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Modified marcy repair of large indirect inguinal hernia in infants and children
Modified Marcy Repair of Large Indirect Inguinal Hernia in Infants and Children By Kinji Yokomori, Mitsuhisa Ohkura, Yoshihiro Kitano, Hiroshi Toyoshima, and Yoshiaki Tsuchida Tokyo. Japan • Based on a review of operative notes of recurrent inguinal hernia cases from the authors' primary series, a surgical technique modified from the Marcy repair is described. With this technique, emphasis is placed on preservation of the intact internal spermatic fascia and reduction in the size of the internal inguinal ring. Through the inguinal approach, the sleeve-like extension of the internal spermatic fascia is incised longitudinally along the cord and up to the internal ring. The cord structures are dissected off the sac, and as much of the fascial tissue as possible is preserved intact. Both edges of the fascial defect are approximated with an unabsorbable suture; great care is taken to not penetrate the wall of the sac. The same suture is then used for high ligation, via a stay suture placed on the transversalis fascia on the other side of the neck, to reduce the size of the internal ring. The technique can be used in premature babies who have a flimsy, easily torn sac, and in some cases of giant hernia with a widely dilated internal inguinal ring, if the direct wall integrity remains adequate.
Copyright © 1995 by W.B. Saunders Company INDEX WORDS: Inguinal hernia, indirect, recurrence.
ROM 1976 through 1984, 1,280 boys (under 15
F years of age) with indirect inguinal hernia were treated in our hospital (JRCMC). Five patients had
recurrence, which necessitated reoperation. To elucidate possible causes of recurrence and to improve surgical techniques, a thorough review was undertaken of the operative records of both the initial and the second repairs. MATERIALS AND METHODS
and then enter the inguinal canal. Within the canal, these three structures are enclosed within a tough, thin, Sleeve-like extension of the transversalis fascia, the internal spermatic fascia (ISF) (Fig
I). In light of the anatomy of the indirect inguinal hernia and the findings from the operative notes, we speculate that recurrence of the hernia represents a de novo protrusion of peritoneum proximal to the high ligation of the original sac, originating from peritoneum denuded or exposed from the original sac proximal to the ligation, through a defect in the ISF when the ISF is moved up to the level of the internal ring, inevitably widening the ring (Fig 2). Based on this assumption we have used a modification of the Marcy repair 2 since 1.985. With this procedure, great emphasis is placed on preservation of the ISF around the hernia sac, uSing it tO reduce the size at the level of the internal inguinal ring by including the ISF as a tough sheath around the peritoneal sac. Through the inguinal approach, ~che outer surface of the ISF, which encases the cord structures and the hernia, is exposed by separating cremasteric muscle fibers. As the hernia sac is separated from the cord structures, the thin but tough layer of ISF (transversalis fascia) can be identified encircling the cord. The ISF is incised with scissors, longitudinally and laterally, just as it passes around the cord, up to the internal ring. The cord structures are dissected off the sac, preserving as much of the ISF as possible, and the sac is transected (Fig 3). Now the hernia sac is covered by a layer of the ISF in most parts, except for the denuded area between the two edges of the fascial mantle (Fig 4). Both edges of the internal spermatic fascia at the level of the internal ring are then approximated above the retroperitoneal cord structures, with great care taken to not Penetrate the wall of tile sac (Fig 5). The suture is then used for high ligation, via a stay suture placed on the transversal is fascia at the other cephalad side of the ring. This serves to narrow the internal ring back to a size that just accommodates the cord, because the ligation now closes off the peritoneal sac as well as most of the transversalis (internal spermatic) fascial sleeve.
Review of Operative Records
DISCUSSION
Ligation of the hernia sac at the level of the internal inguinal ring without opening the external inguinal ring, after Pons' procedure, 1 has been our standard operation. A review of the records of the initial surgery in five recurrent cases disclosed that two had a large, dilated internal inguinal ring ( > 115 cm in diameter) and that the hernia sac was doubly ligated at the level of the internal inguinal ring, with silk sutures in three cases and absorbable sutures in two. The distal portion of the sac was removed in each case. Common findings from the surgical records for second repairs included (1) residual suture material and/or scar tissue, presumably from ligation of the hernia sac at the time of the initial operation, evident at the level of the internal inguinal ring and (2) a very thin and friable hernia sac.
