pain remembered that tliesc cases are discovered only slicn they give risc to symptoms The commonest discal picture is one of acute intestinal obstruction of unknown ongin duc to strangulation of a loop of small intestine in the neck of the sac. The strangulated loop is usually small and because of the small size and rigid margins of the opening it often involves part of the intestinal wall only (Richters hernua) and early gangrene and perforation are common There is often a lustory of vaguc abdomunal symptoms accomparued felt along the inner side of the thigh and knce Thus association of intestinal symptoms with pain referred to the cutancous distribution of the obturator neric should prompt the scarch for an obturator hertua but the diagnosis is seldom made till the onset of strangulanon points to the explanauon of the earlier symptoms Very rarely a lump is noticed by the patient More often the surgeon socking for an explanation of obturator pain notices a slight fullness to the inner side of the femoral vessels compared with the other side The lump of an obturator hernua since it lies deep to the pectineus muscle is much less definute in outline than a femoral hernia and it becomes even less defined when the muscles are contracted if the large one it may gnc an impulse on coughing and be reduable with a gurgle but these signs arc cxceptional The obturator operung can be palpatcd from the vagina or the rectum and if a hernua 15 present an entering loop of gut may be felt or the naghbourhood of the opening may bc tender Treatment The treatment of obturator herua is by operation. In most cases since the hernua presents as an acute abdomunal emergency operation comes first and diagnosis follows Even if the diagnosis is made in a symptomless period operation must be advised since strangulation is an ever present nsk. Two approaches to the obturator canal are descnbed from the abdomen and from the thigh The second is difficult and dangerous and has nothing to recommend it Operation The abdominal cavity is opened by a mud-line inasion below the umbilicus extending down to the pubis When it is seen that an hemma is a ·CHAPTER 10 HERNIAE IN THE PELVIC REGION The number of possible herniae is almost unlimited Whercier a nerve or a blood vessel passes through the abdominal walls wherever a muscle anıses, is inserted or changes from fleshy to tendinous fasacul. a pouch of peritoneum may be forced out by excessive prolonged, or repeated abdominal pressure The only unusual hemiae that are encountered with any frequency are those in the pelvis and of these only obturator hemia is reasonably common The importance of these herniac is that they are often unrecognized all they strangulate OBTURATOR HERNIA Obturator hernia is a hemia through the obturator canal a small channel between the horizontal ramus of the pubis above and the upper border of the thyroid membrane below that transmits the obturator nerve and vessels through the upper part of the thyroid foramen. The thyroid membrane closes the foramen except for this channel it gives origin on its medial aspect to the obturator intemus muscle and on its outer aspect to the obturator externus The hertual sac is usually a small protrusion of parietal peritoneum that is neither visible nor palpable The neck of the sac lies to the inner side of the obturator artery and nerve The fundus in most cases lies between the pectineus muscle in front and the obturator externus behind but it may present between fasaculi of the obturator extemus or rarely lie between that muscle and the thyroid membranc Obturator hernia is unknown in children and is very rare under the fact age of 20 It is six times as common in women as in men, a which suggests that like femoral hernia it is due to the strains of labour The maximum inadence in reported scnics is between the aços of so and 70 that is beyond the age of child beanng but it must be 128 ·SCIATIC MICRNIA 131 enters and distends the labium majus Posterior penincal hernua presents bchund the transscrsus perine muscle through a separation in the fibres of the lerator anı muscle it is seen as a su clling to the side of the anus or it may bulge into the anterior rectal wall Eighty per cent are in Women A petincal hema is