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Inguinal hernia in Saudi Arabia
REVIEW
Inguinal Hernia in Saudi Arabia A 10 Year Experience
Saleh AI-Khuwaiter, MD, Riyadh, Saudi Arabia
There are differing opinions regarding the cause of inguinal hernias in adults. For years, the importance of the congenital factors, a patent vaginal process, and muscular weakness have been emphasized. More recently, acquired factors have been investigated. Now it seems that altered collagen metabolism plays a significant role in many hernias in adults and that most are actually caused by a mixture of congenital and acquired factors [1,2]. Thus a patent vaginal process may determine the type of herniation that occurs in an adult but may not actually cause the hernia. Consequently, it follows that there are different opinions regarding surgical repair of adult inguinal hernia. Many surgeons believe chat the type of surgical repair performed should depend on the type of hernial defect found. Thus, small to moderate indirect hernias need have only a repair of the abdominal ring, and only direct and large indirect hernias should have Cooper's ligament repair. Advocates of this approach include McVay [3], Nyhus and Condon [4], and Ponka [5]. Other surgeons favor a complete Cooper's ligament repair on all adult groin hernias. Advocates of this approach include Palumbo and Sharpe [6], Lichtenstein and Shore [7], Shearburn and Myers [8], and Glassow [9] at the Shouldice Clinic. I believe that Bassini's repair has been frequently criticized, and sometimes condemned on theoretic grounds only. This type of repair has stood the test of time (in use since 1888) and has probably cured more inguinal hernias than any other method. However, no method yet known can provide permanent cure in all cases of inguinal hernia. From the Department of Surgery. King ~ u d University College of Medicine, Rlyadh, Saudl Arabia, Requests for relxInts should be addressedto Saleh AI-Khuwalter, MD, Department of Surgery, King Saud University College of Medicine, PO Box 2925, RlyEIh, Saudi Ar/=bla.
Volume 140, May 1985
Patients and Methods This study was carried out during mid 1983 in Riyadh, Saudi Arabia. It covered patients admitted by me to four hospitals: Riyadh Central Hospital, National Hospital, King Abdul Aziz University Hospital, and King Khalid University Hospital. One hundred fifty-five primary inguinal hernia repairs in adults were performed in the period from 1973 to 1983 by Bassini's repair with slight modification. Only pure direct or indirect hernias were included. Combined direct, indirect, bilateral, recurrent, and femoral hernias were not investigated. Among these patients, six were dead at the time of the study, three were unfit to continue follow-up, two refused to come in for follow-up,and four were not traced for other reasons. This left one hundred forty patients or 90.3 percent of the total for inclusion in the survey (Figure i). Ninety-five had indirect hernias. Eighty-fivewere men and 10 were women,and they ranged in age from 20 to 75 years. Forty-five had direct hernias, all of whom were men with an age range of 25 to 75 years. All one hundred forty patients had Bassini's repair with slight modification,that is, approximation of the conjoined tendon to Poupart's ligament with nonabsorbable material (nylon or prolene). An incisionwas performed in some cases for suture line relaxation when the suture line was thought to be under tension, and suturing was performed when the posterior wall was thought to be weak. About 50 percent of the operations were carried out by me and 50 percent were performed by junior surgeons. All patients were followed for 2 years after the repair. Only about 71 percent were followedfor 5 years and about 6 percent were followed for 10 years (Table I).
Results Of 95 patients who had indirect hernias repaired, only I had recurrence (1.05 percent) during the second year after operation. At operation, it was found to be, a direct hernia. Only 60 patients (63 percent) were followed for 5 years, and two recurrences were discovered. Again reoperation confirmed t h a t one was a direct hernia and the other, an indirect hernia.
