- Email: [email protected]
Ligation of the Hernial Sac?
Symposium on Hernias
Ligation of the Hernial Sac?
Sam G. G. Smedberg, M.D.,* Albert E. A. Broome, M.D., Ph.D.,t and Ake Gullmo, M.D., Ph.Dr;
Throughout the history of modern surgery for groin hernia, several procedures have been presented, all with very good results, but the results have sometimes been difficult to reproduce. The relationship between type of hernioplasty and recurrences has been a continuing matter of disagreement. There has, however, been no disagreement concerning resection of the sac in surgery of indirect hernia. Additionally, in order to prevent recurrences, the need of high ligation of the sac has been regarded as axiomatic.
REGENERATION OF PERITONEUM Eskeland," Ellis," and Raftery;" among others, have experimentally demonstrated the very rapid healing of peritoneal defects. The whole surface regenerates simultaneously and the healing is completed in about one week. Clinical experience also confirms the ability of the peritoneum to heal even large defects after colorectal surgery with only scanty development of adhesions. 12, 14 Suturing of the peritoneum causes local ischemia, affects the healing, and causes adhesions. 15 Ellis and Heddle in 1977 presented a prospective randomized study showing no increase in wound ruptures or incisional hernias if the peritoneum was not sutured at laparotomy. 3 As a consequence of these facts, one might postulate that the high ligature of the hernial sac per se does not prevent recurrences, provided that the repair is properly done. A recurrence that is due only to the absence of a high ligature should develop within a week or two and cause an early recurrence. When this study was started, we had already had some experience in performing herniectomy From the Central Hospital, Helsingborg, Sweden *Senior Registrar, Department of Surgery t Associate Professor, Department of Surgery :j:Associate Professor, Department of Diagnostic Radiology
Surgical Clinics of North America-Vol. 64, No.2, April 1984
299
300
SAM
G. G.
SMEDBERG ET AL.
without ligature, beginning in 1977, and we had not found all}' disadvantages. In 1978, Ferguson reported the same experience with not ligating the hernial sac." Comparing ligated and nonligated hernias, we wanted to study the healing and recurrence rates clinically and herniographically.
PERITONEUM AND PAIN The peritoneum is a highly innervated, sensitive membrane in which even puncture with a fine needle produces a sensation of pain. Thus, a ligature causing ischemia and necrosis is very likely to increase postoperative pain. The consequences of peritoneal suturing on postoperative symptoms have not been previously investigated, and one of the intentions of this study was to compare the postoperative pain with and without ligation.
METHODS Except for the special procedures connected with this investigation, the patients included were treated as ordinary patients, and all the surgeons of the clinic participated in all steps of the study. Male patients under 65 years of age with .symptoms of inguinal hernia were examined and those with a suspected indirect hernia were selected for the study. Other kinds of hernias, including recurrences, were excluded. All patients were preoperatively examined with herniography according to
Cullmo." Procedure At operation the diagnosis of indirect hernia was confirmed or rejected. All other hernias, including combined varieties, were excluded from being randomized. Thus, the finding at the operation, not the herniographic finding, was the final point of selection. The selected patients were randomized into two groups. In one group the herniectomy was performed without ligature of the neck of the sac, and in the other group the herniectomy was done with a transfixed high ligature of the neck. In both groups the repair was made according to the following recommendations: when there was no widening of the deep inguinal ring, no repair wasmade;" when a small or moderate widening of the deep ring was present, a fascia transversalis repair according to Marcy" was made; and when the defect was large, a Cooper's ligament hernioplasty according to MCVaylO was made. On all patients the hernioplasty was made with absorbable polyglycolic acid sutures (Dexon and Vicryl). According to the general routines of the clinic, as many patients as possible were operated on as outpatients.
Follow-up The patients were followed up as outpatients after two weeks, six weeks, one year, and in some cases up to three years postoperatively (average, two years and one month). The severity of symptoms during the postoperative period was evaluated. At the one-year control, postoperative
301
LIGATION OF THE HERNIAL SAC?