usually seen as an obvious swelling presenting feu urgent symptoms in an ageing woman who looks upon it as onc of the lesser afflictions in a life of drudgery and repeated chuld-bearing The su clang gives an impulse on coughing and is casily reducible but returns as soon as the pressure of the hand is removed The contents usually include bladder and the patient is often aware that she must support the swelling with her hand in order to empty the bladder completely Treatment A skilled instrument maker can design a truss to support the swelling by a pad held in position by clastic straps but the apparatus is always irksome it is apt to exconate the skin, and it must be removed for urination and defaccation. Operative repair is usually performed by the abdominal route with the patient in the Trendelenburg position. The sac us inverted into the abdomen and the peritoncum is dissected off the defect in the pelvic floor which is defined, and closed in the line of the separated muscle fibres by interrupted sutures of stout catgut Any fascial layers that can be identified are approxmated over the suture linc as additional reinforcement. If thought advisable an additional layer of fascial sutures taken from the cxtemal oblique aponcurosis may be added. Finally the pentoncum of the sac wall is overlapped to provide addstional security SCIATIC HERNIA Hernuation through the great or the lesser sciatic foramen is very rare Unlike obturator and perineal hemia it does not appear to be associated either with labour or with excessive exertion. Ten per cent of the cases reported have been in infants and the numbers in the two sexes are approximately equal The hemia is usually through the upper part of the great sacrosciatic foramen, the sac coming out of the pelvis above the pyriformis ·HERNIA 130 obturator hernia is present the patient is tilted into the Trendelenburg position. If bowel is in the hernia it is gently extracted and the loops of intestine are packed out of the way to expose the herual orifice In most cases the small empty sac can be inverted into the abdomen by seizing the fundus from within with a haemostat Radical dosure of the canal a rigid opening between bone and ligament transmutting a nerve and an artery, is out of the question The best safeguard against recurrence is to convert the peritoncal hollow into a peritoneal hummock Through an inasion in the neck of the sac, the empty canal is filled with a free transplant of subcutaneous fat from the abdominal wall The inverted sac is then converted by a few stitches of catgut into a flat tampon or nvet head that lies over the fat transplant as a further protection. PERINEAL HERNIA A perineal hemia is a protrusion of the pentoncum of the recto- Vesical pouch through the musculature of the pelvic floor It is almost limited to women It occurs between the ages of 40 and 60 and is attributed to the strain of repeated or complicated pregnancies Two varieties are described the antenor and the posterior (Fig sr) Anterior perineal hernia is a protrusion in front of the transversus perunei muscle and is seen only in women The hernia as it enlarges Anterior hernia Posterior hernia Fic si Perical heraus ·SCIATIC IIERNIA 131 Homct. enters and distends the labium majus Postcnor perincal hiernia presents behind the transiersus perinci muscle through a separation in the fibres of the levator anu muscle It is seen as a swelling to the side of the anus or it may bulge into the antenor rectal wall Lighty per cent arc in A penncal hemia is usually seen as an obvious swelling presenting feu urgent symptoms in an agang woman who looks upon it as onc of the lesser afflicuons in a life of drudgery and repeated chuld-bearing The swelling gives an impulse on coughing and is casily reducblc but returns as soon as the pressure of the hand removed The contents usually include bladder and the patient is often aware that she must support the suclling with her hand in order to empty the bladder completely Treatment A skilled instrument maker can design a truss to support the swelling by a pad held in position by clastic straps but the apparatus is always irisome it is apt to excoriate the skin, and it must be removed for urination and defaccation. Operative repair is usually