691
AI-Khuwaiter
{ndlrecc p r l ~ r y
Ptlre d~r~ct o r InRui~1
~ern£A r e p s l r ~
b e t w e e n 1973 ~nd 19~3
should have the actual rate multiplied by 5 to project the eventual recurrence rate at 25 years. Similarly, if all the patients in a series have been followed for 2 years, the 25 year rate should be obtained by multiplying the recorded recurrence rate by 2.5. In this study and according to the tabulation suggested by Halverson and McVay ~14], we could project the 25 year recurrence rate from our 2 year recurrenc~ rate as all our patients were followed for 2 years. Our 2 year recurrence rate for primary repair of pure indirect inguinal hernia was 1.05 percent (I of 95 patients), and our 2 year recurrence rate for primary repair or pure direct inguinal hernias was 4.4 percent (2 of 45 patients); therefore, the overall 2 year recurrence rate was 2.14 percent (3 of 140 patients). With these figures, our projected 25 year recurrence rate would be 5.3 percent (Table II). Recurrences are the most i m p o r t a n t but not the only consideration in the evaluation of hernia repairs. In our series, other complications such as wound infection, sinus formation, and testicular atrophy were not. significant. T h e r e were no,serious complications.
i
lt!,O I n v o s t ~
i 45 d i r e c t
- ~ died -
3 unfit
All
- 2 refused - ~ case
'l
~] 95 i n d i r e c t
I~mles
}
25-75 yearm of a~e
~ote~
~ot
ava|lah¢
]. . . .
I 85 ~ l l e s
10 y e ~ m l e s
R~nge o f 2 5 - 7 5 y e a r ~ o f a g e
Figure 1. Identification of the patients studied.
Six patients (6.3 percent) were followed for 10 years and no recurrence was found. Of 45 patients who had direct hernias repaired, only 2 had recurrences (4.4 percent) during the second year after surgery. One was found to be direct and the other, indirect when t h e y were repaired later. Thirty-nine patients (87 percent) were followed for 5 years and again, two recurrences were discovered, one proving to be direct and the other, indirect at operation. Subsequently, only three patients (6.6 percent) were followed for 10 years with no recurrence. F r o m the results of Lund et al [10], T h i e m e [11], Hagan and Roads [1;t], Clear [13], and the experience of Halverson and McVay [t4], and because of uniform reporting of recurrences and their similarities, Halverson and McVay have suggested a tabulation be. used for projecting 25 year recurrence rates. Using the 1 year follow-up recurrence rate, multiply it by 5 to arrive at the 25 year rate, multiply the 2 year rate by 2.5, multiply the 5 year rate by 1.5, and multiply the 10 year rate by 1.2. A series of patients with hernias, all of whom have been followed for 1 year,
TABLE I
Comments T h e chance of successful inguinal hernia repair varies according to the expertise of the surgeon. In series from clinics t h a t specialize in hernia operations, recurrence rates as low as 0.7 to 2 percent after primary inguinal hernia repair in adults have been achieved during the last 20 to 30 years. F r o m the technical point of view, suture tension, even after making a relaxing incision, is at a higher level after McVay's repair than after Bassini's repair [15]. This is probably due to the deeper, more posterior Cooper's ligament compared with Poupart's ligament. Therefore, in theory, the risk of recurrence should be greater after repair with tension at a higher level than after repair with tension at a lower level.
F o l l o w - U p D a t a o n Direct and Indirect Inguinal Hernia Repair Patients Followed -n ....... %
Years
Rec,urrences
Type
n"
o~
' 'indirect
Direct
Direct Repair (n = 45, all male) 1
45
100
0
2
4s
10o
2
;~i~
"~
5
39
87
2
5.1
t
2
4.4
1
0
.
10
3
6,6
1
95
100
2
95
1oo
.
.
.
.
.
•
"~
,
1
1 .
.
.
Indirect Repair (n -- 95, 85 male & 10 female)
5" ....... 10
,~
60 6
,,
63 6.3
0
. ~_
I
~os
2 0
3.3 ...
.
.
.
.
"~ ,...........
1 ...
• A t 5 years, only 2.1 percent (2 patients) of the total group of 95 patients had recurrence.