Table 1. Patients Included in the Study POSTOPERATIVE HERNIOGRAPHY PATIENTS
MEAN AGE
(yrs.)
S.D.
PERFORMED
Nonligated
53
43.5
12.6
31
Ligated
57
43.9
11.7
29
110
43.7
12.0
60
TOTAL
herniography was requested. This was performed in 31 nonligated cases and in 29 ligated cases (see Table 1). Patients A total of 110 hernias were treated in 105 male patients. Herniectomy without ligature was performed in 53 cases and with ligature in 57 cases. The mean ages of the groups were 43.5 and 43.9 years, respectively, with corresponding standard deviations of 12.6 and 11.7 (Table 1). Only five patients were admitted to hospital for the operation. The mean age of these five patients was 60.4 years. Three patients stayed overnight, and the remaining 97 patients (92.4 per cent) returned home on the day of operation. In 10 cases no repair was done because there was no widening of the deep inguinal ring. A Marcy repair was done in 78 cases and a McVay repair in 16. In six cases a Bassini repair was chosen. There was no significant difference between the two groups concerning method of repair.
RESULTS Preoperative Herniography When the results of the operative findings and the preoperative herniography were compared, all the patients operated on for an indirect hernia had a positive herniography. In three cases the herniographic findings were interpreted as direct hernias, whereas the findings at operation were indirect hernias. In 10 cases herniography showed combined direct-indirect hernias (the direct hernias not found at operation). Two weeks postoperatively there were no differences between the groups concerning moderate pain, but in the ligated group there were five patients with severe pain, compared with none in the nonligated group, a difference that is significant (Table 2). Six weeks postoperatively there was a significant difference in the number of patients with remaining symptoms (Table 2). The average need for analgesics, registered as days with oral intake, was less than 1 day in both groups. The average time off work was 3.4 and 3.8 weeks, respectively, in favor of no ligature, a nonsignificant difference. Recurrences and New Hernias After 2 and 6 weeks no clinical recurrences were found in the two groups (Table 2). One recurrence in each group appeared within one year postoperatively. One year or later postoperatively, two recurrences were
302
SAM
G. G.
SMEDBERG ET AL.
Table 2. Clinical Findings Two and Six Weeks Postoperatively NONLIGATED
Two Weeks Postoperatively Total number of patients Moderate pain Severe pain Recurrences Six Weeks Postoperatively Total nurn ber of patients Moderate pain Recurrences
50 20
LIGATED
55 22
o o
5*
o
43 5
49
20t
o
o
*p < 0.05 tp < 0.01
found in the group without ligation and one in the group with ligation (Table 3). At postoperative herniography another recurrence, asymptomatic and without clinical signs, was found in each group. Additionally, two new hernias were found in each group. One of the clinically observed recurrences proved to be a new hernia, the other three new hernias were all asymptomatic and had no clinical signs (Table 3). Taken together there were no differences between the groups concerning recurrences and new hernias. Among the patients without ligation and without hernioplasty there were no recurrences (Fig. 1). Four of the recurrences had received a Marcy repair and two a McVay repair. Of the new hernias, one was previously operated on without a repair of the deep ring and three received a Marcy repair (Fig. 2). Complications There was no bleeding or other complication from the nonligated peritoneal sacs. In the ligated group, there was one case of wound infection and one patient had epididymitis three weeks postoperatively. No sinuses developed in the entire material. Table 3. Number of Recurrences and New Hernias; Clinical and H erniographic Findings
Number of Patients Clinical findings Recurrence 0-1 years Recurrences 1-3 years Additional herniographic findings Recurrences New hernias
NONLIGATED
LIGATED
49
54
1
1* 1 2
1 2
*The data exclude one patient whose hernia was regarded as a recurrence at clinical investigation but was reclassified as a new hernia after herniography.
LIGATION OF THE HERNIAL SAC?
303
Figure 1. A, A 32-year-old man with an indirect hernia on the right side. Herniectomy without ligation of sac and without hernioplasty was performed. B, Two years after surgery herniography was normal. Arrow indicates deep inguinal ring.
