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An anterior transversalis fascia repair for adult inguinal hernias
An Anterior Transversalis Fascia Repair for Adult lnguinal Hernias Stanley Berliner, MD, FACS, New Hyde Park, New York Leonard Burson, MD, FACS, New Hyde Park, New York Paul Katz, MD, New Hyde Park, New York Leslie Wise, MD, FACS, New Hyde Park, New York
If there is any truth to the story that William Stewart Halsted refused to have his inguinal hernia repaired, it was probably a reflection of the disappointing recurrence rates of the day. How much they have improved over the last few decades is not clear. In recent years the recurrence rate after inguinal herniorrhaphy has been reported to vary from 0.2 to 39 per cent. Two of us have been performing inguinal herniorrhaphies as part of a general surgical practice for the past twenty years with many minor modifications and one major change. Before 1972, adult inguinal hernias were repaired using either a Bassini or a Cooper’s ligament procedure. Because of dissatisfaction with recurrences, an anterior transversalis fascia repair has been used since March 1972. The present report compares the results of herniorrhaphies performed by us during the period from January 1967 through February 1972 and the subsequent period from March 1972 through February 1975. Clinical Material and Methods During the eight year period from January 1967 through February 1975, we performed 1,311 inguinal hernia operations on 1,020 patients more than eighteen years old. The procedures were divided into two groups. Group I, January 1967 through February 1972, consisted of 720 inguinal herniorrhaphies performed on 526 patients under inhalation or spinal anesthesia. Local anesthesia was reserved for poor risk patients. One hundred fourteen patients had simultaneous bilateral hernia repair. The choice of repair in group I using the Bassini or Cooper’s ligament method depended on the anatomic findings. Most recurrent hernias, sliding hernias, and large direct defects were repaired using Cooper’s ligament; the others were repaired by the From the Department of Surgery, Long Island Jewish-HillsideMedical Cant8r. New Hyde Park. and Ths State University of New York at Stony Brook, Stony Brook, New York. Reprint requests should be addressed to Leslie Wise, MD, Department of Surgery, Long Island Jewish+lillsida Medical Center, New Hyde Park, New York 11040.
Volume 135, May 1979
Bassini technic. Group II, March 1972 through February 1975, consisted of 591 inguinal herniorrhaphies performed on 494 patients utilizing the anterior transversalis fascia technic under local anesthesia. The Bassini operation consisted of high ligation and excision of the sac and reinforcement of the floor of the canal by suturing the conjoined tendon to the inguinal ligament beneath the cord. In addition, the transversalis fascia was reinforced with interrupted sutures, particularly at the internal ring. The use of Cooper’s ligament to anchor the medial parietal wall in the repair is credited to Lotheissen [I], and the use of this structure as an integral part of hernia repair was popularized in the United States by McVay [2]. This procedure also consists of high ligation and excision of the hernial sac [3]. Conjoined tendon or rectus sheath is sutured to Cooper’s ligament, and a relaxing incision is made in the rectus fascia. The internal ring is tightened as in the Bassini procedure. In 1920 William Downes [4] described a technic in which he excised the direct sac and sutured the transversalis fascia with a continuous stitch whenever possible. He completed the procedure with a Bassini repair, also using a rectus relaxing incision [4]. In 1945 Shouldice described a modification of the Downes procedure in which he imbricated a double layer of transversalis fascia and also sutured it to the inguinal ligament. He reinforced this with two additional layers of conjoined muscle approximated to the undersurface of the external oblique [5-71. The group II procedure was a three-layer interior approach (Figure l), which reunited the transversalis fascia and also utilized the transversus abdominis superiorly in the first layer and the inguinal ligament inferiorly to stabilize the second layer. High dissection of the peritoneum or indirect sac away from the spermatic cord and transversalis fascia is essential to prevent an indirect recurrence. The first step in the repair of the floor consists of an incision into the transversalis fascia from the internal ring to the pubic tubercle. When open, the bright yellow preperitoneal fat pushes through, and dissection of the medial leaf is facilitated. This dissection is carried back to a white line which represents the combined fibers of the transversalis fascia and the transversus abdominis. To aid in the dissection of the transversalis fascia at the internal
633
Berliner et al
pRE-OPERATIVE excess direct sac r. to be excised /’ ‘\ , \ \ .’