692
The
Antic.an
Joumsl
of SurDory
Inguinal Hernia in Saudi Arabia
The main criticisms of Bassini's repair are based on the grounds that it is unphysiologic; it has been reported to interfere with the shutter action of the internal oblique muscle, and furthermore, it has been suggested that union is unlikely to occur between fleshy muscle and a ligament or that, at best, such union would be weak and liable to stretching or disruption [16]. Such criticisms appear to be more theoretic than real. It is true that by causing fibrosis of the lower fibers of the internal oblique muscle, the physiologic action of this muscle in guarding the canal may become impaired, but it is more than doubtful whether such action, the mechanism uf which is obscure, can ever be regained once herniation has occurred. In addition, firm fibrous tissue is preferable to active but ineffectual muscle as a safeguard against recurrence. There does not appear to be a valid reason why the lower border of the fleshy muscle should not adhere to the inguinal ligament. provided that the structures are not stitched together under" tension. To avoid such tension, a relaxing incision is indicated in some cases. Probably the only chance of finally settling the controversy concerning the best form of repair is by studying controlled clinical trials in which sufficient numbers of patients are randomly allocated to one of the two methods of repair (Cooper's or Poupart's ligament repairs); however, such a trial will require several years for patients to be collecLed. A follow-up study of 140 adult patients with primary inguinal hernia repaired using Poupart's ligament (modified Bassini's repair) revealed comparable results with those of other techniques. I believe that the criticisms of Bassini's repair are based on theoretic grounds only and that Bassini's repair has the following advantages: It has stood the test of time, being performed since 1888; it is easier to teach and can be performed by junior surgeons; and the chance of complications of thrombophlebitis and pulmonary embolism is less than the chance with Cooper's ligament repair [16, 17]. Summary
There are differing opinions regarding the cause of inguinal hernias in adults. It seems that a patent vaginal process may determine the type of herniation that occurs in an adult but may not actually cause the hernia. Also, altered collagen metabolism seems to play a significant role in many cases of hernias in adults. Thus, most of these hernias are actually caused by a mixture of congenital and acquired factors [1,2]. Consequently, it follows t h a t there are a varmty of opmmns regarding surgmal repmr. This follow-up study on recurrence after inguinal hernia repair in Saudi Arabia was aimed at testing the effectiveness of Bassini's repair and the results achieved when it is employed for primary inguinal
TABLE II
Projected Recurrence Rates at 25 Years Using Tabulation of Halverson and McVay
1141 Type of Hernia Indirect Direct Both types (tolal)
Actual Recurrence Rate with 100% Follow-Up
Projected Recurrence at 25 years
Year 1:0 Year 2: 1.05%
1.05 X 2,5 = 2.6%
Year t: 0 Year 2: 4.4%
4.4 X 2.5 ~- 11%
Year 1:0 Year 2: 2,4%
2.14 X 2.5 = 5.3%
hernia repair in adults. One hundred forty patients (95 with indirect and 45 with direct hernias) who had Bassini's repair were studied. Only pure direct or indirect hernias were included. Combined direct, indirect bilateral, recurrent, or femoral hernias were not investigated. All the patients were followed for 2 years after repair, with a total recurrence rate of 2.14 percent. The projected recurrence rate at 25 years is 5.3 percent. These results are comparable to those achieved with other techniques. Therefore, I believe that the criticisms of Bassini's repair are based on theoretic grounds only. Bassini's repair has stood the test of time, is easier to teach and to perform by junior surgeons, and the chance of being complicated by thrombophlebitis and pulmonary embolism is less than the chance with Cooper's ligament repair [16]. References 1. Percock EE Jr. Biology of hernia, In: Nyhus LM, ~ RE, eds. Hernia. 