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Hernias in the Poor Risk Patient: Their Surgical Management
Hernias in the Poor Risk Patient Their Surgical Management
KENNETHW.WARREN
are relatively common in the elderly and in the poor risk patient. The surgical problems pertaining to hernias occurring in these particular groups may be divided into those that constitute an acute surgical emergency and those that appear for evaluation of elective repair. By far the most important are those hernias which, because of incarceration or strangulation, require early surgical intervention. These patients often present a serious challenge in terms of proper surgical management but the decision to operate is usually forced. The other category of patients include those in whom there are no complications that demand immediate surgery but who, in turn, require careful evaluation before a decision is made to embark upon an elective repair. Because of the continuous improvements in anesthetic agents and techniques and more particularly because of newly acquired knowledge in the field of fluid and electrolyte balance it can now be stated categorically that almost any patient who is ambulatory can be carried safely through a herniorrhaphy without too much concern for advanced age or serious cardiovascular impairment. When there is serious incarceration or strangulation, the surgeon may be forced to operate even in the presence of active heart failure. We have, in fact, operated successfully for the relief of incarcerated femoral hernia in a patient with severe cardiac failure who had such serious orthopnea that it was necessary to perform the procedure with the patient in Fowler's position. In assuming the position that most hernias can be repaired in the presence of advanced age and in the poor risk patient we do not wish to minimize the seriousness of the undertaking and wish rather to emphasize the numerous precautions which must be taken to carry such patients successfully through these procedures. Although it is undoubtedly true that many patients are denied the benefits of surgery in the presence of symptomatic hernias because of advanced age or serious systemic disease, one would not wish to foster a reckless attitude in the approach to these patients. It is frequently true that the patient of advanced age or with serious HERNIAS
761
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Kenneth W. Warren
infirmity is prone to have a large hernia and in many instances the hernia is associated with complications such as incarceration or strangulation. Not infrequently these complications derive from the fact that the patient has previously been denied the benefits of surgical intervention because of the increased risk. The patient with symptomatic hernia, particularly if some degree of incarceration persists, is treated more safely in most instances by early operation than by expectant treatment. The real problem in approaching patients of advanced age or with other serious infirmity is to evaluate carefully the nature and the extent of their physiological reserve and to concentrate upon restoring their physiological balance. Once this objective has been achieved, the next most important consideration is the selection and careful administration of the proper type of anesthetic. It is no exaggeration to say that in this particular type of patient the choice and execution of the anesthesia are likely to be more decisive in determining the outcome than is the precise type or technique of surgical repair. There is all too frequently a feeling that the patient with a large hernia of long duration and with some element of incarceration will require some special reparative technique or the use of autogenous or heterogenous graft. Although no one can deny that some of the newer materials which have been advocated and employed in the repair of exceptional hernias have a real place in surgery, neither can one deny that there is a tendency to employ the unusual technique and the foreign substance graft far beyond their rational indications. In a previous communication on the repair of inguinal hernias,4 I pointed out that the endless stream of new techniques and methods of surgical repair of these hernias indicates a lack of agreement regarding the fundamental anatomical and technical requirements for successful repair. EVALUATION OF THE PATIENT
The approach to the evaluation of the patient who comes for hernia repair varies considerably, depending upon whether or not the associated symptoms are acute or mild and chronic. A small percentage of elderly patients with actual external hernias may first appear in the emergency room because of acute abdominal symptoms without knowing that they have a hernia. It is in this particular group of patients that one is most likely to overlook the true nature of the lesion. In evaluating any patient with acute abdominal symptoms a routine search should be made for all the common and the uncommon sites of external hernias. Assuming that a hernia is present and that the patient has acute symptoms, one would expect to find either an associated incarceration or strangulation. If either of these complications occurs, the patient's condition must immediately be evaluated in terms of the possibility that intestinal obstruc-
Hernias in the Poor Risk Patient
763
tion exists. If distention is present and if the patient has had any vomiting it is extremely important to insert a Miller-Abbott tube immediately in order to decompress the intestine as rapidly as possible. Evaluation of the fluid and electrolyte status is extremely urgent under these circumstances and is only slightly less urgent in all elderly and poor risk patients with hernias. Cardiovascular status should be checked carefully since it will influence greatly the choice and management of the anesthetic. A feature in preoperative evaluation that is frequently overlooked is the urinary tract. Particular attention should be paid to the prostatic evaluation in the male and if any cardiovascular or urinary deficiency is present, an indwelling catheter should be inserted. The physician should be particularly alert in evaluating the mental status of these patients and this evaluation may require an interview with a responsible relative. In the elderly individual with a history of cerebral arteriosclerosis, anesthesia should be administered with exceeding care in order to avoid the oecurrence of cerebral anoxia. The presence of serious cardiac disease, particularly the presenee of any cardiac failure, requires immediate rapid digitalization. Strangulating obstruetion incidental to external hernias constitutes a special problem. Most of these patients have had repeated vomiting with depletion of their fluid and electrolytes and in many instanees they have major degrees of abdominal distention. Although it is only reasonable to prefer to restore the fluid and electrolyte balanee and to diminish the distention by intestinal intubation, the surgeon should not lose sight of the fact that the condition of these elderly or poor