Indirect recurrences of inguinal hernias

Indirect

Recurrences

of Inguinal

Hernias

JOHN H. MEHNERT, M.D., MAURICE J. BROWN, M.D., WILLIAM KROUTIL, BENJAMIN WOODLVARD. M.D., San Diego, California

T

HE repair of an inguina1 hernia is a common operation, but one of uncommon compIexity. The perplexing probIems reIated to this procedure are we11 iIIustrated in a weaIth of pertinent Iiterature. Curiously, aIthough most facets of the subject have been repeatedly investigated, a reIative Iack of information stiI1 exists regarding a frequent comphcation, that of the indirect recurrence. This study comprises a review of I 22 indirect type, recurrent hernias coIIected from the records of Mercy and DonaId N. Sharp MemoriaI HospitaIs, San Diego, CaIifornia. We intend to emphasize the frequency of indirect recurrence, and indicate certain deficiencies in popuIar methods of primary repair. FoIIowing this we wiI1 outIine severa basic tenets for proper reconstruction of the inguinal canal in indirect hernia1 repair.

INTERVAL

of Surgery,

Volume

106. December

1963

OF

AND

RECURRENCE

The time Iapse between the original operation and the recurrence was recorded accurateIy in about 60 per cent of the charts. I.) A third of the hernias recurred (Fig. promptIy, that is, within a year of the original operation. A decreasing tendency for recurrence is evidenced in those hernias which did not recur during this first vuInerabIe period. When a recurrence was noted shortly after the initia1 operation, it seemed obvious that a proper repair had not been accompIished. This reasoning cannot account for Iater recurrences. We postuIate that strong support was not achieved in some repairs, and a breakdown occurred in a short time with the return of activity. In other persons, inherent tissue weakness, obesity, trauma, a stressfu1 occupation or other extraneous factors may have been major contributors to a new defect.

To determine the numerical ratio of indirect to direct inguinal recurrences as encountered in a private genera1 hospita1, we reviewed the records of the 140 patients with recurrent hernias who were admitted to Mercy Hospital in 1959. Forty-seven per cent of the recurrent hernias were found to be of the indirect type and 53 per cent of direct origin. This ratio correIates with the findings of other authors [I]. We aIso discovered that indirect recurrence is excIusiveIy a comphcation of the repair of a primary indirect hernia. In this series, as an exampIe, we can document only two instances in which the indirect recurrence foIIowed the repair of an initia1 direct hernia. In each of these cases the cord was transpIanted into the subcutaneous position at the time of the origina repair. This type of reconstruction predisposes to indirect recurrence, a fact which we shaI1 demonstrate more fuIIy Iater. Journal

AND

BETWEEN ORIGINAL SURGERY ONSET

INCIDENCE

American

M.D.

TYPE

OF

RECURRENCES

No hernia was incIuded in this series unless a definite statement was made in the operative note that the recurrence was of the indirect type. OnIy sixty-four (52 per cent) of the operative notes contained a sufficiently detailed description of the hernia1 defect to determine the exact point of origin of the sac, and its reIationship to the spermatic cord. Since by definition an indirect recurrence is merely one which presents in the inguinal cana Iateral to the epigastric vesseIs, it is apparent that the sac may vary considerably in position. BasicaIIy, a11 indirect hernias, and a11 recurrences as weI1, can be reduced to two types. In the first, or funicuIar, the sac arises at the interna ring, within the confines of the spermatic cord coverings, and descends aIong the 958

Indirect

Recurrences

of Inguinal

Hernias

FIG. I. An inverse relationship is demonstrated between the time lapse and iikelihood of hernia recurrcncr. A third of indirect recurrences form within the first year following repair.

inguinal canal in an oblique manner, remaining entirely within the cord structure during its progression. This form of indirect hernia is the !y!>e encountered almost universaIIy at the lnrtial repair. In this recurrent series, the sac ~zas found to be in this position in twenty instances or in 30 per cent of those recurrences in which the sac position was preciseIy stated. In the second tvpe of indirect hernia, although the sac originates in the indirect area, an d ma?; carry attenuated transversalis fascia (internal spermatic fascia) ahead of it as it advances, the line of progression of the sac is not obliquely down the cana within the confines of the cord. Rather, it is a direct protrusion into the floor of the canal alongside the cord, in the manner of a direct hernia. We have elected to call this the juxta-funicular form of indirect hernia. It was encountered in forty-four (70 per cent) of the recurrences of indirect type in which the position of the sac \vas preciseI)known. The juxta-funicuIar hernia is, then, the most common form of indirect recurrence. AIthough uncommon as a form of primary indirect hernia, we have recently encountered one of this type.