304
SAM
G. G.
SMEDBERG ET AL.
Figure 2. A, A 35-year-old man with an indirect hernia on the right side. Herniectomy without ligation of sac and with a Marcy repair was performed. B, Herniography 18 months after surgey shows lateral fossa tightened by previous repair (arrow) and a new hernia (double arrows).
305
LIGATION OF THE HERNIAL SAC?
DISCUSSION Operative Procedure It is of great value to know that indirect hernial sacs can be resected and not ligated without the occurrence of a decline in the quality of the operation as far as risk of recurrence is concerned. On the contrary, there seems to be a reduction of discomfort in the postoperative period. This knowledge can be very useful, for example, in patients with fragile hernial sacs that rupture very easily during dissection and when stretched to enable a proper high ligature. While the surgeon tries to mend the peritoneum, there are the obvious risks of consequent bleeding from the epigastric vessels and even from the femoral vein and of accidental sutures in the bowel. Ferguson has noted that "the excision is more complete and more rapid when no ligature or suture is contemplated."5 In some patients with large defects, it may be necessary to ligate or suture the sac in order to keep the bowel away when doing the repair. The difficulties associated with handling the peritoneum in sliding hernias are eliminated with the nonligature method. A general opinion is that without a processus vaginalis, no indirect hernia will develop since the deep inguinal ring is effectively protected by the shutter mechanism. In small indirect hernias with no widening of the deep ring, we considered repair to be unnecessary. In contrast to Shuttleworth, 13 we had no bad experience with this procedure in our patients over 39 years of age. Postoperative Pain Evaluation of the degree of postoperative discomfort is very; difficult. One way is to register the postoperative consumption of analgesics. However, we were unable to obtain satisfactory information from the patients, and the variation among patients in both groups was great. The average period of consumption was less than one day in both groups. No conclusion could be made from this, except that severe postoperative pain is seldom a major problem after hernia surgery. Time off work was also recorded. It is easy, however, to bias the patient in the direction wanted. Therefore, no conclusions have been drawn. For instance the motivation for early return to work is important, as shown by Barwell 1982. 1 We found a mean time off work of 3.6 weeks in the whole population. The most reliable information was found to be the estimation of pain by the doctor and the patient together at the ambulatory controls. The symptoms were graded as no pain, moderate pain, and severe pain. The significant difference in pain between the groups six weeks postoperatively is unexpected. Healing should have taken place by this time, even of the necrotized peritoneum around the ligatures. One explanation could be a development of edema surrounding the necrotic tissue but also affecting the hernioplasty, a hypothesis that might be further studied experimentally. Postoperative Herniography
A clinical evaluation of the herniographic technique was not intended in this study, but previous experience showing the method to be reliable
306
SAM
G. G.
SMEDBERG ET AL.
confirmed. In all 110 cases a hernia was seen at preoperative herniography and the diagnosis specified proved to be correct in 107; findings that could be considered remarkable. From a clinical point of view, there was a tendency toward overdiagnosis. In ten of the patients operated upon, herniography showed combined direct-indirect hernias. At operation, the direct component was not observed. Among those who received a Marcy repair, the direct hernia persisted unchanged when postoperatively examined with herniography. There were still no clinical signs of the direct hernia. Recurrences and New Hernias With herniography, 50 per cent more recurrences were found than clinically diagnosed. The definition of a recurrence varies,": 9, 13 and there has been no reliable way to distinguish clinically between a recurrence and a new hernia. A long follow-up period is regarded as necessary since recurrences and new hernias obviously can exist for a long time without symptoms or clinical signs, and new hernias might develop at any time during the remaining lifetime. Herniography is a diagnostic tool that may help us solve this problem.