a
POST- OPERATIVE
,’
e ..--8 --- __-A_”
,’
al
ring, several small branches of epigastric vessels may have to be divided; division of the main epigastric vessels is of no aid. In the repair, the first continuous line of 3-O Tevdek” suture begins at the pubic tubercle and ends by forming a new internal ring lateral to the epigastric vessels. It approximates the lateral edge of transversalis fascia to the undersurface of transversalis fascia medially and to the overlying transversus abdominis. Superiorly, the lateral margin of the transversalis fascia is thin and the sutures must be superficial, since it is the investing fascia of the femoral sheath. Any excess medial leaf of transversalis fascia comprising the direct sac is excised. A second layer of the same 3-O Tevdek suture is then used to join the free margin of the medial leaf to the transversalis fascia laterally and also to the shelf of the inguinal ligament. Joining the medial edge of transversalis fascia to its lateral margin reconstructs the posterior floor anatomically. Suturing this medial edge also to the shelf of the inguinal ligament stabilizes the transversalis repair. A third layer of continuous 3-O Tevdek suture approximates the internal oblique and the conjoined tendon to the undersurface of the external oblique just superficial to the inguinal ligament. Relaxing incisions are not necessary, and the cord is replaced under the external oblique fascia. The average age of patients in group I was fifty years and in group II fifty-five years, and there was no significant difference between the age distribution of the patients in the two groups. Of the 720 group I hernias, 37 per cent were indirect, 27 per cent were direct, 19 per cent were combined indirect and direct, 15 per cent were recurrent, and 4 per
634
a
Figure 1. The modified DownesShouldice anterior transversalis inguinal hernia repair. A, lateral cut edge of transversalis (al) is sutured to the undersurface of the medlal cut edge (a*) and to the transversus abdominis muscle (b). B, medial cut edge of transversalis ( a2) is sutured to the lateral margin of transversal/s and the she/f of the ing&at ligament (e). C, internal oblique (c) and conjoined muscle are sutured to the undersurface of the external oblique (d). D, the cord Is replaced under the external oblique.
cent were sliding. On statistical analysis, there were no significant differences in the types of inguinal hernias between the two groups. The follow-up period in group I was a minimum of four years and a maximum of nine years; the median follow-up time was seventy-eight months. Thirty-three patients (6.3 per cent) could not be traced, and sixteen patients died of unrelated causes. Follow-up in group II was from two to five years with a median follow-up time of thirty-five months. Four patients (0.8 per cent) could not be traced, and five died of unrelated causes. Follow-up in each group consisted of examination three times the first year and at yearly intervals thereafter. The anterior transversalis repair required between 60 and 90 minutes of operating time. Local anesthesia was used in all but eleven patients; this permitted us to operate on many poor risk patients. The average hospital stay was 4.3 days for unilateral hernias. The ninety-five patients with bilateral hernias had the second side repaired on the third day after the initial surgery.
Results In group I (Bassini-Cooper’s ligament repair) the operative mortality was zero and the complication rate was 4.3 per cent (14 wound infections, 3 hematomas, 9 cord indurations, 3 testicular atrophies, and 2 urinary retentions). During the four to nine year follow-up, there was a total of 83 recurrences among the 720 operations, a failure rate of 11.5 per cent. The primary hernia group had a recurrence rate of 7 per
The American Journal of Surgery
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cent (41 of 590 operations) and the secondary hernia group had a recurrence rate of 32 per cent (42 of 130 operations). In the 114 simultaneous bilateral primary repairs, the recurrence rate was 8 per cent. In group I, there were sixty-eight patients who were traced with much difficulty and who would not come in for examination. As reported by family or friends, the hernia had recurred in twenty-one of these patients (31 per cent). This was added to our recurrence figures and emphasized the importance of complete follow-up. It also raised serious questions as to the validity of reports in which the untraceable group exceeded 10 per cent. In group II (anterior transversalis repair) the operative mortality was again zero and the complication rate was 2.6 per cent (9 wound infections, 2 hematomas, 7 cord indurations, 2 testicular atrophies, 1 urinary retention, and 1 pneumonia). During the two to five year follow-up period the recurrence rate was 2.7 per cent (16 of 591 operations); 1.8 per cent (9 of 504) for primary repairs and 8.0 per cent (7 of.87) for recurrent hernias. Comments