performed by the abdominal route with the patient in the Trendelenburg position. The sac is in erted into the abdomen and the periconcum is dissected off the defect in the pelvic floor whuch is defined, and closed in the linc of the separated muscle fibres by interrupted sutures of stout catgut Any fascial layers that can be identificd are approximated over the suture line as additional reinforcement If thought advisable an additional layer of fascal sutures taken from the external oblique aponeurosis may be added pentoncum of the sac wall is overlapped to provide adde- Finally the tional security SCIATIC HERNIA Herruation through the great or the lesser sciatic foramen is very rare Unlike obturator and perineal hernia it does not appear to be associated either with labour or with excessive exertion. Ten per cent of the cases reported have been in infants and the numbers in the two sexes are approximately cqual The hemia is usually through the upper part of the grcat sacro sciatic foramen, the sac coming out of the pelvis above the pynformis ·HERNIA 132 muscle and in front of the sciatic nerve It is covered by the gluteus maximus and as it enlarges it extends downwards and finally presents at the lower border of the muscle The clinical picture has many similarities to that of obturator hernua —that is the patient may present himself for three reasons because he has vague abdominal discomfort accompanied by pain referred among the distribution of the sciatic nerve, because he has observed a reduable lump or because of an unexplained attack of acute intestinal obstruction Strangulation however is much rarer than in the case of obturator hernia Operation The treatment of sciatic hema is along the same lines as that of obturator hernia and for the same reasons Control by a truss is impossible the risk of strangulation can never be dismissed and operative repair from the buttock is difficult and unsatisfactory Laparotomy is therefore essential With the patient in the Trendelenburg position, the abdomen is opened by an infra-umbilical mid-line inasion Thc hemial opening is displayed and the sac is inverted into the abdomen by grasping the fundus with a haemostat The peritoneum is inased at the neck to display the hernial opening above the pynfornus muscle and the canal is filled with a frec transplant of subcutaneous fat sufficient to project beyond the pelvic wall into the retroperitoneal space The sac is aed off and cut away or converted by catgut sutures into a flat washer that covers the site of the former hemsal opening ·INDEX Anaenhesua local for inguinal hemu Lxomphalos, complete it! 31 32 operation for 112 Ajoneurosis, external obligue reflec tion of 37 Tasual suturc 11 79 304 repair of 43 femoral anal, closure of 105 --- future of 104 Bassinu s method, 1005 Aponeurotic layer repair of 118 Marcy s method 106 Apparatus, slice of in treatment, : 6 femoralt 713 4 124 131(se Dclts and Trusses) - aetiology of 93 Astley Cooper fascia, 18 dugnosis of 94 ligament, 101 103 in Home 94 - inguinal operation 102 Babcock s operation 88 Large modificanons of operative Basstra method of closure of femoral procedure 104 --- low operation in los canal, 100 operative treatment 97 operation 71 84 - fascual suture 104 - and recurrent herua 61 Delay for intants 5 6 free transplants reinforcement of 104 in incisional bemia 124 reduable and irreduable 95 Bloodgood s flat operation 84 104 Brandon s operation of lateralization -- Standard operation for (modified of the cord, 75 76 MacEvcdy) 98 100 101 abdominal exposure of neck of sac 92 Castration 65 closure or wound 101 Causes and types of hernia defitution skın incision and exposure of 1 of sac 98 Childhood and infancy ingunal hernua strangulated 66 in.) 34 ring alternative treatment of zo. Colts cutting needle 10 42 Ferguson s operation 87 Cremaster muscle anatomical role of Forceps Lane s tissue 40 98 19 -- non toothed dassecting 39 ---reflection of from cord 37 Ochsner 125 repair of 42 Foster s operation 87 sub-cremastic space opening of Free transplants reinforcement by 104 38 Gallie s needles (small and Large) 10 Derma use of in surgical repair 15 -operanon of fascial repair 77 Dissecting forceps pon-toothed 19 Halsted operation 86 87 88 - for reconstruction