2nd ed. Philadelphia: JB Llpptncort, 1978:79-91. 2. Read RC, White PU. Inguinal hecniation: 1777-1977. Am J Surg 1978; 136:65 t-4. 3. McVay CB. Inguinal and femoral hernioplasty. Surgery 1965; 57:615-25. 4. Nyhus LM, Condon RE. Hernia. 2nd ed. Philadelphia: JB Lil~ plncotl, 1978. 5. Po.'lka JL. Groin hernia: Current personal approach, In: Nyhus LM, C,orclon RE, eds. Hernia. 2nd ed, Philadelphia: JB Lipplncott 1978;t53:162. 6. Patumbo LT, Sharpe WS. Primary tnguinal hernfoplasty in the adult. Surg CIIn North Am 1971;51:1293-307. 7. Uchtenstain L, Shore JM. Exploding the myths of hernia repair, Am J Surg 1976;132:307-15. 8. S t ' m ~ EW, Myers RN. Shou~ice repair for inguinal hernia. Surgery 1969;66:450-9. 9. Giassow F. Short-stay surgery (Shouldice technique) for repair of inguinal hernia, Ann Roy Coil Surg [Engl] 1976;58: 133-9, 10. Lurid J, Havio't V, Kjetoisen-Anderson J, Inguinal and ferrc¢al hemlopiasty: five-year follow up of 284 Csses of M<:Vay repair. Acta Chlr Scand 1966;131:72-80. 11. Thlerne ET, Recurrence after inguinal hernlorrhal~y. Sur9 Gynecol Obstet 1951;93:641-3, 12. Hagen WB, Roads JE. Ingufnat and fen'K)~l hernias: a foJ~ow up study. Surg Gyrmcol Obs~et 1953;96:226-32. 13. Clear JJ. Ten year statistical study of Inguinal hernias: a corn-
AI-Khuwalter
parison rate of recurrence after repair by the Halsted I operation and other operations. Arch Surg 1951;62:70-8. 14. Halverson K, McVay CB. Inguinal and femoral herntoplasty: a 22-year study of the authors' methods. Arch Su,,g 1970; 101:127-35. 15. Read RC, McLeod PC Jr. Influence of a relaxing incision on sL~ture tension In Basslnl's and McVay's repair. Arch Surg
694
1981;116:440-5. 16. Rlntoul RF. Operations for hernia. In: Farguharson's textbook of operative surgery. 6th ed. NY: Churchill Livingstone, 1978:749, 17. Brown RE, Klrmteder RJ, Rosenberg N. Ipsllateral thrombophlebitis and pulmonary embolism after Cooper's ligament hernloplast'/. Surgery 1980;87:230-2.
'Tim Aremrl~m ,Jmernalof
Inguinal Hernia in Saudi Arabia A 10 Year Experience
Saleh AI-Khuwaiter, MD, Riyadh, Saudi Arabia
There are differing opinions regarding the cause of inguinal hernias in adults. For years, the importance of the congenital factors, a patent vaginal process, and muscular weakness have been emphasized. More recently, acquired factors have been investigated. Now it seems that altered collagen metabolism plays a significant role in many hernias in adults and that most are actually caused by a mixture of congenital and acquired factors [1,2]. Thus a patent vaginal process may determine the type of herniation that occurs in an adult but may not actually cause the hernia. Consequently, it follows that there are different opinions regarding surgical repair of adult inguinal hernia. Many surgeons believe chat the type of surgical repair performed should depend on the type of hernial defect found. Thus, small to moderate indirect hernias need have only a repair of the abdominal ring, and only direct and large indirect hernias should have Cooper's ligament repair. Advocates of this approach include McVay [3], Nyhus and Condon [4], and Ponka [5]. Other surgeons favor a complete Cooper's ligament repair on all adult groin hernias. Advocates of this approach include Palumbo and Sharpe [6], Lichtenstein and Shore [7], Shearburn and Myers [8], and Glassow [9] at the Shouldice Clinic. I believe that Bassini's repair has been frequently criticized, and sometimes condemned on theoretic grounds only. This type of repair has stood the test of time (in use since 1888) and has probably cured more inguinal hernias than any other method. However, no method yet known can provide permanent cure in all cases of inguinal hernia. From the Department of Surgery. King ~ u d University College of Medicine, Rlyadh, Saudl Arabia, Requests for relxInts should be addressedto Saleh AI-Khuwalter, MD, Department of Surgery, King Saud University College of Medicine, PO Box 2925, RlyEIh, Saudi Ar/=bla.