To evaluate the literature on hernia repair, uniformity in the recorded data is necessary and the data should include: (1) the number of patients and the number of operations; (2) the length of follow-up and the median follow-up time; (3) the number of recurrences; (4) the number of untraceable patients; (5) the number of patients who died during the follow-up period; and (6) the method of follow-up. We reviewed ten series, which included almost 15,000 operations, that fulfilled most of the above criteria [5,8-151. At first glance the reports suggested that a variety of operations gave equally good results. However, closer investigation revealed that in some the manner of follow-up or the number of cases lost to follow-up precluded proper evaluation. Although the 3.5 per cent recurrence rate of Halverson and McVay [IO] is admirable, only 76 per cent of patients were available for study during the course of the one to twenty-two year follow-up, detracting from the value of the report. In the 2,700 cases reviewed by Glassow [4], the recurrence rate was 0.7 per cent, but the follow-up decreased from 81 per cent at five years to 55 per cent at seven years. The 0.2 per cent recurrence rate reported by Shearburn and Myers [6] is marred because the data under items 4,5, and 6 are unrecorded. Similarly, Lichtenstein [1 I] and Lichtenstein and Shore [16] have a 0.9 per cent recurrence rate using mesh in more than 2,000 operations, but their follow-up period varies from zero to
Volume 135, May 1670
four and a half years [17]. Palumbo and Sharpe [14] report 3,500 primary repairs with a 1 per cent recurrence rate. Unfortunately, many of these patients were followed by letter rather than personal examination. The intervals before recurrence of inguinal hernias vary considerably in different reports. In our group I series, 47 per cent of the total recurrences occurred within the first year; by the end of the second year 59 per cent had recurred. This differs from the report by Palumbo and Sharpe [14], in which only 25 per cent of recurrences were detected in the first three years. However, in that series information was collected by various means, including questionnaire and employment physical. We believe that there is no substitute for examination by the operating surgeon. In the Hagan and Rhoads series [9], 55 per cent of the recurrent hernias recurred within two years and 75 per cent by the end of the fifth year. These authors also decry the use of a questionnaire as a means of follow-up and note that almost 50 per cent of their patients were unaware of the recurrence. In addition to the manner of follow-up, the type of recurrent hernia may also play a role in the time interval from surgery to recurrence. In the series reported by Postlethwait [B], 50 per cent of forty-eight recurrent direct hernias recurred within the first year and more than 70 per cent had recurred within the two to five year follow-up period. On the other hand, in a group of 176 indirect recurrences [7], only 20 per cent appeared within the first year and only 55 per cent within the two to five year follow-up period. In many series that have been followed beyond five years, almost 50 per cent of the patients are untraceable or dead. Glassow [5] reported a decrease in the patients followed from 81 per cent at five years to 55 per cent at seven years. When we reflect that in our series of long-term follow-ups the sixty-eight patients who were traced with much difficulty had a recurrence rate of 31 per cent, we must be cautious in interpreting the reported recurrence rates in series in which the follow-up falls much below the 90 per cent level. A discouraging aspect of our group I series was the large number of recurrences of repeat hernias. Patients in this group had had from one to four previous operations. With a median follow-up time of six and a half years, 32 per cent of these reoperations were failures. These poor results for recurrent hernias are matched by the study of Clear [a], in which fiftythree patients were followed ten years with twentyone recurrences (39 per cent). The recurrence rate for recurrent hernias in a report by Thieme [19] was 33 per cent. Except for McVay’s series [IO], reports with