CHARACTERISTICS

OF

INDIRECT

RECURRENCE

In the seven patients with recurrences of the funicular type who were operated upon by the authors, the recurrent sacs had, in most instances, an appearance identical to those sacs found in virginal indirect inguinal hernias. This was true even when there was evidence by direct statement in the previous operative note, or by pathologic report, that a sac had been removed from the cord at the initial operation. We have been able to collect Iobjective evidence of prior sac removal in eight of the twenty funicular recurrences reported in this article. This information is convincing evidence that a peritoneal sac can reform at the interna ring within the coverings of the spermatic cord and then stretch down aIong the canal within the cord, which is the path of least resistance. The circumstances required for the beginning of this process most frequentIy originate in an insufficiently high ligation of the original sac. However, even when adequate excision of the sac is done, the peritoneum may be pushed down into the cord if the fascia1 cIosure is 959

Mehnert,

Brown,

KroutiI

and

Woodward

FIG. 2. A comparison of the primary repairs which were foIlowed by indirect recurrences and the subsequent operations used to correct these recurrences. The large number of primary HaIsted procedures is significant, indicating that this form of repair shouId not be used for primary indirect hernias.

defective at the interna ring, or if the cord attitude at the ring invites direct protrusion. We have come to beIieve that a primary funicular hernia can originate in this same manner. We reaIize that this opinion is at variance with the theory that a11 primary indirect hernias of the funicuIar type are truIy cqngenita1, that is, they possess a sac which was preformed at birth. However, if recurrences can form in the manner described previousIy, we can onIy concIude that some of the aduIt primary hernias may originate simiIarIy. A proportion of the recurrences of the funicular type certainIy represents primary hernias from which the sac was never removed. This is we11 iIIustrated in this series by an infant who had immediate recurrence of biIatera1 hernias folIowing an initia1 repair eIsewhere. At the time of prompt re-expIoration compIete indirect sacs were found within each spermatic cord. As aIready noted, the majority of recurrent indirect herniations do not descend within the cord, but present adjacent to the cord through the weakened transversaIis fascia IateraI to the inferior epigastric vesseIs. They are in a11 respects simiIar to direct hernias except for their position in the cana ffoor. Many of these recurrences, as we11 as most of the recurrences of the congenita1 type, resuIt from basic deficiencies in the principIes of the initia1 operation, or from inattention to technical detaiIs on the part of the surgeon. FaiIure of many surgeons to recognize the importance of correcting the diIated internal ring is indi-

cated by the fact that aImost none of the initia1 operative notes detaiIed the steps taken to repair the transversaIis fascia1 defect. Furthermore, this important step was mentioned as a factor in the repair in only zs per cent of the recurrent operations. TYPES

OF

INITIAL

SURGERY

In those instances in this series in which the primary operative reports couId be surveyed, 95 per cent of the operations were of the origina HaIsted or Bassini type. (Fig. 2.) A carefu1 appraisal of the basic principles of these repairs wiI1 uncover deficiencies, the correction of which wiI1 greatly improve operative results. Most of the indirect recurrences foIlowed an initia1 subcutaneous transprantation of the spermatic cord, the original HaIsted operation. This fact is especiaIIy striking considering the uncommon usage of the operation in recent years. A direct subcutaneous transpIantation of the cord has Iittle pIace in the correction of an indirect hernia, since it superimposes the externa1 ring upon the weakened interna ring and pIaces both directIy in the Iine of intraabdomina1 force. (Fig. 3.) Most of the remaining recurrences followed a Bassini repair. BasicaIIy, this is an adequate procedure as originaIIy described. The one inherent deficiency of the Bassini operation is the conversion of the cord attitude from a norma obIiquity at the interna ring to one at right angIes to the abdomina1 waI1, since

960

Indirect

Recurrences

5. 6.