risk patients frequently will continue to deteriorate unless the obstruction is relieved. It is often necessary, therefore, to eompromise with one's concept of optimal preoperative preparation and to pursue the operation under unfavorable circumstances. It is usually possible within two or three hours to administer sufficient fluid and electrolytes and to achieve a moderate degree of digitalization that will permit successful repair of strangulating obstruction. The tendency to depend upon Miller-Abbott decompression and to defer operation until such decompression has been achieved is usually a grievous error. The evaluation and preparation of the patient for elective herniorrhaphy are entirely different matters. Here, emphasis is placed upon optimal preparation. The patient can be earefully digitalized if necessary; fluid and electrolyte balance ean be restored. If urinary retention attributable to prostatism is present a preliminary transurethral prostatectomy should be performed. The preoperative administration of antibioties in the presence of chronic pulmonary infection is extremely important. Perhaps even more important in this respect is the careful anti-allergic program for patients with chronic asthmatic bronchitis. These patients are particularly prone to hernia formation and all too frequently they
+
764
Kenneth W. Warren
are rushed into the hospital and are operated upon without sufficient preparation. They almost invariably go into severe asthmatic bronchitis postoperatively and present a real problem. If they are carefully desensitized, if they are given adequate preoperative antibiotic therapy and especially if narcotics are used sparingly, or not at all, these patients will withstand an operation well without a flare-up of their allergic bronchitis. TECHNICAL CONSIDERATIONS
Since most hernias encountered, even in the elderly patient, occur in the groin, being either direct or indirect inguinal or femoral hernias, any technical considerations in their repair should be devoted primarily to these three anatomical types. It is conventional, particularly in surgical textbooks, to stress the anatomical differences between a direct and an indirect inguinal hernia. It is perhaps more important, as we have previously stressed,4 to recognize that an indirect inguinal hernia with a greatly widened internal ring is similar in its fundamental defect to a direct hernia because both in the large indirect hernia with the greatly enlarged internal ring and in the direct hernia there is loss of integrity of the transversalis fascia. Thus, solely from the standpoint of the surgical requirements for adequate repair it is perhaps best to place the small indirect inguinal hernia with little or no enlargement of the internal ring in a separate category and to attack surgically the large indirect hernia with the greatly expanded internal ring and all direct hernias in a similar fashion. In terms of surgical considerations alone the small indirect inguinal hernias in children and in young adults require for their surgical elimination only complete excision and high ligation of the sac. In large, indirect hernias the transversalis fascia constituting the internal ring has been disrupted, and it is possible, of course, for it to be disrupted from the level of the original internal ring all the way to the pubic ,spine by a progressively expanding indirect hernia. Therefore, in such hernias and in direct hernias, the primary concern is repair with the restoration of the integrity of the transversalis fascia. There are certain structures constituting the abdominal wall in the region of the groin which, despite diminished strength and resiliency characteristic of advancing age, are usually adequate for repair of a primary hernia almost irrespective of size. For instance, there is always an adequate layer of transversalis fascia immediately lateral to the lateral margin of the rectus sheath. Less frequently there is also an adequate layer of transversalis fascia just superior and medial to Poupart's ligament. An even more important and constant structure that is available for repair of hernias in the groin is the musculofibrous bundle at the lateral and inferior edge of the rectus sheath, as has been emphasized by Fallis. 2 Anson and McVay! have pointed out and popularized the im-
p
Hernias in the Poor Risk Patient
765
portance of Cooper's ligament in the repair of certain hernias occurring in the groin. In our experience it is only occasionally necessary to employ Cooper's ligament in the repair of inguinal hernias, but when the transversalis fascia and Hesselbach's triangle have been completely disrupted by a large direct or indirect inguinal hernia, the utilization of Cooper's ligament becomes extremely important. Thus, the musculofibrous bundle along the lateral inferior edge of the rectus sheath can always be approximated to Cooper's ligament in such a fashion that one should always anticipate success in the repair of any primary inguinal hernia. Harkins et al. 3 have advocated the employment of a Cooper's ligament repair after the manner of McVay as a routine procedure in almost all inguinal groin hernias, including direct, indirect and femoral. Although it is our belief that the Cooper's ligament repair should be ap~ plied only when the integrity of the transversalis fascia has been so destroyed that it cannot be adequately restored, it is nevertheless true that all groin hernias can be repaired by utilization of Cooper's ligament. With an increasing experience in the utilization of the transversalis fascia in the repair of the average direct and large indirect hernia and with the further realization that the musculofibrous bundle at the inferiolateral margin of the rectus sheath can always be approximated to Cooper's ligament, it becomes increasingly obvious that very few hernias occurring in the groin require the utilization of autogenous or heterogenous grafts. THE ESSENTIALS OF AN ADEQUATE GROIN HERNIA REPAIR
There are certain essentials regardless of one's personal preference for a particular type of anatomical repair that should be met in all surgical repairs of hernias occurring in the groin. Anesthesia, Suture Material, Incision
Adequate muscular relaxation should always be maintained throughout the operation. By and large, the greatest degree of muscular relaxation can be obtained by spinal anesthesia. In those patients in whom this appears unduly hazardous, and that will apply to only an occasional patient, one may today prefer to use Anectine* by continuous or intermittent intravenous drip. This agent undoubtedly is preferable in the extremely poor risk patient. It affords a degree of muscular relaxation comparable to that of spinal anesthesia; its effects can be attained almost instantaneously and the physiological activity of this substance is rapidly eliminated. In the desperately ill patient local anesthesia may be preferred and with care and patience adequate anesthesia and suffi-
* Diacetylcholine chloride or succinic acid bis (beta-dimethylaminoethyl) ester dimethochloride.