Volume 140, May 1985
Patients and Methods This study was carried out during mid 1983 in Riyadh, Saudi Arabia. It covered patients admitted by me to four hospitals: Riyadh Central Hospital, National Hospital, King Abdul Aziz University Hospital, and King Khalid University Hospital. One hundred fifty-five primary inguinal hernia repairs in adults were performed in the period from 1973 to 1983 by Bassini's repair with slight modification. Only pure direct or indirect hernias were included. Combined direct, indirect, bilateral, recurrent, and femoral hernias were not investigated. Among these patients, six were dead at the time of the study, three were unfit to continue follow-up, two refused to come in for follow-up,and four were not traced for other reasons. This left one hundred forty patients or 90.3 percent of the total for inclusion in the survey (Figure i). Ninety-five had indirect hernias. Eighty-fivewere men and 10 were women,and they ranged in age from 20 to 75 years. Forty-five had direct hernias, all of whom were men with an age range of 25 to 75 years. All one hundred forty patients had Bassini's repair with slight modification,that is, approximation of the conjoined tendon to Poupart's ligament with nonabsorbable material (nylon or prolene). An incisionwas performed in some cases for suture line relaxation when the suture line was thought to be under tension, and suturing was performed when the posterior wall was thought to be weak. About 50 percent of the operations were carried out by me and 50 percent were performed by junior surgeons. All patients were followed for 2 years after the repair. Only about 71 percent were followedfor 5 years and about 6 percent were followed for 10 years (Table I).
Results Of 95 patients who had indirect hernias repaired, only I had recurrence (1.05 percent) during the second year after operation. At operation, it was found to be, a direct hernia. Only 60 patients (63 percent) were followed for 5 years, and two recurrences were discovered. Again reoperation confirmed t h a t one was a direct hernia and the other, an indirect hernia.
691
AI-Khuwaiter
{ndlrecc p r l ~ r y
Ptlre d~r~ct o r InRui~1
~ern£A r e p s l r ~
b e t w e e n 1973 ~nd 19~3
should have the actual rate multiplied by 5 to project the eventual recurrence rate at 25 years. Similarly, if all the patients in a series have been followed for 2 years, the 25 year rate should be obtained by multiplying the recorded recurrence rate by 2.5. In this study and according to the tabulation suggested by Halverson and McVay ~14], we could project the 25 year recurrence rate from our 2 year recurrenc~ rate as all our patients were followed for 2 years. Our 2 year recurrence rate for primary repair of pure indirect inguinal hernia was 1.05 percent (I of 95 patients), and our 2 year recurrence rate for primary repair or pure direct inguinal hernias was 4.4 percent (2 of 45 patients); therefore, the overall 2 year recurrence rate was 2.14 percent (3 of 140 patients). With these figures, our projected 25 year recurrence rate would be 5.3 percent (Table II). Recurrences are the most i m p o r t a n t but not the only consideration in the evaluation of hernia repairs. In our series, other complications such as wound infection, sinus formation, and testicular atrophy were not. significant. T h e r e were no,serious complications.
i
lt!,O I n v o s t ~
i 45 d i r e c t
- ~ died -
3 unfit
All
- 2 refused - ~ case
'l
~] 95 i n d i r e c t
I~mles
}
25-75 yearm of a~e
~ote~
~ot
ava|lah¢
]. . . .
I 85 ~ l l e s
10 y e ~ m l e s
R~nge o f 2 5 - 7 5 y e a r ~ o f a g e
Figure 1. Identification of the patients studied.