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shorter follow-up periods, including mesh and Cooper’s ligament repairs, have recurrence rates ranging from 10 to 21 per cent [9,11,20]. The reduction of our recurrences from 32 to 8 per cent (allowing for the shorter median follow-up of 3 years) is striking. The importance of high dissection of the peritoneum for all types of inguinal hernias should be emphasized. In our series of 130 recurrent hernias in group I, forty-one (31 per cent) had an indirect sac at operation. This suggests that in 31 per cent the indirect sac was either missed or not completely dissected at the original operation. In a report by Postlethwait [28], 154 of 300 recurrent inguinal hernias were found to have an indirect sac. Our results suggest that with the anterior transversalis repair the recurrence rate can be significantly decreased. Because of the difference in median follow-up time (35 versus 78 months), the recurrence rates require adjustment. In group I there was a gradual increase with time in the number of recurrences. Assuming that the recurrences in group II will occur with the same frequency and proportion as in group I, we project that at the seventy-eight month median follow-up point for group II we will have an additional four recurrences over our sixteen known ones. This would give a 3.4 per cent projected recurrence rate for the anterior transversalis procedure, as compared with the 11.5 per cent rate for the Bassini-Cooper’s ligament repair. Summary
During the eight year period from 1967 to 1975, 1,020 patients more than eighteen years old underwent 1,311 inguinal herniorrhaphies. Group I consisted of 720 inguinal herniorrhaphies in which either a Bassini or a Cooper’s ligament repair was used. During a four to nine year follow-up period, the total recurrence rate was 11.5 per cent; the recurrence rate for the primary repair group was 7 per cent and for the recurrent group 32 per cent. The follow-up rate was 93.7 per cent. Group II consisted of 591 herniorrhaphies in which the repair was performed by an anterior transversalis fascia technic. During a two
636
follow-up period, the total recurrence rate was 2.7 per cent; 1.8 per cent for primary repairs and 8.0 per cent for recurrent hernias. The follow-up rate was 98 per cent (95 per cent by personal examination) . Assuming that the recurrences in group II will occur with the same frequency as in group I, our projected four to nine year recurrence rate is 3.4 per cent. This suggests that the anterior transversalis fascia repair results in a lower recurrence rate than either the Bassini or Cooper’s ligament repairs. to five year
References 1. Lotheissen G: Zur Radikaloperation der Schenkelhernien. Zentralbl Chir 25: 546, 1896 2. McVay CB: lnguinal and femoral hernioplasty: anatomic repair. Arch Surg 57: 524, 1946. 3. Harkins HN: The Cooper’s ligament repair of direct inguinal hernia, p 179. Hernia (Nyhus LM, Harkins HN, ed). Philadelphia, Lippincott, 1964. 4. Downes WA: Management of direct inguinal hernia. Arch Surg 1: 53, 1920. 5. Glassow F: The surgical repair of inguinal and femoral hernias. Can Med Assoc J 108: 308, 1973. 6. Shearburn EW, Myers RN: Shouldice repair for inguinal hernia. Surgery 66: 450, 1969. 7. Welsh DRJ: lnguinal hernia repair: a contemporary approach to a common procedure. Mod Med 12: 49, 174. a. Clear JJ: Ten year statistical study of inguinal hernias. Arch Surg 62: 70, 1951. 9. Hagan WH, Rhoads JE: lnguinal and femoral hernias. Surg Gynecol Obstet 96: 226. 1953. 10. Halverson K, McVay CB: lnguinal and femoral hernioplasty. Arch Surg 101: 127, 1970. 11. Lichtenstein IL: Hernia Repair without Disability. St. Louis, CV Mosby, 1970. 12. Marsden JJ: lnguinal hernia, a review of 2000 cases. Br J Surg 49: 384, 1962. 13. Shuttelworth KED, Davis WA: Treatment of inguinal hernia. Lancet 1: 126, 1960. 14. Palumbo LT. Sharpe WS: Primary inguinal hernioplasty in the adult. Surg C/in North Am 51: 1293, 1971. 15. Skinner HR, Duncan RD: lnguinal hernia. Report of 1126 cases. Surg C/in North Am 25: 219, 1945. 16. Lichtenstein IL, Shore JM: Exploding the myths of hernia repair. Am J Surg 132: 307, 1976. 17. Lichtenstein IL: Personal communication, 1977. ia. Postlethwait RW: Causes of recurrence after inguinal herniorrhaphy. Surgery 69: 772, 1971. 19. Thieme ET: Recurrent inguinal hernia. Arch Surg 103: 236, 1971. 20. Burton CC, Ramos RJ: The results of surgical treatment of recurrent inguinal hernias. Surg Gynecol Obstet 70: 969, 1940.