766
Kenneth W. Warren
cient relaxation can be obtained to repair most hernias. With the excellent control of spinal anesthesia available today and more particularly with the availability of the muscular relaxants, the need for local anesthesia for hernia repairs is less than it was formerly. It is generally agreed today that silk, cotton or other nonabsorbable suture material is preferable in hernia repairs. It is best to adhere to a choice of one of these materials unless active infection is present. The incision should be generous and should extend over the pubic spine (Fig. 193). Routine opening of the peritoneum at the internal ring in both direct and indirect inguinal hernias should be practiced. One of the commonest errors in the treatment of direct hernia is failure
Fig. 193. Anatomic topography, showing the line of incision which extends from the spine of the pubis to a point approximately 2 cm. below the anterior superior spine of the ilium. The incision is 2 cm. above and parallel to the inguinal ligament.
to open the peritoneum. By this failure the sac may not be completely eliminated and the presence of an indirect or femoral hernia may not be detected. The universal preference for opening the peritoneum at the internal ring will obviate injury to the bladder and will also preclude the possibility of overlooking an indirect hernia. In the presence of direct hernias (Fig. 194), the direct sac is converted into an indirect sac after the maneuver of Hoguet. The anterior rectus sheath is relaxed by a vertical incision near the midline to facilitate the approximation of the lateral margin of the rectus sheath to the shelving edge of the inguinal ligament (Fig. 195). Anatolllical Considerations
Following elimination of the peritoneal sac the next most important consideration is the restoration of the integrity of the transversalis
767
Hernias in the Poor Risk Patient
fascia (Fig. 196). This is particularly true in all direct hernias and equally true in all large indirect hernias in which the internal ring has been greatly expanded. Even in small indirect hernias the edges of the transAnt. sup. spine
X
Fig. 194. The transversalis fascia in direct hernias is thinned out and redundant. Opening the hernial sac in this position is dangerous in terms of possible injury to the urinary bladder.
X
Fig. 195. Relaxation of the anterior rectus sheath near the midline facilitates the approximation of the musculofibrous bundle along the lateral aspect of the rectus sheath to the inguinal or to Cooper's ligament.
versalis fascia which constitute the margins of the internal ring should be reapproximated until the caliber of the ring is within normal limits (Fig. 196, insert). In order to restore the integrity of the transversalis fascia it must be thoroughly exposed from the anterior pubic spine to
768
Kenneth W. Warren
the internal abdominal ring. The transversalis fascia in Hesselbach's triangle is best exposed by excising the cremasteric muscle. If one prefers not to excise this muscle, it should be elevated completely and detached from the region of the internal ring and the spine of the pubis. If the transversalis fascia is thoroughly exposed in this area it can be carefully and satisfactorily approximated with interrupted sutures of silk.
x
Fig. 196. The integrity of the transversalis fascia is restored by approximating the edges of the defect with interrupted sutures. Insert, careful approximation of the margins of the transversalis fascia about the spermatic cord reconstitutes the internal abdominal ring.
ReinforceIllent of the Transversalis Fascia
In small and direct hernias, particularly in children and young adults, it is not necessary to reinforce the transversalis fascia. The simple elimination of the hernial sac by high ligation of its neck and approximation of the margins of the transversalis fascia around the spermatic cord is sufficient. Most hernias in the older age group, however, require reinforcement of the transversalis fascia. A wide variety of methods calculated to achieve this end is available. We prefer to approximate the musculofascial bundle along the medial inferior aspect of the rectus sheath to Poupart's ligament where the integrity of the transversalis fascia has previously been restored (Fig. 197). If the defect in the transversalis fascia is so large that the separated edges of this structure cannot be approximated we then prefer to disregard the lateral or inferior leaflet of the transversalis fascia and approximate the musculofibrous bundle along the lateral rectus sheath to Cooper's ligament with interrupted sutures of heavy silk (Fig. 198). In utilizing the latter procedure
769
Hernias in the Poor Risk Patient
the surgeon must pay considerable attention to protection of the femoral vem.