7.

ot InguinaI

Hernias

TRANWJEPSb3 &fXXMINIS TRANSVERSALIS FASCIA P&RITOF)EU(

APDNEW?OSIS

3. This is :I diagrammatic wpresrntation of the normal anatomic arrangrrncnt of the internal inguinal ring and the changes productd by various forms of rrpair. The IMstcd repair is dernonstratcd to change the attitude of the inviting protrusion. The cord and produce a direct abdominal \wII defect, Bassini repair similarly elevates the cord, which predisposes to recurrence. The modified Zimmerman repair is the most nearly anatomic, by preserving the sphincteric action at the intcrrul inguinal ring and utilikng only f;tscia for strcsngthrning the posterior canal \vall. FIG.

the lower muscular border of the internal oblique muscle is included in the suture carried beneath the cord. (Fig. 3.) This creates a defect in the wali of the abdomen identical to that of the H&ted repair, except for the outer buttress of the external oblique aponeurosis, which is sutured over the cord rather than beneath it. Although the presence of this external reinforcement decreases the number of indirect recurrences, it cannot rectify the In addition, surgeons underlying deficiency. frequently place too great a reliance on the fleshy intern:11 oblique muscle rather than attempt to include the underlying strong fascial layers which are the real basis for support. TYPES

OF

RECURRENT

OPERATIONS

A comparison of the Iist of initial operations with those procedures used to repair the recur-

rences (Fig. 2) reveals a striking decrease in the number of original HaIsted operations in the current series. At the second operation, if the cord was found in the suhcntaneous position, the surgeon returned it to the inguinal canal in almost half the patients. The Bassini repair continued to be the most popular hernioplasty. Nevertheless, a considerable number of McVay repairs were utilized for the recurrences, probably indicating the surgeons’ attempt to improvc the fascial support of the entire posterior wall. SUGGESTIONS

FOR

REPAIR

OF

INDIRECT

HERNIAS

The objectives of hernia repair should be: obliteration of the sac, reconstitution of strong cana wails, and restoration of the normal position and attitude of the spermatic cord. In the

Mehnert,

Brown,

KroutiI

repair of an indirect hernia, tion must necessariIy be

the major attenfocused on the pathoIogic internal ring rather than on the frequentIy norma direct portion of the cana floor. With these points in mind, two cardina1 features in the repair of an indirect hernia, whether primary or recurrent, present themselves. First, a high Iigation of the hernia1 sac is mandatory. Secondly, the damaged inguina1 cana shouId be reconstructed in the most anatomic manner. This necessitates repair of the fascia1 floor of the cana and proper pIacement of the spermatic cord. In infants, high ligation of the sac frequentIy corrects the entire pathologic situation, since secondary anatomic defects have not yet developed. If diIatation of the internal ring is apparent, the re-approximation of the transversalis fascia1 margin beneath the cord suffices to correct the entire deficiency. On these minimal requirements for adequate repair in infants there is a preponderance of agreement in the literature 121. In oIder persons, various degrees of destruction of the floor of the inguinal cana have been produced by the enlarging sac. If investigation reveaIs an excellent direct canal floor, the dilated interna ring can be cIosed by carrying the upper rim of fascia down to the lower margin of the transversajis defect, which usuaIIy consists of the iliopubic band of the transversaIis fascia, or its extension as the anterior femora1 sheath. The sutures are first pIaced at the media1 margin of the fascia1 defect and are then carried IateraIIy to effect a snug repair about the spermatic cord. Occasionahy, the Iower edge of the inguina1 ligament is included in the suture of the Iower rim, or the inguina1 ligament is substituted for the iliopubic fascia as the inferior margin for approximation, if the fascia proves to be thin and weak. The upper rim of the transversaIis fascia1 defect is we11 defined and of considerabIe strength. The aponeurotic fibers of the transversus abdominus muscIe usually Iie adjacent to the edge of the transversabs fascia. The transversus aponeurosis is such an exceIIent layer, and Iies in such close approximation (transversahs analog-Nyhus) [J] that it is advisable to incIude this layer in the bite of the upper rim of the fascia1 defect. UsuaIIy the transversus abdominus aponeurosis is the strongest contributor to the repair. Occa-