The American Journal of Surgery
If there is any truth to the story that William Stewart Halsted refused to have his inguinal hernia repaired, it was probably a reflection of the disappointing recurrence rates of the day. How much they have improved over the last few decades is not clear. In recent years the recurrence rate after inguinal herniorrhaphy has been reported to vary from 0.2 to 39 per cent. Two of us have been performing inguinal herniorrhaphies as part of a general surgical practice for the past twenty years with many minor modifications and one major change. Before 1972, adult inguinal hernias were repaired using either a Bassini or a Cooper’s ligament procedure. Because of dissatisfaction with recurrences, an anterior transversalis fascia repair has been used since March 1972. The present report compares the results of herniorrhaphies performed by us during the period from January 1967 through February 1972 and the subsequent period from March 1972 through February 1975. Clinical Material and Methods During the eight year period from January 1967 through February 1975, we performed 1,311 inguinal hernia operations on 1,020 patients more than eighteen years old. The procedures were divided into two groups. Group I, January 1967 through February 1972, consisted of 720 inguinal herniorrhaphies performed on 526 patients under inhalation or spinal anesthesia. Local anesthesia was reserved for poor risk patients. One hundred fourteen patients had simultaneous bilateral hernia repair. The choice of repair in group I using the Bassini or Cooper’s ligament method depended on the anatomic findings. Most recurrent hernias, sliding hernias, and large direct defects were repaired using Cooper’s ligament; the others were repaired by the From the Department of Surgery, Long Island Jewish-HillsideMedical Cant8r. New Hyde Park. and Ths State University of New York at Stony Brook, Stony Brook, New York. Reprint requests should be addressed to Leslie Wise, MD, Department of Surgery, Long Island Jewish+lillsida Medical Center, New Hyde Park, New York 11040.
Volume 135, May 1979
Bassini technic. Group II, March 1972 through February 1975, consisted of 591 inguinal herniorrhaphies performed on 494 patients utilizing the anterior transversalis fascia technic under local anesthesia. The Bassini operation consisted of high ligation and excision of the sac and reinforcement of the floor of the canal by suturing the conjoined tendon to the inguinal ligament beneath the cord. In addition, the transversalis fascia was reinforced with interrupted sutures, particularly at the internal ring. The use of Cooper’s ligament to anchor the medial parietal wall in the repair is credited to Lotheissen [I], and the use of this structure as an integral part of hernia repair was popularized in the United States by McVay [2]. This procedure also consists of high ligation and excision of the hernial sac [3]. Conjoined tendon or rectus sheath is sutured to Cooper’s ligament, and a relaxing incision is made in the rectus fascia. The internal ring is tightened as in the Bassini procedure. In 1920 William Downes [4] described a technic in which he excised the direct sac and sutured the transversalis fascia with a continuous stitch whenever possible. He completed the procedure with a Bassini repair, also using a rectus relaxing incision [4]. In 1945 Shouldice described a modification of the Downes procedure in which he imbricated a double layer of transversalis fascia and also sutured it to the inguinal ligament. He reinforced this with two additional layers of conjoined muscle approximated to the undersurface of the external oblique [5-71. The group II procedure was a three-layer interior approach (Figure l), which reunited the transversalis fascia and also utilized the transversus abdominis superiorly in the first layer and the inguinal ligament inferiorly to stabilize the second layer. High dissection of the peritoneum or indirect sac away from the spermatic cord and transversalis fascia is essential to prevent an indirect recurrence. The first step in the repair of the floor consists of an incision into the transversalis fascia from the internal ring to the pubic tubercle. When open, the bright yellow preperitoneal fat pushes through, and dissection of the medial leaf is facilitated. This dissection is carried back to a white line which represents the combined fibers of the transversalis fascia and the transversus abdominis. To aid in the dissection of the transversalis fascia at the internal
633
Berliner et al
pRE-OPERATIVE excess direct sac r. to be excised /’ ‘\ , \ \ .’
a
POST- OPERATIVE
,’
e ..--8 --- __-A_”
,’
al
ring, several small branches of epigastric vessels may have to be divided; division of the main epigastric vessels is of no aid. In the repair, the first continuous line of 3-O Tevdek” suture begins at the pubic tubercle and ends by forming a new internal ring lateral to the epigastric vessels. It approximates the lateral edge of transversalis fascia to the undersurface of transversalis fascia medially and to the overlying transversus abdominis. Superiorly, the lateral margin of the transversalis fascia is thin and the sutures must be superficial, since it is the investing fascia of the femoral sheath. Any excess medial leaf of transversalis fascia comprising the direct sac is excised. A second layer of the same 3-O Tevdek suture is then used to join the free margin of the medial leaf to the transversalis fascia laterally and also to the shelf of the inguinal ligament. Joining the medial edge of transversalis fascia to its lateral margin reconstructs the posterior floor anatomically. Suturing this medial edge also to the shelf of the inguinal ligament stabilizes the transversalis repair. A third layer of continuous 3-O Tevdek suture approximates the internal oblique and the conjoined tendon to the undersurface of the external oblique just superficial to the inguinal ligament. Relaxing incisions are not necessary, and the cord is replaced under the external oblique fascia. The average age of patients in group I was fifty years and in group II fifty-five years, and there was no significant difference between the age distribution of the patients in the two groups. Of the 720 group I hernias, 37 per cent were indirect, 27 per cent were direct, 19 per cent were combined indirect and direct, 15 per cent were recurrent, and 4 per
634
a
Figure 1. The modified DownesShouldice anterior transversalis inguinal hernia repair. A, lateral cut edge of transversalis (al) is sutured to the undersurface of the medlal cut edge (a*) and to the transversus abdominis muscle (b). B, medial cut edge of transversalis ( a2) is sutured to the lateral margin of transversal/s and the she/f of the ing&at ligament (e). C, internal oblique (c) and conjoined muscle are sutured to the undersurface of the external oblique (d). D, the cord Is replaced under the external oblique.