Edge of
Rectus Sheath
Fig. 197. The dense fibromuscular bundle along the lateral edge of the rectus sheath is approximated to the shelving edge of the inguinal ligament.
x
Fig. 198. The fibromuscular bundle along the lateral margin of the rectus sheath is approximated to Cooper's ligament. When the integrity of the transversalis fascia in Hesselbach's triangle cannot be restored, care must be exercised to protect the femoral vessels during the placement of these sutures.
FEMORAL HERNIA
Femoral hernias, particularly in the elderly and poor risk patient, present additional technical problems. These hernias are frequently
770
Kenneth W. Warren
associated with incarceration and strangulation. Most femoral hernias in our experience can be dealt with satisfactorily through an incision placed parallel to and below Poupart's ligament. If the incarcerated contents of the sac cannot be reduced safely from below, we then prefer to make a vertical, lower rectus, abdominal incision in order that the contents of the sac may be manipulated both by way of the femoral canal and intra-abdominally. The same rule applies to the patient who has a strangulated femoral hernia. Most femoral hernias, even in the presence of incarceration, can be treated successfully through an incision placed parallel to and below the inguinal ligament. If it is impossible to reduce the incarcerated viscera or omentum by this method, a vertical, lower rectus incision should be made. When strangulation is present it is almost always necessary to make an abdominal incision, and again we would prefer to make a large, lower rectus, muscle splitting incision rather than an oblique incision in the inguinal area. It is usually possible to reduce the strangulated bowel by manipulating it intra-abdominally and by way of the incision overlying the femoral canal. It may be necessary to divide the inguinal ligament in order to relieve the strangulation. If, following reduction, it is apparent that the strangulated portion of the bowel has been compromised, a primary resection is usually feasible. If there is considerable disparity in the diameter of the proximal and distal loops of intestine, a side-to-side anastomosis is the safest method of management. In the neglected case of strangulation, particularly in the poor risk patient, it is best to approach the field through a lower rectus incision and to perform a side-to-side anastomosis between the proximal and distal loops of the bowel without attempting to manipulate the segment of bowel which is caught in the femoral canal. Following this anastomosis and the closure of the abdominal wound, the strangulated portion of the bowel can then be decompressed. This decompression may be achieved by inserting a needle, or preferably by inserting a catheter. Adequate drainage of this region is necessary. Secondary closure can be done later. In all cases of neglected strangulation, associated small intestinal obstruction will be present with moderate to considerable distention of the small intestine. A Miller-Abbott tube and constant suction should always be utilized. Once the sac has been eliminated the surgeon may choose to repair the femoral hernia, approximating the inguinal ligament to the iliofemoral fascia or by going above the inguinal ligament and breaking through the transversalis fascia and approximating the edge of the rectus sheath to Cooper's ligament. The latter is preferable in the patient with a large femoral hernia and should be employed whenever it has been necessary to divide the inguinal ligament to release a strangulated hernia. Division of the inguinal ligament in order to reduce a femoral hernia is rarely necessary.
Hernias in the Poor Risk Patient
771
Ventral hernias occur at such diverse locations and following such a wide variety of abdominal incision as to defy classification. As they pertain to the elderly and the poor risk patient, the same principles apply. Practically all of these hernias, regardless of size and location, can be repaired by one of a variety of methods. In the presence of symptomatic incarceration or strangulation, operation will be indicated. In other varieties of ventral hernia in which the symptoms are minimal, the risk of operation should indicate whether or not surgical intervention is advised. It is in the repair of large ventral hernias that autogenous or heterogenous grafts may be used, but even in this category the use of such substances is rarely necessary. We have employed tantalum mesh in some instances with good results but in every instance we have used it to reinforce a conventional plastic procedure and not to bridge a gap in the anterior abdominal wall. By insisting that all obese patients who are to have elective repair of ventral hernias reduce their weight to a reasonable level before operation, it is almost always possible to approximate the hernial ring without undue tension. The postoperative use of suction by means of the Miller-Abbott tube is extremely important in the care of patients with large ventral hernias. The importance of hernias in the aged is stressed, and the anatomical requirements for adequate repair are detailed. REFERENCES 1. Anson, B. J. and McVay, C. B.: Inguinal hernia; anatomy of region. Surg., Gynec. and Obst. 66: 186-191 (Feb.) 1938. 2. Fallis, L. S.: Recurrent inguinal hernia; analysis of 200 operations. Ann. Surg. 106: 363-371 (Sept.) 1937. 3. Harkins, H. N., Szilagyi, E., Brush, B. E. and Williams, R.: Clinical experiences with McVay herniotomy. Surgery 12: 364--377 (Sept.) 1942. 4. Warren, K. W.: The repair of inguinal hernias. S. CLIN. NORTH AMERICA 29: 795-804 (June) 1949.