REFERENCES 1. Barwell, N. J.: Recurrence and early activity after groin hernia repair. Lancet, 2:985, 1981. 2. Ellis, H., Harrison, W., and Hugh, T. B.: The healing of peritoneum under normal and pathological conditions. Br. J. Surg., 52:471, 1965. 3. Ellis, H., and Heddle, R.: Does the peritoneum need to be closed at laparotomy? Br. J. Surg., 64:733, 1977. 4. Eskeland, G.: Regeneration of parietal peritoneum. Acta Path. Microbiol. Scand., 62:459, 1964. 5. Ferguson, D. J.: Closure of the hernial sac-Pro and con. In Nyhus, L M., and Condon, R. E. (eds.): Hernia, 2nd ed., Philadelphia, J. B. Lippincott, 1978, pp. 152-153. 6. Gullmo, A.: Herniography. The diagnosis of hernia in the groin and incompetence of the pouch of Douglas and pelvic floor. Acta Radiol., Suppl. 361, 1980. 7. Ljungdahl, I.: Inguinal and femoral hernia. An investigation of 502 own operated cases. Acta Chir. Scand., Suppl. 439, 1973. 8. Marcy, H. 0.: The cure of hernia. JAMA, 8:589, 1887. 9. Marsden, A. J.: Inguinal hernia. A three-year review of one thousand cases. Br. J. Surg., 46:234, 1958. 10. McVay, C. B.: Inguinal hernioplasty. Surg. Clin. North Am., 46:1089, 1966. 11. Raftery, A. T.: Regeneration of parietal and visceral peritoneum. A light microscopical study. Br. J. Surg., 60:293, 1973. 12. Robbins, G. F., Brunschweig, A., Foote, F. W.: Deperitonealization: Clinical and experimental observations. Ann. Surg., 130:466, 1949. 13. Shuttleworth, K. E. D., and Davies, W. H.: Treatment of inguinal herniae. Lancet, 1:126, 1960. 14. Trimpi, H. D., and Bacon, H. E.: Clinical and experimental study of denuded surfaces in extensive surgery of the colon and rectum. Am. J. Surg., 84:596, 1952. 15. Ellis, H.: The cause and prevention of postoperative intraperitoneal adhesions. Surg. Gynecol. Obstet., 133:497, 1971. Central Hospital S 251 87 Helsingborg Sweden
Ligation of the Hernial Sac?
Sam G. G. Smedberg, M.D.,* Albert E. A. Broome, M.D., Ph.D.,t and Ake Gullmo, M.D., Ph.Dr;
Throughout the history of modern surgery for groin hernia, several procedures have been presented, all with very good results, but the results have sometimes been difficult to reproduce. The relationship between type of hernioplasty and recurrences has been a continuing matter of disagreement. There has, however, been no disagreement concerning resection of the sac in surgery of indirect hernia. Additionally, in order to prevent recurrences, the need of high ligation of the sac has been regarded as axiomatic.
REGENERATION OF PERITONEUM Eskeland," Ellis," and Raftery;" among others, have experimentally demonstrated the very rapid healing of peritoneal defects. The whole surface regenerates simultaneously and the healing is completed in about one week. Clinical experience also confirms the ability of the peritoneum to heal even large defects after colorectal surgery with only scanty development of adhesions. 12, 14 Suturing of the peritoneum causes local ischemia, affects the healing, and causes adhesions. 15 Ellis and Heddle in 1977 presented a prospective randomized study showing no increase in wound ruptures or incisional hernias if the peritoneum was not sutured at laparotomy. 3 As a consequence of these facts, one might postulate that the high ligature of the hernial sac per se does not prevent recurrences, provided that the repair is properly done. A recurrence that is due only to the absence of a high ligature should develop within a week or two and cause an early recurrence. When this study was started, we had already had some experience in performing herniectomy From the Central Hospital, Helsingborg, Sweden *Senior Registrar, Department of Surgery t Associate Professor, Department of Surgery :j:Associate Professor, Department of Diagnostic Radiology
Surgical Clinics of North America-Vol. 64, No.2, April 1984
299
300
SAM
G. G.
SMEDBERG ET AL.
without ligature, beginning in 1977, and we had not found all}' disadvantages. In 1978, Ferguson reported the same experience with not ligating the hernial sac." Comparing ligated and nonligated hernias, we wanted to study the healing and recurrence rates clinically and herniographically.