cent were sliding. On statistical analysis, there were no significant differences in the types of inguinal hernias between the two groups. The follow-up period in group I was a minimum of four years and a maximum of nine years; the median follow-up time was seventy-eight months. Thirty-three patients (6.3 per cent) could not be traced, and sixteen patients died of unrelated causes. Follow-up in group II was from two to five years with a median follow-up time of thirty-five months. Four patients (0.8 per cent) could not be traced, and five died of unrelated causes. Follow-up in each group consisted of examination three times the first year and at yearly intervals thereafter. The anterior transversalis repair required between 60 and 90 minutes of operating time. Local anesthesia was used in all but eleven patients; this permitted us to operate on many poor risk patients. The average hospital stay was 4.3 days for unilateral hernias. The ninety-five patients with bilateral hernias had the second side repaired on the third day after the initial surgery.
Results In group I (Bassini-Cooper’s ligament repair) the operative mortality was zero and the complication rate was 4.3 per cent (14 wound infections, 3 hematomas, 9 cord indurations, 3 testicular atrophies, and 2 urinary retentions). During the four to nine year follow-up, there was a total of 83 recurrences among the 720 operations, a failure rate of 11.5 per cent. The primary hernia group had a recurrence rate of 7 per
The American Journal of Surgery
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cent (41 of 590 operations) and the secondary hernia group had a recurrence rate of 32 per cent (42 of 130 operations). In the 114 simultaneous bilateral primary repairs, the recurrence rate was 8 per cent. In group I, there were sixty-eight patients who were traced with much difficulty and who would not come in for examination. As reported by family or friends, the hernia had recurred in twenty-one of these patients (31 per cent). This was added to our recurrence figures and emphasized the importance of complete follow-up. It also raised serious questions as to the validity of reports in which the untraceable group exceeded 10 per cent. In group II (anterior transversalis repair) the operative mortality was again zero and the complication rate was 2.6 per cent (9 wound infections, 2 hematomas, 7 cord indurations, 2 testicular atrophies, 1 urinary retention, and 1 pneumonia). During the two to five year follow-up period the recurrence rate was 2.7 per cent (16 of 591 operations); 1.8 per cent (9 of 504) for primary repairs and 8.0 per cent (7 of.87) for recurrent hernias. Comments
To evaluate the literature on hernia repair, uniformity in the recorded data is necessary and the data should include: (1) the number of patients and the number of operations; (2) the length of follow-up and the median follow-up time; (3) the number of recurrences; (4) the number of untraceable patients; (5) the number of patients who died during the follow-up period; and (6) the method of follow-up. We reviewed ten series, which included almost 15,000 operations, that fulfilled most of the above criteria [5,8-151. At first glance the reports suggested that a variety of operations gave equally good results. However, closer investigation revealed that in some the manner of follow-up or the number of cases lost to follow-up precluded proper evaluation. Although the 3.5 per cent recurrence rate of Halverson and McVay [IO] is admirable, only 76 per cent of patients were available for study during the course of the one to twenty-two year follow-up, detracting from the value of the report. In the 2,700 cases reviewed by Glassow [4], the recurrence rate was 0.7 per cent, but the follow-up decreased from 81 per cent at five years to 55 per cent at seven years. The 0.2 per cent recurrence rate reported by Shearburn and Myers [6] is marred because the data under items 4,5, and 6 are unrecorded. Similarly, Lichtenstein [1 I] and Lichtenstein and Shore [16] have a 0.9 per cent recurrence rate using mesh in more than 2,000 operations, but their follow-up period varies from zero to
Volume 135, May 1670