KENNETHW.WARREN
are relatively common in the elderly and in the poor risk patient. The surgical problems pertaining to hernias occurring in these particular groups may be divided into those that constitute an acute surgical emergency and those that appear for evaluation of elective repair. By far the most important are those hernias which, because of incarceration or strangulation, require early surgical intervention. These patients often present a serious challenge in terms of proper surgical management but the decision to operate is usually forced. The other category of patients include those in whom there are no complications that demand immediate surgery but who, in turn, require careful evaluation before a decision is made to embark upon an elective repair. Because of the continuous improvements in anesthetic agents and techniques and more particularly because of newly acquired knowledge in the field of fluid and electrolyte balance it can now be stated categorically that almost any patient who is ambulatory can be carried safely through a herniorrhaphy without too much concern for advanced age or serious cardiovascular impairment. When there is serious incarceration or strangulation, the surgeon may be forced to operate even in the presence of active heart failure. We have, in fact, operated successfully for the relief of incarcerated femoral hernia in a patient with severe cardiac failure who had such serious orthopnea that it was necessary to perform the procedure with the patient in Fowler's position. In assuming the position that most hernias can be repaired in the presence of advanced age and in the poor risk patient we do not wish to minimize the seriousness of the undertaking and wish rather to emphasize the numerous precautions which must be taken to carry such patients successfully through these procedures. Although it is undoubtedly true that many patients are denied the benefits of surgery in the presence of symptomatic hernias because of advanced age or serious systemic disease, one would not wish to foster a reckless attitude in the approach to these patients. It is frequently true that the patient of advanced age or with serious HERNIAS
761
762
Kenneth W. Warren
infirmity is prone to have a large hernia and in many instances the hernia is associated with complications such as incarceration or strangulation. Not infrequently these complications derive from the fact that the patient has previously been denied the benefits of surgical intervention because of the increased risk. The patient with symptomatic hernia, particularly if some degree of incarceration persists, is treated more safely in most instances by early operation than by expectant treatment. The real problem in approaching patients of advanced age or with other serious infirmity is to evaluate carefully the nature and the extent of their physiological reserve and to concentrate upon restoring their physiological balance. Once this objective has been achieved, the next most important consideration is the selection and careful administration of the proper type of anesthetic. It is no exaggeration to say that in this particular type of patient the choice and execution of the anesthesia are likely to be more decisive in determining the outcome than is the precise type or technique of surgical repair. There is all too frequently a feeling that the patient with a large hernia of long duration and with some element of incarceration will require some special reparative technique or the use of autogenous or heterogenous graft. Although no one can deny that some of the newer materials which have been advocated and employed in the repair of exceptional hernias have a real place in surgery, neither can one deny that there is a tendency to employ the unusual technique and the foreign substance graft far beyond their rational indications. In a previous communication on the repair of inguinal hernias,4 I pointed out that the endless stream of new techniques and methods of surgical repair of these hernias indicates a lack of agreement regarding the fundamental anatomical and technical requirements for successful repair. EVALUATION OF THE PATIENT
The approach to the evaluation of the patient who comes for hernia repair varies considerably, depending upon whether or not the associated symptoms are acute or mild and chronic. A small percentage of elderly patients with actual external hernias may first appear in the emergency room because of acute abdominal symptoms without knowing that they have a hernia. It is in this particular group of patients that one is most likely to overlook the true nature of the lesion. In evaluating any patient with acute abdominal symptoms a routine search should be made for all the common and the uncommon sites of external hernias. Assuming that a hernia is present and that the patient has acute symptoms, one would expect to find either an associated incarceration or strangulation. If either of these complications occurs, the patient's condition must immediately be evaluated in terms of the possibility that intestinal obstruc-
Hernias in the Poor Risk Patient
763
tion exists. If distention is present and if the patient has had any vomiting it is extremely important to insert a Miller-Abbott tube immediately in order to decompress the intestine as rapidly as possible. Evaluation of the fluid and electrolyte status is extremely urgent under these circumstances and is only slightly less urgent in all elderly and poor risk patients with hernias. Cardiovascular status should be checked carefully since it will influence greatly the choice and management of the anesthetic. A feature in preoperative evaluation that is frequently overlooked is the urinary tract. Particular attention should be paid to the prostatic evaluation in the male and if any cardiovascular or urinary deficiency is present, an indwelling catheter should be inserted. The physician should be particularly alert in evaluating the mental status of these patients and this evaluation may require an interview with a responsible relative. In the elderly individual with a history of cerebral arteriosclerosis, anesthesia should be administered with exceeding care in order to avoid the oecurrence of cerebral anoxia. The presence of serious cardiac disease, particularly the presenee of any cardiac failure, requires immediate rapid digitalization. Strangulating obstruetion incidental to external hernias constitutes a special problem. Most of these patients have had repeated vomiting with depletion of their fluid and electrolytes and in many instanees they have major degrees of abdominal distention. Although it is only reasonable to prefer to restore the fluid and electrolyte balanee and to diminish the distention by intestinal intubation, the surgeon should not lose sight of the fact that the condition of these elderly or poor risk patients frequently will continue to deteriorate unless the obstruction is relieved. It is often