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Development of right inguinal hernia after appendectomy
Development of Right lnguinal Hernia After Appendectomy
Einar Arnbjiimsson, MD, Lund, Sweden
Although appendectomy is one of the most common operative procedures, there have been few reports on the choice of incision in the right lower quadrant of the abdomen. The incision introduced by McBurney [1] in 1894 is the time-honored approach. The efficiency of this incision is well established. It has a low complication rate and provides excellent access to the cecum. However, several other incisions have gained popular use. The transverse incision (Jelenco and Davis [2]) and the paramedian incision are adequate for appendectomy, as is the “bikini” incision described by Delany and Carnevale [3]. The importance of preserving the nerves of the abdominal wall during laparotomy has been realized, and the development of right inguinal hernia after appendectomy and damage to the segmental nerve supply of the abdominal muscles has been reported. The present study was designed to examine the incidence of right inguinal hernia after appendectomy. Material and Methods This is a retrospective study based on the records of 826 male patients with inguinal hernias treated at the Department of Surgery, Lund, Sweden, between 1975 and 1978. Their ages ranged from 19 to 79 years. Results A total of 826 patients were operated on. Fortythree of these had previously undergone appendectomy. Of these 43 patients right inguinal hernia developed in 35, left inguinal hernia in 6 and bilateral hernia in 2. In the 35 patients with right inguinal hernia the previous appendectomy had been performed through a McBurney’s approach in 17 patients, a lower paramedian incision in 2 and a bikini or low transverse incision in 16. The time from appendectomy to the development of right inguinal hernia in these 33 patients varied from 3 to 17 years (mean 14). The type of hernia was indirect in 21 patients, direct in 9 and bilateral in 2. From the Department of Surgery, University of Lund, S-221 85, Lund, Sweden. Requests for reprints should be addressed to Einar Arnbjbrnsson, MD, Department of Surgery, University of Lund, S-221 85, Lund, Sweden.
174
The incidence of right inguinal hernia after appendectomy was compared with the incidence in patients who had not undergone appendectomy (Table I). In the 783 patients who had not had a previous appendectomy the ratio of right-sided to left-sided hernias was approximately 2 to 1, whereas in the postappendectomy group the ratio was approximately 6 to 1. This difference is statistically significant (chi-square test significant at the 5 percent level). Comparison of the two groups shows that incidence of right inguinal hernia is approximately three times greater after appendectomy. Comments It was previously reported that a right inguinal hernia may develop after appendectomy. Hoguet [4] in 1911 first described the frequent development of right inguinal hernia after appendectomy. He found eight right inguinal hernias in 190 patients who had In 1951 Lichtenstein and Isoe had appendectomy. [5] reviewed 567 patients with inguinal hernia. In 67 of these patients the appendix had been removed (40 hernias were right-sided and 12 bilateral). In a series of 1,357 inguinal hernias, Walker [6] found that 110 patients had had previous appendectomy. Gue [7] in 1972 found 41 postappendectomy patients with right inguinal hernia among 701 patients with inguinal hernia. After statistical studies, the consensus was phrased by Seulberger and Peters [8] that lateral abdominal incisions predispose to the development of inguinal hernia. To understand the possible iatrogenic causes and the etiologic relation in the development of right inguinal hernia after appendectomy, one needs to refer to the anatomy of the internal ring and the inguinal canal. This was illustrated by Lytle [9] in 1970. The internal ring is U-shaped. It is composed of thickened transversalis fascia and suspended by its two pillars, medial and lateral to the posterior aspect of transversus abdominis muscle. The curve of the U lies at or just above the lower border of the aponeurosis of the transversus muscle. This aponeurosis
The American Journal of Surgery
Right lnguinal
TABLE I
Hernia
After
Appendectomy
incidence of lnguinal Hernia in Patients Who Had and Had Not Undergone Appendectomy ___._~___ _______
Right Number Percent Ratio of right to left
35 81.4
lnguinal Hernia Preceded by Appendectomy (43 patients) Bilateral Left -~ ___6 14.0 5.83:l
forms the floor of the ring and is supported in front by the internal oblique muscle. An efficient valve is thereby provided which closes when intraabdominal pressure is increased. Injury to the transversus abdominis muscle and posteriorly adherent transversalis fascia can damage the shutter mechanism of the internal ring and also weaken the posterior wall of the triangle of Hesselbach. Practically all of the muscles in the region of the inguinal canal receive their nerve supply from the first lumbar nerve through its iliohypogastric and ilioinguinal branches. The ilioinguinal nerve is practically out of reach of the surgeon, emerging just below Poupart’s ligament about 1.5 inches internal to and below the anterosuperior iliac spine. The iliohypogastric branch, however, is generally more than 1 inch above the ilioinguinal nerve, and runs downward and inward between the internal oblique and transversalis muscles. It crosses a line drawn from the umbilicus to the anterosuperior iliac spine almost 2 inches above the latter. The ordinary McBurney incision would run roughly parallel to the nerve, which is in danger if the fibers of the internal oblique muscle are cut and not separated. Incisions much below the anterosuperior iliac spine are to be avoided if possible, as segmental nerves penetrate at this level and course downward. Cutting these nerve branches so that the muscles become paralyzed might admit the passage of a hernia. Electromyographic studies of patients admitted because of a hernia after appendectomy would be useful to confirm denervation as a cause of hernia. Observations from the present study suggest that appendectomy predisposes to the development of right-sided inguinal hernia. In spite of the tempting simplicity of etiologic reasoning, a cause-and-effect relation cannot be confirmed based on these observations. The multitude of etiologic factors in the development of inguinal hernias reduces further the value of statistical data.