Six patients (6.3 percent) were followed for 10 years and no recurrence was found. Of 45 patients who had direct hernias repaired, only 2 had recurrences (4.4 percent) during the second year after surgery. One was found to be direct and the other, indirect when t h e y were repaired later. Thirty-nine patients (87 percent) were followed for 5 years and again, two recurrences were discovered, one proving to be direct and the other, indirect at operation. Subsequently, only three patients (6.6 percent) were followed for 10 years with no recurrence. F r o m the results of Lund et al [10], T h i e m e [11], Hagan and Roads [1;t], Clear [13], and the experience of Halverson and McVay [t4], and because of uniform reporting of recurrences and their similarities, Halverson and McVay have suggested a tabulation be. used for projecting 25 year recurrence rates. Using the 1 year follow-up recurrence rate, multiply it by 5 to arrive at the 25 year rate, multiply the 2 year rate by 2.5, multiply the 5 year rate by 1.5, and multiply the 10 year rate by 1.2. A series of patients with hernias, all of whom have been followed for 1 year,
TABLE I
Comments T h e chance of successful inguinal hernia repair varies according to the expertise of the surgeon. In series from clinics t h a t specialize in hernia operations, recurrence rates as low as 0.7 to 2 percent after primary inguinal hernia repair in adults have been achieved during the last 20 to 30 years. F r o m the technical point of view, suture tension, even after making a relaxing incision, is at a higher level after McVay's repair than after Bassini's repair [15]. This is probably due to the deeper, more posterior Cooper's ligament compared with Poupart's ligament. Therefore, in theory, the risk of recurrence should be greater after repair with tension at a higher level than after repair with tension at a lower level.
F o l l o w - U p D a t a o n Direct and Indirect Inguinal Hernia Repair Patients Followed -n ....... %
Years
Rec,urrences
Type
n"
o~
' 'indirect
Direct
Direct Repair (n = 45, all male) 1
45
100
0
2
4s
10o
2
;~i~
"~
5
39
87
2
5.1
t
2
4.4
1
0
.
10
3
6,6
1
95
100
2
95
1oo
.
.
.
.
.
•
"~
,
1
1 .
.
.
Indirect Repair (n -- 95, 85 male & 10 female)
5" ....... 10
,~
60 6
,,
63 6.3
0
. ~_
I
~os
2 0
3.3 ...
.
.
.
.
"~ ,...........
1 ...
• A t 5 years, only 2.1 percent (2 patients) of the total group of 95 patients had recurrence.
692
The
Antic.an
Joumsl
of SurDory
Inguinal Hernia in Saudi Arabia
The main criticisms of Bassini's repair are based on the grounds that it is unphysiologic; it has been reported to interfere with the shutter action of the internal oblique muscle, and furthermore, it has been suggested that union is unlikely to occur between fleshy muscle and a ligament or that, at best, such union would be weak and liable to stretching or disruption [16]. Such criticisms appear to be more theoretic than real. It is true that by causing fibrosis of the lower fibers of the internal oblique muscle, the physiologic action of this muscle in guarding the canal may become impaired, but it is more than doubtful whether such action, the mechanism uf which is obscure, can ever be regained once herniation has occurred. In addition, firm fibrous tissue is preferable to active but ineffectual muscle as a safeguard against recurrence. There does not appear to be a valid reason why the lower border of the fleshy muscle should not adhere to the inguinal ligament. provided that the structures are not stitched together under" tension. To avoid such tension, a relaxing incision is indicated in some cases. Probably the only chance of finally settling the controversy concerning the best form of repair is by studying controlled clinical trials in which sufficient numbers of patients are randomly allocated to one of the two methods of repair (Cooper's or Poupart's ligament repairs); however, such a trial will require several years for patients to be collecLed. A follow-up study of 140 adult patients with primary inguinal hernia repaired using Poupart's ligament (modified Bassini's repair) revealed comparable results with those of other techniques. I believe that the criticisms of Bassini's repair are based on theoretic grounds only and that Bassini's repair has the following advantages: It has stood the test of time, being performed since 1888; it is easier to teach and can be performed by junior surgeons; and the chance of complications of thrombophlebitis and pulmonary embolism is less than the chance with Cooper's ligament repair [16, 17]. Summary