necessary, therefore, to eompromise with one's concept of optimal preoperative preparation and to pursue the operation under unfavorable circumstances. It is usually possible within two or three hours to administer sufficient fluid and electrolytes and to achieve a moderate degree of digitalization that will permit successful repair of strangulating obstruction. The tendency to depend upon Miller-Abbott decompression and to defer operation until such decompression has been achieved is usually a grievous error. The evaluation and preparation of the patient for elective herniorrhaphy are entirely different matters. Here, emphasis is placed upon optimal preparation. The patient can be earefully digitalized if necessary; fluid and electrolyte balance ean be restored. If urinary retention attributable to prostatism is present a preliminary transurethral prostatectomy should be performed. The preoperative administration of antibioties in the presence of chronic pulmonary infection is extremely important. Perhaps even more important in this respect is the careful anti-allergic program for patients with chronic asthmatic bronchitis. These patients are particularly prone to hernia formation and all too frequently they
+
764
Kenneth W. Warren
are rushed into the hospital and are operated upon without sufficient preparation. They almost invariably go into severe asthmatic bronchitis postoperatively and present a real problem. If they are carefully desensitized, if they are given adequate preoperative antibiotic therapy and especially if narcotics are used sparingly, or not at all, these patients will withstand an operation well without a flare-up of their allergic bronchitis. TECHNICAL CONSIDERATIONS
Since most hernias encountered, even in the elderly patient, occur in the groin, being either direct or indirect inguinal or femoral hernias, any technical considerations in their repair should be devoted primarily to these three anatomical types. It is conventional, particularly in surgical textbooks, to stress the anatomical differences between a direct and an indirect inguinal hernia. It is perhaps more important, as we have previously stressed,4 to recognize that an indirect inguinal hernia with a greatly widened internal ring is similar in its fundamental defect to a direct hernia because both in the large indirect hernia with the greatly enlarged internal ring and in the direct hernia there is loss of integrity of the transversalis fascia. Thus, solely from the standpoint of the surgical requirements for adequate repair it is perhaps best to place the small indirect inguinal hernia with little or no enlargement of the internal ring in a separate category and to attack surgically the large indirect hernia with the greatly expanded internal ring and all direct hernias in a similar fashion. In terms of surgical considerations alone the small indirect inguinal hernias in children and in young adults require for their surgical elimination only complete excision and high ligation of the sac. In large, indirect hernias the transversalis fascia constituting the internal ring has been disrupted, and it is possible, of course, for it to be disrupted from the level of the original internal ring all the way to the pubic ,spine by a progressively expanding indirect hernia. Therefore, in such hernias and in direct hernias, the primary concern is repair with the restoration of the integrity of the transversalis fascia. There are certain structures constituting the abdominal wall in the region of the groin which, despite diminished strength and resiliency characteristic of advancing age, are usually adequate for repair of a primary hernia almost irrespective of size. For instance, there is always an adequate layer of transversalis fascia immediately lateral to the lateral margin of the rectus sheath. Less frequently there is also an adequate layer of transversalis fascia just superior and medial to Poupart's ligament. An even more important and constant structure that is available for repair of hernias in the groin is the musculofibrous bundle at the lateral and inferior edge of the rectus sheath, as has been emphasized by Fallis. 2 Anson and McVay! have pointed out and popularized the im-
p
Hernias in the Poor Risk Patient
765
portance of Cooper's ligament in the repair of certain hernias occurring in the groin. In our experience it is only occasionally necessary to employ Cooper's ligament in the repair of inguinal hernias, but when the transversalis fascia and Hesselbach's triangle have been completely disrupted by a large direct or indirect inguinal hernia, the utilization of Cooper's ligament becomes extremely important. Thus, the musculofibrous bundle along the lateral inferior edge of the rectus sheath can always be approximated to Cooper's ligament in such a fashion that one should always anticipate success in the repair of any primary inguinal hernia. Harkins et al. 3 have advocated the employment of a Cooper's ligament repair after the manner of McVay as a routine procedure in almost all inguinal groin hernias, including direct, indirect and femoral. Although it is our belief that the Cooper's ligament repair should be ap~ plied only when the integrity of the transversalis fascia has been so destroyed that it cannot be adequately restored, it is nevertheless true that all groin hernias can be repaired by utilization of Cooper's ligament. With an increasing experience in the utilization of the transversalis fascia in the repair of the average direct and large indirect hernia and with the further realization that the musculofibrous bundle at the inferiolateral margin of the rectus sheath can always be approximated to Cooper's ligament, it becomes increasingly obvious that very few hernias occurring in the groin require the utilization of autogenous or heterogenous grafts. THE ESSENTIALS OF AN ADEQUATE GROIN HERNIA REPAIR
There are certain essentials regardless of one's personal preference for a particular type of anatomical repair that should be met in all surgical repairs of hernias occurring in the groin. Anesthesia, Suture Material, Incision
Adequate muscular relaxation should always be maintained throughout the operation. By and large, the greatest degree of muscular relaxation can be obtained by spinal anesthesia. In those patients in whom this appears unduly hazardous, and that will apply to only an occasional patient, one may today prefer to use Anectine* by continuous or intermittent intravenous drip. This agent undoubtedly is preferable in the extremely poor risk patient. It affords a degree of muscular relaxation comparable to that of spinal anesthesia; its effects can be attained almost instantaneously and the physiological activity of this substance is rapidly eliminated. In the desperately ill patient local anesthesia may be preferred and with care and patience adequate anesthesia and suffi-
* Diacetylcholine chloride or succinic acid bis (beta-dimethylaminoethyl) ester dimethochloride.