and

Woodward

sionally, transversahs fascia aIone may furnish adequate support, and proper utiIization in an individual case is a matter of surgica1 judgment. If reenforcement of the direct floor of the cana is indicated, the above Iine of approximation is carried mediaIIy to the pubic tubercIe utilizing these identical structures. This wiI1 include the use of the conjoined tendon mediaIIy, when it is present. A relaxing incision shouId be made in the anterior rectus sheath whenever tension is present. (Figs. 4, 5 and 6.) The basic concepts embodied in this repair were originated by Bassini, emphasized by Edmund Andrews [4] and others [y], and perfected and publicized by Anson, McVay and Zimmerman 123. This repair strengthens the entire posterior canal waI1 in an anatomic manner utilizing fascia. It aIso preserves the norma obliquity of the spermatic cord at the interna ring, since it does not wedge the interna obIique muscIe beneath the cord as does the Bassini repair. If the lowest margin of the interna oblique muscIe does not cover the interna ring after compIetion of the repair, we have devised an additional reconstructive maneuver. At the IeveI of the interna ring, the interna oblique muscIe is attached to Poupart’s Iigament over the spermatic cord. (Fig. 6.) No tension is necessary to effect the approximation, since the previous apposition of the margins of the fascia1 defect have already pulled the internal obIique muscIe downward. The approximation shouId be carried as far mediaIIy as is possibIe without tension, but Iimited at a point which aIIows easy exit of the cord through the hiatus between the lowest attachment to Poupart’s Iigament and the insertion of the muscle into the conjoined tendon. When the muscle is utilized in this manner, the cord carries through a tunne1 between the underIying fascia1 Iayers and the overIying internal oblique muscle. The resuItant external muscuIar compression against the interna ring, in association with the exceIIent underIying fascia1 repair, makes indirect recurrence extremeIy diffkuIt. The optima1 effectiveness of this arrangement is confirmed when one reaIizes that, except for the surgical strengthening of the posterior wall with the transversus abdominus aponeuroarrangement of the sis, this is the norma inguinaI canal. In those instances in which the Iower border of the interna obIique muscIe 962

Indirect

Recurrences

of Inguinal

Hernias

4

WERMAL BZFECT

LXTERFWL

OBLIOVE

%I0 PUBIC TRACT

already covers the internal ring, the muscle is left undisturbed. A large indirect hernia may destroy the entire floor of the inguinaI canal. It then becomes mandator>- to repair the direct floor as well as the indirect area. Despite the large size of the defect, paipation xvi11 usually con963

firm a strong fascia remaining inferior to the inguinal ligament, cIosing the femoral space. The presence of this fascia makes the necessity of repair to the superior pubic (Cooper’s) ligament the unusual rather than the usual circumstance in the repair of indirect hernias, regardless of size. The Ziopubic band of the

Mehnert,

Brown,

KroutiI

and Woodward

FIG. 6. The cord has been dropped onto the strengthened canal floor. The internal oblique muscIe is being sutured to the inguinal Iigament as far medialIy as the media1 margin of the femora1 sheath. The obliquity of the spermatic cord exit, and the externa1 compression of the internal oblique at the internal ring are assured by this procedure. The external obIique nponeurosis is closed over this Iayer, completing the repair.