of inguinai Epigastric hernia 119 canal, sa - operation for 120 - modifications of 87 133 ·134 INDEX Hernial sac isolation and ligature of 39 Lagunal hemis oblique operare tespecial points 45 pair of, 7 - Operation on gencral principles, 33 Incisional hernia s 122 special problems 38 belt in peatment of s standard operabon 35 operation for 124 after treatment 43 reconstruction of defect 125 skin incision closure of 44 treatment of 1-4 - not recommended 71 -- with really large defects 126 types of 22 Infants inguinal hernia in 70 Very large 60 - newbom eromphalos in III Internal ring repair of closure of sciatic hernia in, 131 wound so trusses for 3 Levator Annul, Intemi - umbilical hernia in IIO III 113 operation 49 Inguinal canal anatomical structure of Lyle s method 48 17 Interstitial hertua intramuscular 58 Lipomata in removal of 46 -- properitoneal, 58 operations on anaesthesia superficial 58 local 33- general principles 30 incision site of 30 36 Lane s fascial needles ro plugging of 105 Ussue forceps 40 08 reconstruction of si Lunca semilunaris heroia in (Spigelian - alternauve methods 33 herna) 120 anterior to the cord 86 Lyles method of repair of internal cxposure of defect 33 ring amplification of 48 Halsted soperation 52 posterior wall ss MacArthur soperation, 79 silk lattice repair 52 MacEvedys operation for femoral repair of and closure of wound hernia (modified) 98 100 101 47 McGavin salver filigrec operation 80 posterior priethods of 88 McVay principle 83 through abdominal Marcy s method of closure of femoral approach intraperitoneal and extra canal, 100 peritoneal 89 Mayo scissors use of 37 Inguinal hemia 17 Mayo s operation for umbilical hemia congenital 47 116 117 - treatment of tuma vaginalis, overlap operation in cpigastric 43 herrita 120 diagnosis of 28 Michel clips 44 direct 4 22 37 - congenital 27 28 59 in female operation on 46 Narath s prenascular herri, 107 in infants, operations for 70 Needles used in surgery 10 internal ring repair of defcc, 48 Colt scutting 10,4- oblique 32 - Galles, 50 -acquired, 26 Mayo trocar-point, 35 - Lanc, fascial 10 - congenital, 23 developmental abnor. Ogilvie : Nos 4 and 5 s malitics 25 Nylon nettung 15 futures, 44 IOS 114 --- large operation for 47 ·INDEX 133 Sutures mesh materiais 12 - monofilament 12 nylon 44 101 114 - - advantages of 14 - silk disadvantages of 14 -absorbable 12 Obrurator hemu 123 - Operation for 129 treatment of 129 Ochsner forceps, 125 Opisie sneedler, 10 55 Operative repair 7 derma use of 15 fascial strip 9 10 materials for filling gaps, 14 *YSIS, use of in 34 silk Lattice 52 sils er wire filigree 15 -- futures, 8 10 12 14 101 114 Tanner slide operation :) Tantalum wire gauze 16 Testus emergence of in inguinal canal os cruption of 19 undescended hormone therapy 67 - - operation for 67 Turner s operation of trans. stotal roposition 68 69 Thread lattice 36 -- repast 64 Trus dangers of 4 6 place of in treatment 2 6 - in inguinal hemja 4 - in perineal hernu 131 - indications and contraindicanons Pelvic region hertiae in 128 Penicillin powder use of s7 Perineal hernia, 130 operation for 131 treatment of, 131 Pouparts ligament anatomial struc ture of .0 fibrous attachment to the pelvis 9 hernua below 30 reconstruction of,66 Prevascular herrija (Narath s hernu) 107 - operative procedure 108 Rectus sheach hernitac in 109 Recurrent hernuae 61 - auses of 61 operation for 62 os - reconstituting the canal, 63 Turner s flap operation 85 - operation of transscrotal reposition, Sac ligature of at neck 41 Schmieden s operation 74 75 Scutchernji 131 - in infants 131 - operasion for 132 Sepsis avoidance of 13 34 - use of in operative repair 34 "Silk lattice repas modification of 52 Silver wire filigrce use of in repair 15 Sliding hemia 59 Spigelian hemia 120 - treatment of, 121 Sutures catgut, 8 - fascial strips 9 10 Umbilical hetnia 110 congenscal 111 — into the cord, 113 in adults S 114 - Mayo s operation, 116 very large treatment of 118 - in infants belt and pad in treatmet of so infantile operation for 113 - incision, site of 114 Operation for 112 types of 111 Umbilicus preservation of 114 119 Willys Andrews method in femoral hernia 104 - Operation 72 74 88 Xylocair

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