766
Kenneth W. Warren
cient relaxation can be obtained to repair most hernias. With the excellent control of spinal anesthesia available today and more particularly with the availability of the muscular relaxants, the need for local anesthesia for hernia repairs is less than it was formerly. It is generally agreed today that silk, cotton or other nonabsorbable suture material is preferable in hernia repairs. It is best to adhere to a choice of one of these materials unless active infection is present. The incision should be generous and should extend over the pubic spine (Fig. 193). Routine opening of the peritoneum at the internal ring in both direct and indirect inguinal hernias should be practiced. One of the commonest errors in the treatment of direct hernia is failure
Fig. 193. Anatomic topography, showing the line of incision which extends from the spine of the pubis to a point approximately 2 cm. below the anterior superior spine of the ilium. The incision is 2 cm. above and parallel to the inguinal ligament.
to open the peritoneum. By this failure the sac may not be completely eliminated and the presence of an indirect or femoral hernia may not be detected. The universal preference for opening the peritoneum at the internal ring will obviate injury to the bladder and will also preclude the possibility of overlooking an indirect hernia. In the presence of direct hernias (Fig. 194), the direct sac is converted into an indirect sac after the maneuver of Hoguet. The anterior rectus sheath is relaxed by a vertical incision near the midline to facilitate the approximation of the lateral margin of the rectus sheath to the shelving edge of the inguinal ligament (Fig. 195). Anatolllical Considerations
Following elimination of the peritoneal sac the next most important consideration is the restoration of the integrity of the transversalis
767
Hernias in the Poor Risk Patient
fascia (Fig. 196). This is particularly true in all direct hernias and equally true in all large indirect hernias in which the internal ring has been greatly expanded. Even in small indirect hernias the edges of the transAnt. sup. spine
X
Fig. 194. The transversalis fascia in direct hernias is thinned out and redundant. Opening the hernial sac in this position is dangerous in terms of possible injury to the urinary bladder.
X
Fig. 195. Relaxation of the anterior rectus sheath near the midline facilitates the approximation of the musculofibrous bundle along the lateral aspect of the rectus sheath to the inguinal or to Cooper's ligament.
versalis fascia which constitute the margins of the internal ring should be reapproximated until the caliber of the ring is within normal limits (Fig. 196, insert). In order to restore the integrity of the transversalis fascia it must be thoroughly exposed from the anterior pubic spine to
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the internal abdominal ring. The transversalis fascia in Hesselbach's triangle is best exposed by excising the cremasteric muscle. If one prefers not to excise this muscle, it should be elevated completely and detached from the region of the internal ring and the spine of the pubis. If the transversalis fascia is thoroughly exposed in this area it can be carefully and satisfactorily approximated with interrupted sutures of silk.
x
Fig. 196. The integrity of the transversalis fascia is restored by approximating the edges of the defect with interrupted sutures. Insert, careful approximation of the margins of the transversalis fascia about the spermatic cord reconstitutes the internal abdominal ring.
ReinforceIllent of the Transversalis Fascia
In small and direct hernias, particularly in children and young adults, it is not necessary to reinforce the transversalis fascia. The simple elimination of the hernial sac by high ligation of its neck and approximation of the margins of the transversalis fascia around the spermatic cord is sufficient. Most hernias in the older age group, however, require reinforcement of the transversalis fascia. A wide variety of methods calculated to achieve this end is available. We prefer to approximate the musculofascial bundle along the medial inferior aspect of the rectus sheath to Poupart's ligament where the integrity of the transversalis fascia has previously been restored (Fig. 197). If the defect in the transversalis fascia is so large that the separated edges of this structure cannot be approximated we then prefer to disregard the lateral or inferior leaflet of the transversalis fascia and approximate the musculofibrous bundle along the lateral rectus sheath to Cooper's ligament with interrupted sutures of heavy silk (Fig. 198). In utilizing the latter procedure
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the surgeon must pay considerable attention to protection of the femoral vem.