transversalis fascia, lying just below the inguinal ligament, is most frequently the inferior margin of exceIIent fascia. A smooth repair employing this structure can be carried across the entire floor of the canal and is superior to a repair to the superior pubic ligament for the foIlowing reasons: (I) it is cIoser to the upper rim of the defect and, therefore, requires minima1 tension for approximation; (2) transitiona sutures are not required to carry the approximation along the entire floor of the canal. A few large hernias will break down the fascia closing the femoral triangle, leaving a femora1 “empty space” which would invite femora1 recurrence. If this situation is apparent, repair of the direct area by approximating the upper fascia1 rim to the superior pubic Iigament becomes the procedure of choice. In those patients in whom a marked superior weakness of the transversaIis fascia or a high lying transversus abdominus aponeurosis precIude adequate repair of the cana floor, a satisfactory herniopIasty can be accompIished by one of two methods. If a strong external oblique aponeurosis is present it may be utilized to support the floor of the canal by attachment of the Iower Ieaf beneath the cord as outIined by Zimmerman [6]. If the aponeu-

rosis is weak or this repair is not technicaIIy feasible, we then advise the use of a prosthesis attached below to the inguinal Iigament or iliopubic fascia, and above to the interna oblique muscIe or reaching beneath it to the IeveI necessary to obtain fascia of good strength. One added advantage to the utiIization of a prothesis is that, if indicated, it can be attached inferiorly to Cooper’s ligament in the direct area, to cIose the femoral space. The preperitoneal approach for inguinal hernia1 repairs [J] is, in most respects, an exceIIent operation since basically it follows the tenets of anatomic repair. Some disadvantages for routine utilization are: inability to incIude accurateIy the Iower margin of the transversus abdominus aponeurosis in the bite of the upper rim of the defect; inability to make a reIaxing incision with accuracy; inabiIity to cover the interna ring with the interna obIique muscle; and occasionaIIy, inabi1ity to remove the sac compIeteIy from the spermatic cord. The Iack of disturbance of the canal and the spermatic cord, the preservation of norma cord attitude, good visualization of the Iower fascia1 rim and high Iigation of the sac are advantages of this approach. AIthough this method may be indicated under certain circumstances, for exampIe in the 964

Indirect

Recurrences

of Inguinal

correction of strangulated, incarcerated or slid~ng hernias in which a second incision might otherwise IX necessary, we believe that the external approach to the inguinal canal is routinely preferable. Transection of the cord with preservation of the testicle, or removal of the testicle and cord \vill occasionally be necessary to eliminate ~c)mpletcl,v the defect necessitated by emergenw of the corcl structures. This technic slic~ultl I)0 reserved for repeated recurrences and in \wp elderly persons; however, when utiliwd, it aives opt’imnl opportunity for strong abdominal wall closure. SUMMAP.?’

AND

Hernias

(3) An indirect inguina1 sac may reform within the spermatic cord even though a sac was removecl at the initial surgery. (4) Indirect recurrences are usuaIly the result of inadequate repair of the dilated internal ring, low ligation of the hernial sac, or surgical alteration of the normal oblique attitude of the spermatic cord. (5) Deficiencies in certain conventional rcpairs predispose to indirect recurrences. We IX describe principles of repair which ma? expected to reduce the incidence of indirect recurrence. REFERENCES I. STKIX, II. E. Inguinal

CONCLUSIOKS

hernia.

Am. J. Surg.,

56: 480,

‘942.

‘l-he records of 122 patients with recurrent indirect inguinal hernias are analyzed, from which certain facts become evident: ( I 1 Indirect recurrent hernias are common, almost al\vays following a primary indirect hernial repair. (21 ‘I‘MY)forms of indirect recurrence occur, ctne lying bvithin the spermatic cord (funicular) and one adjacent to it (juxta-funicuIar). AIthough almost all primary hernias are of the funicular type, the juxta-funicular constitutes the majority of the recurrent group.

965

2.

L. XI. and Arson, B. L. Anatomy and Surgery of flernia. BaItimorc, 1953. Williams & Wilkins Co. 3. NYHUS, L. M., Cowxxv, 1~. E. and HAKKI~S, FX. N. Clinical experiences with preperitoncal hernial repair for all types of hernia of the groin. Am. J. Surg., IOO: 234, 1960. 4. AWKEWS. E. A method c;f hcrniotomy utilizing only white fascia. Ann. Surp., 80: 225, rgz4. steps in the tcchniquc 01 5. PIIZMAY, M. Suggested inguinal herniotomy. .Surg. Gylzec. <*- Ohstet., 28: 329, ‘919. ZIMMEKMAi\l,