Volume 143, January 1982
2 4.6 -_ ____L
lnguinal Hernia Not Preceded by Appendectomy (783 patients) Right Left Bilateral ____ 462 59.0
227 29.0 ___2.03: 1
94 12.0
This study emphasizes, however, that nerve injury should be avoided during surgery and also that the structures of the right lower abdominal wall should be preserved. Incisions much below the anterior superior iliac spine should be avoided if possible because segmental nerves penetrate at this level. The possibility of herniation might thus be reduced. Summary The incidence of right inguinal hernia is significantly greater in patients who have undergone appendectomy than in the general population. The most likely cause of such hernias is injury to the segmental nerve supply to the inguinal musculature. The choice of incision at appendectomy may therefore be important, and the surgeon should avoid injury to the nerve branches and important structures in the inguinal region, especially below the horizontal line extending from the anterosuperior iliac spine to the rectus muscle. References 1. McBurney C. The incision made in the abdominal wall in cases of appendicitis with a description of the method of operation. Ann Surg 1894;20:38-46. 2. Jelenco D, Davis L. A transverse lower abdominal appendectomy incision with minimal muscle derangement. Surg Gynecol Obstet 1973;136:451-2. 3. Delany HM, Carnevale NJ. A “bikini” incision for appendectomy. Am J Surg 1976;132:126-7. 4. Hoguet JP. Right inguinal herniae following appendectomy. Ann Surg 1911;54:673-6. 5. Lichtenstein ME, lsoe IM. Right inguinal herniae following appendectomy. Am J Surg 1951;81:436-8. 6. Walker F. Leistenbruch als Appendectomiefolge und Folge anderer Trauma der Bauchwand. Wien Med Wochenschr 1954;104:538-9. 7. Gue S. Development of right inguinal herniae following appendectorny. Br J Surg 1972;59:352-3. 8. Seulberger P, Peters H. ober die Manifestation won Leisten und Schenkelhernias nach seitlichen Bauchschnitten. Chirurgia 1951;22:257760. 9. Lytle WJ. The deep inguinal ring, development, function and repair. Br J Surg 1970;57:531-6.
175
Einar Arnbjiimsson, MD, Lund, Sweden
Although appendectomy is one of the most common operative procedures, there have been few reports on the choice of incision in the right lower quadrant of the abdomen. The incision introduced by McBurney [1] in 1894 is the time-honored approach. The efficiency of this incision is well established. It has a low complication rate and provides excellent access to the cecum. However, several other incisions have gained popular use. The transverse incision (Jelenco and Davis [2]) and the paramedian incision are adequate for appendectomy, as is the “bikini” incision described by Delany and Carnevale [3]. The importance of preserving the nerves of the abdominal wall during laparotomy has been realized, and the development of right inguinal hernia after appendectomy and damage to the segmental nerve supply of the abdominal muscles has been reported. The present study was designed to examine the incidence of right inguinal hernia after appendectomy. Material and Methods This is a retrospective study based on the records of 826 male patients with inguinal hernias treated at the Department of Surgery, Lund, Sweden, between 1975 and 1978. Their ages ranged from 19 to 79 years. Results A total of 826 patients were operated on. Fortythree of these had previously undergone appendectomy. Of these 43 patients right inguinal hernia developed in 35, left inguinal hernia in 6 and bilateral hernia in 2. In the 35 patients with right inguinal hernia the previous appendectomy had been performed through a McBurney’s approach in 17 patients, a lower paramedian incision in 2 and a bikini or low transverse incision in 16. The time from appendectomy to the development of right inguinal hernia in these 33 patients varied from 3 to 17 years (mean 14). The type of hernia was indirect in 21 patients, direct in 9 and bilateral in 2. From the Department of Surgery, University of Lund, S-221 85, Lund, Sweden. Requests for reprints should be addressed to Einar Arnbjbrnsson, MD, Department of Surgery, University of Lund, S-221 85, Lund, Sweden.