Edge of
Rectus Sheath
Fig. 197. The dense fibromuscular bundle along the lateral edge of the rectus sheath is approximated to the shelving edge of the inguinal ligament.
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Fig. 198. The fibromuscular bundle along the lateral margin of the rectus sheath is approximated to Cooper's ligament. When the integrity of the transversalis fascia in Hesselbach's triangle cannot be restored, care must be exercised to protect the femoral vessels during the placement of these sutures.
FEMORAL HERNIA
Femoral hernias, particularly in the elderly and poor risk patient, present additional technical problems. These hernias are frequently
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associated with incarceration and strangulation. Most femoral hernias in our experience can be dealt with satisfactorily through an incision placed parallel to and below Poupart's ligament. If the incarcerated contents of the sac cannot be reduced safely from below, we then prefer to make a vertical, lower rectus, abdominal incision in order that the contents of the sac may be manipulated both by way of the femoral canal and intra-abdominally. The same rule applies to the patient who has a strangulated femoral hernia. Most femoral hernias, even in the presence of incarceration, can be treated successfully through an incision placed parallel to and below the inguinal ligament. If it is impossible to reduce the incarcerated viscera or omentum by this method, a vertical, lower rectus incision should be made. When strangulation is present it is almost always necessary to make an abdominal incision, and again we would prefer to make a large, lower rectus, muscle splitting incision rather than an oblique incision in the inguinal area. It is usually possible to reduce the strangulated bowel by manipulating it intra-abdominally and by way of the incision overlying the femoral canal. It may be necessary to divide the inguinal ligament in order to relieve the strangulation. If, following reduction, it is apparent that the strangulated portion of the bowel has been compromised, a primary resection is usually feasible. If there is considerable disparity in the diameter of the proximal and distal loops of intestine, a side-to-side anastomosis is the safest method of management. In the neglected case of strangulation, particularly in the poor risk patient, it is best to approach the field through a lower rectus incision and to perform a side-to-side anastomosis between the proximal and distal loops of the bowel without attempting to manipulate the segment of bowel which is caught in the femoral canal. Following this anastomosis and the closure of the abdominal wound, the strangulated portion of the bowel can then be decompressed. This decompression may be achieved by inserting a needle, or preferably by inserting a catheter. Adequate drainage of this region is necessary. Secondary closure can be done later. In all cases of neglected strangulation, associated small intestinal obstruction will be present with moderate to considerable distention of the small intestine. A Miller-Abbott tube and constant suction should always be utilized. Once the sac has been eliminated the surgeon may choose to repair the femoral hernia, approximating the inguinal ligament to the iliofemoral fascia or by going above the inguinal ligament and breaking through the transversalis fascia and approximating the edge of the rectus sheath to Cooper's ligament. The latter is preferable in the patient with a large femoral hernia and should be employed whenever it has been necessary to divide the inguinal ligament to release a strangulated hernia. Division of the inguinal ligament in order to reduce a femoral hernia is rarely necessary.
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Ventral hernias occur at such diverse locations and following such a wide variety of abdominal incision as to defy classification. As they pertain to the elderly and the poor risk patient, the same principles apply. Practically all of these hernias, regardless of size and location, can be repaired by one of a variety of methods. In the presence of symptomatic incarceration or strangulation, operation will be indicated. In other varieties of ventral hernia in which the symptoms are minimal, the risk of operation should indicate whether or not surgical intervention is advised. It is in the repair of large ventral hernias that autogenous or heterogenous grafts may be used, but even in this category the use of such substances is rarely necessary. We have employed tantalum mesh in some instances with good results but in every instance we have used it to reinforce a conventional plastic procedure and not to bridge a gap in the anterior abdominal wall. By insisting that all obese patients who are to have elective repair of ventral hernias reduce their weight to a reasonable level before operation, it is almost always possible to approximate the hernial ring without undue tension. The postoperative use of suction by means of the Miller-Abbott tube is extremely important in the care of patients with large ventral hernias. The importance of hernias in the aged is stressed, and the anatomical requirements for adequate repair are detailed. REFERENCES 1. Anson, B. J. and McVay, C. B.: Inguinal hernia; anatomy of region. Surg., Gynec. and Obst. 66: 186-191 (Feb.) 1938. 2. Fallis, L. S.: Recurrent inguinal hernia; analysis of 200 operations. Ann. Surg. 106: 363-371 (Sept.) 1937. 3. Harkins, H. N., Szilagyi, E., Brush, B. E. and Williams, R.: Clinical experiences with McVay herniotomy. Surgery 12: 364--377 (Sept.) 1942. 4. Warren, K. W.: The repair of inguinal hernias. S. CLIN. NORTH AMERICA 29: 795-804 (June) 1949.