There are differing opinions regarding the cause of inguinal hernias in adults. It seems that a patent vaginal process may determine the type of herniation that occurs in an adult but may not actually cause the hernia. Also, altered collagen metabolism seems to play a significant role in many cases of hernias in adults. Thus, most of these hernias are actually caused by a mixture of congenital and acquired factors [1,2]. Consequently, it follows t h a t there are a varmty of opmmns regarding surgmal repmr. This follow-up study on recurrence after inguinal hernia repair in Saudi Arabia was aimed at testing the effectiveness of Bassini's repair and the results achieved when it is employed for primary inguinal
TABLE II
Projected Recurrence Rates at 25 Years Using Tabulation of Halverson and McVay
1141 Type of Hernia Indirect Direct Both types (tolal)
Actual Recurrence Rate with 100% Follow-Up
Projected Recurrence at 25 years
Year 1:0 Year 2: 1.05%
1.05 X 2,5 = 2.6%
Year t: 0 Year 2: 4.4%
4.4 X 2.5 ~- 11%
Year 1:0 Year 2: 2,4%
2.14 X 2.5 = 5.3%
hernia repair in adults. One hundred forty patients (95 with indirect and 45 with direct hernias) who had Bassini's repair were studied. Only pure direct or indirect hernias were included. Combined direct, indirect bilateral, recurrent, or femoral hernias were not investigated. All the patients were followed for 2 years after repair, with a total recurrence rate of 2.14 percent. The projected recurrence rate at 25 years is 5.3 percent. These results are comparable to those achieved with other techniques. Therefore, I believe that the criticisms of Bassini's repair are based on theoretic grounds only. Bassini's repair has stood the test of time, is easier to teach and to perform by junior surgeons, and the chance of being complicated by thrombophlebitis and pulmonary embolism is less than the chance with Cooper's ligament repair [16]. References 1. Percock EE Jr. Biology of hernia, In: Nyhus LM, ~ RE, eds. Hernia. 2nd ed. Philadelphia: JB Llpptncort, 1978:79-91. 2. Read RC, White PU. Inguinal hecniation: 1777-1977. Am J Surg 1978; 136:65 t-4. 3. McVay CB. Inguinal and femoral hernioplasty. Surgery 1965; 57:615-25. 4. Nyhus LM, Condon RE. Hernia. 2nd ed. Philadelphia: JB Lil~ plncotl, 1978. 5. Po.'lka JL. Groin hernia: Current personal approach, In: Nyhus LM, C,orclon RE, eds. Hernia. 2nd ed, Philadelphia: JB Lipplncott 1978;t53:162. 6. Patumbo LT, Sharpe WS. Primary tnguinal hernfoplasty in the adult. Surg CIIn North Am 1971;51:1293-307. 7. Uchtenstain L, Shore JM. Exploding the myths of hernia repair, Am J Surg 1976;132:307-15. 8. S t ' m ~ EW, Myers RN. Shou~ice repair for inguinal hernia. Surgery 1969;66:450-9. 9. Giassow F. Short-stay surgery (Shouldice technique) for repair of inguinal hernia, Ann Roy Coil Surg [Engl] 1976;58: 133-9, 10. Lurid J, Havio't V, Kjetoisen-Anderson J, Inguinal and ferrc¢al hemlopiasty: five-year follow up of 284 Csses of M<:Vay repair. Acta Chlr Scand 1966;131:72-80. 11. Thlerne ET, Recurrence after inguinal hernlorrhal~y. Sur9 Gynecol Obstet 1951;93:641-3, 12. Hagen WB, Roads JE. Ingufnat and fen'K)~l hernias: a foJ~ow up study. Surg Gyrmcol Obs~et 1953;96:226-32. 13. Clear JJ. Ten year statistical study of Inguinal hernias: a corn-
AI-Khuwalter
parison rate of recurrence after repair by the Halsted I operation and other operations. Arch Surg 1951;62:70-8. 14. Halverson K, McVay CB. Inguinal and femoral herntoplasty: a 22-year study of the authors' methods. Arch Su,,g 1970; 101:127-35. 15. Read RC, McLeod PC Jr. Influence of a relaxing incision on sL~ture tension In Basslnl's and McVay's repair. Arch Surg
694
1981;116:440-5. 16. Rlntoul RF. Operations for hernia. In: Farguharson's textbook of operative surgery. 6th ed. NY: Churchill Livingstone, 1978:749, 17. Brown RE, Klrmteder RJ, Rosenberg N. Ipsllateral thrombophlebitis and pulmonary embolism after Cooper's ligament hernloplast'/. Surgery 1980;87:230-2.
'Tim Aremrl~m ,Jmernalof