PERITONEUM AND PAIN The peritoneum is a highly innervated, sensitive membrane in which even puncture with a fine needle produces a sensation of pain. Thus, a ligature causing ischemia and necrosis is very likely to increase postoperative pain. The consequences of peritoneal suturing on postoperative symptoms have not been previously investigated, and one of the intentions of this study was to compare the postoperative pain with and without ligation.
METHODS Except for the special procedures connected with this investigation, the patients included were treated as ordinary patients, and all the surgeons of the clinic participated in all steps of the study. Male patients under 65 years of age with .symptoms of inguinal hernia were examined and those with a suspected indirect hernia were selected for the study. Other kinds of hernias, including recurrences, were excluded. All patients were preoperatively examined with herniography according to
Cullmo." Procedure At operation the diagnosis of indirect hernia was confirmed or rejected. All other hernias, including combined varieties, were excluded from being randomized. Thus, the finding at the operation, not the herniographic finding, was the final point of selection. The selected patients were randomized into two groups. In one group the herniectomy was performed without ligature of the neck of the sac, and in the other group the herniectomy was done with a transfixed high ligature of the neck. In both groups the repair was made according to the following recommendations: when there was no widening of the deep inguinal ring, no repair wasmade;" when a small or moderate widening of the deep ring was present, a fascia transversalis repair according to Marcy" was made; and when the defect was large, a Cooper's ligament hernioplasty according to MCVaylO was made. On all patients the hernioplasty was made with absorbable polyglycolic acid sutures (Dexon and Vicryl). According to the general routines of the clinic, as many patients as possible were operated on as outpatients.
Follow-up The patients were followed up as outpatients after two weeks, six weeks, one year, and in some cases up to three years postoperatively (average, two years and one month). The severity of symptoms during the postoperative period was evaluated. At the one-year control, postoperative
301
LIGATION OF THE HERNIAL SAC?
Table 1. Patients Included in the Study POSTOPERATIVE HERNIOGRAPHY PATIENTS
MEAN AGE
(yrs.)
S.D.
PERFORMED
Nonligated
53
43.5
12.6
31
Ligated
57
43.9
11.7
29
110
43.7
12.0
60
TOTAL
herniography was requested. This was performed in 31 nonligated cases and in 29 ligated cases (see Table 1). Patients A total of 110 hernias were treated in 105 male patients. Herniectomy without ligature was performed in 53 cases and with ligature in 57 cases. The mean ages of the groups were 43.5 and 43.9 years, respectively, with corresponding standard deviations of 12.6 and 11.7 (Table 1). Only five patients were admitted to hospital for the operation. The mean age of these five patients was 60.4 years. Three patients stayed overnight, and the remaining 97 patients (92.4 per cent) returned home on the day of operation. In 10 cases no repair was done because there was no widening of the deep inguinal ring. A Marcy repair was done in 78 cases and a McVay repair in 16. In six cases a Bassini repair was chosen. There was no significant difference between the two groups concerning method of repair.
RESULTS Preoperative Herniography When the results of the operative findings and the preoperative herniography were compared, all the patients operated on for an indirect hernia had a positive herniography. In three cases the herniographic findings were interpreted as direct hernias, whereas the findings at operation were indirect hernias. In 10 cases herniography showed combined direct-indirect hernias (the direct hernias not found at operation). Two weeks postoperatively there were no differences between the groups concerning moderate pain, but in the ligated group there were five patients with severe pain, compared with none in the nonligated group, a difference that is significant (Table 2). Six weeks postoperatively there was a significant difference in the number of patients with remaining symptoms (Table 2). The average need for analgesics, registered as days with oral intake, was less than 1 day in both groups. The average time off work was 3.4 and 3.8 weeks, respectively, in favor of no ligature, a nonsignificant difference. Recurrences and New Hernias After 2 and 6 weeks no clinical recurrences were found in the two groups (Table 2). One recurrence in each group appeared within one year postoperatively. One year or later postoperatively, two recurrences were
302
SAM
G. G.
SMEDBERG ET AL.