four and a half years [17]. Palumbo and Sharpe [14] report 3,500 primary repairs with a 1 per cent recurrence rate. Unfortunately, many of these patients were followed by letter rather than personal examination. The intervals before recurrence of inguinal hernias vary considerably in different reports. In our group I series, 47 per cent of the total recurrences occurred within the first year; by the end of the second year 59 per cent had recurred. This differs from the report by Palumbo and Sharpe [14], in which only 25 per cent of recurrences were detected in the first three years. However, in that series information was collected by various means, including questionnaire and employment physical. We believe that there is no substitute for examination by the operating surgeon. In the Hagan and Rhoads series [9], 55 per cent of the recurrent hernias recurred within two years and 75 per cent by the end of the fifth year. These authors also decry the use of a questionnaire as a means of follow-up and note that almost 50 per cent of their patients were unaware of the recurrence. In addition to the manner of follow-up, the type of recurrent hernia may also play a role in the time interval from surgery to recurrence. In the series reported by Postlethwait [B], 50 per cent of forty-eight recurrent direct hernias recurred within the first year and more than 70 per cent had recurred within the two to five year follow-up period. On the other hand, in a group of 176 indirect recurrences [7], only 20 per cent appeared within the first year and only 55 per cent within the two to five year follow-up period. In many series that have been followed beyond five years, almost 50 per cent of the patients are untraceable or dead. Glassow [5] reported a decrease in the patients followed from 81 per cent at five years to 55 per cent at seven years. When we reflect that in our series of long-term follow-ups the sixty-eight patients who were traced with much difficulty had a recurrence rate of 31 per cent, we must be cautious in interpreting the reported recurrence rates in series in which the follow-up falls much below the 90 per cent level. A discouraging aspect of our group I series was the large number of recurrences of repeat hernias. Patients in this group had had from one to four previous operations. With a median follow-up time of six and a half years, 32 per cent of these reoperations were failures. These poor results for recurrent hernias are matched by the study of Clear [a], in which fiftythree patients were followed ten years with twentyone recurrences (39 per cent). The recurrence rate for recurrent hernias in a report by Thieme [19] was 33 per cent. Except for McVay’s series [IO], reports with
635
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shorter follow-up periods, including mesh and Cooper’s ligament repairs, have recurrence rates ranging from 10 to 21 per cent [9,11,20]. The reduction of our recurrences from 32 to 8 per cent (allowing for the shorter median follow-up of 3 years) is striking. The importance of high dissection of the peritoneum for all types of inguinal hernias should be emphasized. In our series of 130 recurrent hernias in group I, forty-one (31 per cent) had an indirect sac at operation. This suggests that in 31 per cent the indirect sac was either missed or not completely dissected at the original operation. In a report by Postlethwait [28], 154 of 300 recurrent inguinal hernias were found to have an indirect sac. Our results suggest that with the anterior transversalis repair the recurrence rate can be significantly decreased. Because of the difference in median follow-up time (35 versus 78 months), the recurrence rates require adjustment. In group I there was a gradual increase with time in the number of recurrences. Assuming that the recurrences in group II will occur with the same frequency and proportion as in group I, we project that at the seventy-eight month median follow-up point for group II we will have an additional four recurrences over our sixteen known ones. This would give a 3.4 per cent projected recurrence rate for the anterior transversalis procedure, as compared with the 11.5 per cent rate for the Bassini-Cooper’s ligament repair. Summary
During the eight year period from 1967 to 1975, 1,020 patients more than eighteen years old underwent 1,311 inguinal herniorrhaphies. Group I consisted of 720 inguinal herniorrhaphies in which either a Bassini or a Cooper’s ligament repair was used. During a four to nine year follow-up period, the total recurrence rate was 11.5 per cent; the recurrence rate for the primary repair group was 7 per cent and for the recurrent group 32 per cent. The follow-up rate was 93.7 per cent. Group II consisted of 591 herniorrhaphies in which the repair was performed by an anterior transversalis fascia technic. During a two
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follow-up period, the total recurrence rate was 2.7 per cent; 1.8 per cent for primary repairs and 8.0 per cent for recurrent hernias. The follow-up rate was 98 per cent (95 per cent by personal examination) . Assuming that the recurrences in group II will occur with the same frequency as in group I, our projected four to nine year recurrence rate is 3.4 per cent. This suggests that the anterior transversalis fascia repair results in a lower recurrence rate than either the Bassini or Cooper’s ligament repairs. to five year
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