174
The incidence of right inguinal hernia after appendectomy was compared with the incidence in patients who had not undergone appendectomy (Table I). In the 783 patients who had not had a previous appendectomy the ratio of right-sided to left-sided hernias was approximately 2 to 1, whereas in the postappendectomy group the ratio was approximately 6 to 1. This difference is statistically significant (chi-square test significant at the 5 percent level). Comparison of the two groups shows that incidence of right inguinal hernia is approximately three times greater after appendectomy. Comments It was previously reported that a right inguinal hernia may develop after appendectomy. Hoguet [4] in 1911 first described the frequent development of right inguinal hernia after appendectomy. He found eight right inguinal hernias in 190 patients who had In 1951 Lichtenstein and Isoe had appendectomy. [5] reviewed 567 patients with inguinal hernia. In 67 of these patients the appendix had been removed (40 hernias were right-sided and 12 bilateral). In a series of 1,357 inguinal hernias, Walker [6] found that 110 patients had had previous appendectomy. Gue [7] in 1972 found 41 postappendectomy patients with right inguinal hernia among 701 patients with inguinal hernia. After statistical studies, the consensus was phrased by Seulberger and Peters [8] that lateral abdominal incisions predispose to the development of inguinal hernia. To understand the possible iatrogenic causes and the etiologic relation in the development of right inguinal hernia after appendectomy, one needs to refer to the anatomy of the internal ring and the inguinal canal. This was illustrated by Lytle [9] in 1970. The internal ring is U-shaped. It is composed of thickened transversalis fascia and suspended by its two pillars, medial and lateral to the posterior aspect of transversus abdominis muscle. The curve of the U lies at or just above the lower border of the aponeurosis of the transversus muscle. This aponeurosis
The American Journal of Surgery
Right lnguinal
TABLE I
Hernia
After
Appendectomy
incidence of lnguinal Hernia in Patients Who Had and Had Not Undergone Appendectomy ___._~___ _______
Right Number Percent Ratio of right to left
35 81.4
lnguinal Hernia Preceded by Appendectomy (43 patients) Bilateral Left -~ ___6 14.0 5.83:l
forms the floor of the ring and is supported in front by the internal oblique muscle. An efficient valve is thereby provided which closes when intraabdominal pressure is increased. Injury to the transversus abdominis muscle and posteriorly adherent transversalis fascia can damage the shutter mechanism of the internal ring and also weaken the posterior wall of the triangle of Hesselbach. Practically all of the muscles in the region of the inguinal canal receive their nerve supply from the first lumbar nerve through its iliohypogastric and ilioinguinal branches. The ilioinguinal nerve is practically out of reach of the surgeon, emerging just below Poupart’s ligament about 1.5 inches internal to and below the anterosuperior iliac spine. The iliohypogastric branch, however, is generally more than 1 inch above the ilioinguinal nerve, and runs downward and inward between the internal oblique and transversalis muscles. It crosses a line drawn from the umbilicus to the anterosuperior iliac spine almost 2 inches above the latter. The ordinary McBurney incision would run roughly parallel to the nerve, which is in danger if the fibers of the internal oblique muscle are cut and not separated. Incisions much below the anterosuperior iliac spine are to be avoided if possible, as segmental nerves penetrate at this level and course downward. Cutting these nerve branches so that the muscles become paralyzed might admit the passage of a hernia. Electromyographic studies of patients admitted because of a hernia after appendectomy would be useful to confirm denervation as a cause of hernia. Observations from the present study suggest that appendectomy predisposes to the development of right-sided inguinal hernia. In spite of the tempting simplicity of etiologic reasoning, a cause-and-effect relation cannot be confirmed based on these observations. The multitude of etiologic factors in the development of inguinal hernias reduces further the value of statistical data.
Volume 143, January 1982
2 4.6 -_ ____L
lnguinal Hernia Not Preceded by Appendectomy (783 patients) Right Left Bilateral ____ 462 59.0
227 29.0 ___2.03: 1
94 12.0
This study emphasizes, however, that nerve injury should be avoided during surgery and also that the structures of the right lower abdominal wall should be preserved. Incisions much below the anterior superior iliac spine should be avoided if possible because segmental nerves penetrate at this level. The possibility of herniation might thus be reduced. Summary The incidence of right inguinal hernia is significantly greater in patients who have undergone appendectomy than in the general population. The most likely cause of such hernias is injury to the segmental nerve supply to the inguinal musculature. The choice of incision at appendectomy may therefore be important, and the surgeon should avoid injury to the nerve branches and important structures in the inguinal region, especially below the horizontal line extending from the anterosuperior iliac spine to the rectus muscle. References 1. McBurney C. The incision made in the abdominal wall in cases of appendicitis with a description of the method of operation. Ann Surg 1894;20:38-46. 2. Jelenco D, Davis L. A transverse lower abdominal appendectomy incision with minimal muscle derangement. Surg Gynecol Obstet 1973;136:451-2. 3. Delany HM, Carnevale NJ. A “bikini” incision for appendectomy. Am J Surg 1976;132:126-7. 4. Hoguet JP. Right inguinal herniae following appendectomy. Ann Surg 1911;54:673-6. 5. Lichtenstein ME, lsoe IM. Right inguinal herniae following appendectomy. Am J Surg 1951;81:436-8. 6. Walker F. Leistenbruch als Appendectomiefolge und Folge anderer Trauma der Bauchwand. Wien Med Wochenschr 1954;104:538-9. 7. Gue S. Development of right inguinal herniae following appendectorny. Br J Surg 1972;59:352-3. 8. Seulberger P, Peters H. ober die Manifestation won Leisten und Schenkelhernias nach seitlichen Bauchschnitten. Chirurgia 1951;22:257760. 9. Lytle WJ. The deep inguinal ring, development, function and repair. Br J Surg 1970;57:531-6.
175