Table 2. Clinical Findings Two and Six Weeks Postoperatively NONLIGATED
Two Weeks Postoperatively Total number of patients Moderate pain Severe pain Recurrences Six Weeks Postoperatively Total nurn ber of patients Moderate pain Recurrences
50 20
LIGATED
55 22
o o
5*
o
43 5
49
20t
o
o
*p < 0.05 tp < 0.01
found in the group without ligation and one in the group with ligation (Table 3). At postoperative herniography another recurrence, asymptomatic and without clinical signs, was found in each group. Additionally, two new hernias were found in each group. One of the clinically observed recurrences proved to be a new hernia, the other three new hernias were all asymptomatic and had no clinical signs (Table 3). Taken together there were no differences between the groups concerning recurrences and new hernias. Among the patients without ligation and without hernioplasty there were no recurrences (Fig. 1). Four of the recurrences had received a Marcy repair and two a McVay repair. Of the new hernias, one was previously operated on without a repair of the deep ring and three received a Marcy repair (Fig. 2). Complications There was no bleeding or other complication from the nonligated peritoneal sacs. In the ligated group, there was one case of wound infection and one patient had epididymitis three weeks postoperatively. No sinuses developed in the entire material. Table 3. Number of Recurrences and New Hernias; Clinical and H erniographic Findings
Number of Patients Clinical findings Recurrence 0-1 years Recurrences 1-3 years Additional herniographic findings Recurrences New hernias
NONLIGATED
LIGATED
49
54
1
1* 1 2
1 2
*The data exclude one patient whose hernia was regarded as a recurrence at clinical investigation but was reclassified as a new hernia after herniography.
LIGATION OF THE HERNIAL SAC?
303
Figure 1. A, A 32-year-old man with an indirect hernia on the right side. Herniectomy without ligation of sac and without hernioplasty was performed. B, Two years after surgery herniography was normal. Arrow indicates deep inguinal ring.
304
SAM
G. G.
SMEDBERG ET AL.
Figure 2. A, A 35-year-old man with an indirect hernia on the right side. Herniectomy without ligation of sac and with a Marcy repair was performed. B, Herniography 18 months after surgey shows lateral fossa tightened by previous repair (arrow) and a new hernia (double arrows).
305
LIGATION OF THE HERNIAL SAC?
DISCUSSION Operative Procedure It is of great value to know that indirect hernial sacs can be resected and not ligated without the occurrence of a decline in the quality of the operation as far as risk of recurrence is concerned. On the contrary, there seems to be a reduction of discomfort in the postoperative period. This knowledge can be very useful, for example, in patients with fragile hernial sacs that rupture very easily during dissection and when stretched to enable a proper high ligature. While the surgeon tries to mend the peritoneum, there are the obvious risks of consequent bleeding from the epigastric vessels and even from the femoral vein and of accidental sutures in the bowel. Ferguson has noted that "the excision is more complete and more rapid when no ligature or suture is contemplated."5 In some patients with large defects, it may be necessary to ligate or suture the sac in order to keep the bowel away when doing the repair. The difficulties associated with handling the peritoneum in sliding hernias are eliminated with the nonligature method. A general opinion is that without a processus vaginalis, no indirect hernia will develop since the deep inguinal ring is effectively protected by the shutter mechanism. In small indirect hernias with no widening of the deep ring, we considered repair to be unnecessary. In contrast to Shuttleworth, 13 we had no bad experience with this procedure in our patients over 39 years of age. Postoperative Pain Evaluation of the degree of postoperative discomfort is very; difficult. One way is to register the postoperative consumption of analgesics. However, we were unable to obtain satisfactory information from the patients, and the variation among patients in both groups was great. The average period of consumption was less than one day in both groups. No conclusion could be made from this, except that severe postoperative pain is seldom a major problem after hernia surgery. Time off work was also recorded. It is easy, however, to bias the patient in the direction wanted. Therefore, no conclusions have been drawn. For instance the motivation for early return to work is important, as shown by Barwell 1982. 1 We found a mean time off work of 3.6 weeks in the whole population. The most reliable information was found to be the estimation of pain by the doctor and the patient together at the ambulatory controls. The symptoms were graded as no pain, moderate pain, and severe pain. The significant difference in pain between the groups six weeks postoperatively is unexpected. Healing should have taken place by this time, even of the necrotized peritoneum around the ligatures. One explanation could be a development of edema surrounding the necrotic tissue but also affecting the hernioplasty, a hypothesis that might be further studied experimentally. Postoperative Herniography
A clinical evaluation of the herniographic technique was not intended in this study, but previous experience showing the method to be reliable
306
SAM
G. G.
SMEDBERG ET AL.
confirmed. In all 110 cases a hernia was seen at preoperative herniography and the diagnosis specified proved to be correct in 107; findings that could be considered remarkable. From a clinical point of view, there was a tendency toward overdiagnosis. In ten of the patients operated upon, herniography showed combined direct-indirect hernias. At operation, the direct component was not observed. Among those who received a Marcy repair, the direct hernia persisted unchanged when postoperatively examined with herniography. There were still no clinical signs of the direct hernia. Recurrences and New Hernias With herniography, 50 per cent more recurrences were found than clinically diagnosed. The definition of a recurrence varies,": 9, 13 and there has been no reliable way to distinguish clinically between a recurrence and a new hernia. A long follow-up period is regarded as necessary since recurrences and new hernias obviously can exist for a long time without symptoms or clinical signs, and new hernias might develop at any time during the remaining lifetime. Herniography is a diagnostic tool that may help us solve this problem.
REFERENCES 1. Barwell, N. J.: Recurrence and early activity after groin hernia repair. Lancet, 2:985, 1981. 2. Ellis, H., Harrison, W., and Hugh, T. B.: The healing of peritoneum under normal and pathological conditions. Br. J. Surg., 52:471, 1965. 3. Ellis, H., and Heddle, R.: Does the peritoneum need to be closed at laparotomy? Br. J. Surg., 64:733, 1977. 4. Eskeland, G.: Regeneration of parietal peritoneum. Acta Path. Microbiol. Scand., 62:459, 1964. 5. Ferguson, D. J.: Closure of the hernial sac-Pro and con. In Nyhus, L M., and Condon, R. E. (eds.): Hernia, 2nd ed., Philadelphia, J. B. Lippincott, 1978, pp. 152-153. 6. Gullmo, A.: Herniography. The diagnosis of hernia in the groin and incompetence of the pouch of Douglas and pelvic floor. Acta Radiol., Suppl. 361, 1980. 7. Ljungdahl, I.: Inguinal and femoral hernia. An investigation of 502 own operated cases. Acta Chir. Scand., Suppl. 439, 1973. 8. Marcy, H. 0.: The cure of hernia. JAMA, 8:589, 1887. 9. Marsden, A. J.: Inguinal hernia. A three-year review of one thousand cases. Br. J. Surg., 46:234, 1958. 10. McVay, C. B.: Inguinal hernioplasty. Surg. Clin. North Am., 46:1089, 1966. 11. Raftery, A. T.: Regeneration of parietal and visceral peritoneum. A light microscopical study. Br. J. Surg., 60:293, 1973. 12. Robbins, G. F., Brunschweig, A., Foote, F. W.: Deperitonealization: Clinical and experimental observations. Ann. Surg., 130:466, 1949. 13. Shuttleworth, K. E. D., and Davies, W. H.: Treatment of inguinal herniae. Lancet, 1:126, 1960. 14. Trimpi, H. D., and Bacon, H. E.: Clinical and experimental study of denuded surfaces in extensive surgery of the colon and rectum. Am. J. Surg., 84:596, 1952. 15. Ellis, H.: The cause and prevention of postoperative intraperitoneal adhesions. Surg. Gynecol. Obstet., 133:497, 1971. Central Hospital S 251 87 Helsingborg Sweden