Surgical Technique In boys with indirect inguinal hernias, the spermatic vessels, vas deferens, and hernia sac join together at the internal inguinal ring
Journa/ofPed/atric Surgery,Vo130, No 1 (January),
1995: pp 97-100
To allow adequate
high ligation, most textbooks of
pediatric surgery recommend thorough dissection of the hernia sac from the cord structures and the areolar tissues, until the preperitoneal pad of fat is seen at the neck of the s a c Y However, because the From the Department of Pediatric Surgery, Japanese Red Cross Medical Center, and the Department of Pediatric Surgery, Universityof Tokyo Hospital, Tokyo, Japan. Date accepted:January 12, I994. Address reprint requests to Kinji Yokomori, MD, Department of Pediatric Surgery; Universityof Tokyo Hospital, 7-3-1, Hongo, Bunkyoku, Tokyo 113, Japan. Copyright © 1995 by W.B. Saunders Company 0022-3468/95/3001-0025503.00/0
97
Fig 1, Schematic illustration of indirect inguinal hernia in the male infant. The internal spermatic fascia, a sleeve-like continuation of the transversalis fascia, covers the hernia sac, vas deferens, and the testicular vessels within the inguinal canal.
Fig 2. Hypothetical schema illustrating the process of recurrent hernia after simple herniorrhaphy for indirect inguinal hernia in the male infant. A de novo protrusion of the hernia originates from the thin portion of the original hernia sac, through a defect of the internal spermatic fascia.
Fig 3. Schema showing dissection of the cord structures from the hernia sac. The internal spermatic fascia is incised longitudinally with scissors. Care must be taken to preserve, intact, as much of the fascial tissues covering the sac as possible.
MODIFIED MARCY REPAIR OF INDIRECT INGUINAL HERNIA
99
Fig 4. Schema showing the hernia sac after dissection of the cord structures. Note that the longitudinal facial defect forms a narrow slit, with almost the entire portion of the internal spermatic fascia preserved unharmed.
preperitoneal adipose tissues lie beneath the transversalis fascia, direct exposure of the fat tissues simply implies that the integrity of the internal spermatic fascial sleeve has been breached, effectively widening the internal ring. This may well predispose to a de novo protrusion of the hernia sac, from increased abdominal pressure, in cases having an enlarged internal ring, especially when the hernia sac and adjacent peritoneum are particularly flimsy. Marcy is credited as being the first surgeon to describe transversalis fascia repair of the internal inguinal ring with interrupted sutures of catgut, in 1871~2 In his procedure, the ISF, an evagination of the transversalis fascia, is incised circumferentially at the
Fig 5. Schema showing the approximation of two edges of the facial defect, under the sac and above the cord structures. Care must be taken to ensure that the needle never catches the wall of the sac and penetrates it.
internal ring for its closure with interrupted sutures. However, with our procedure, attention is paid to preserving intact as much of the ISF tissue as possible; the hernia sac is ligated together with the ISF, as a tougher monolayer, effectively narrowing the internal ring by tightening the neck of the "sleeve" (Figs 5 and 6). Therefore, the technique is best for premature babies, whose internal rings often are widened and whose sacs are composed of thin, friable peritoneal tissue. It also may be useful for some older patients who have large hernias and widely dilated internal rings. Additionally, it can be used in female cases without sliding components. In these cases, the ISF sleeve can be used to truly close the internal ring. Since the introduction of this policy in 1985, there have been no recurrences, to our knowledge, among the 945 boys with indirect inguinal hernia.
Fig 6. Schematic illustration of high ligation of the hernia sac at the internal inguinal ring. After closure of the fascial defect {left), the same suture is used for high ligation, by passing it through the ISF on the other side of the neck, to establish complete closure of the hernia sac and reduction in the size of internal inguinal ring (right).
100
YOKOMORI ET AL
REFERENCES
1. Potts WJ, Riker WL, Lewis JE: The treatment of inguinal hernia in infants and children. Ann Surg 132:566-576, 1950 2. Griffith CA: The Marcy repair of indirect inguinal hernia, in Nyhus LM, Condon RE (eds): Hernia (ed 2). Philadelphia, PA, Lippincott, 1964, pp 137-152 (chap 5) 3. Tam PKH: Inguinal hernia, in Lister J, Irving IM (eds): Neonatal Surgery (ed 3). Austin, TX, Butterworth, 1990, pp 367-375 (chap 26)
4. Idriss FS: Inguinal hernia, hydroceles, undescended testicle, and torsion of testicle, in Swenson O (ed): pediatric Surgery (ed 3). Norwalk, CT, Appleton-Century-Crofts, 1969, pp 559-579 (chap 33) 5. Rowe MI, Lloyd DA: Inguinal hernia, in Welch KJ, Randolph JG, Ravitch MM, et al (eds): Pediatric Surgery (ed 4). Chicago, IL, Year Book Medical, 1986, pp 779-793 (chap 78)
Copyright © 1995 by W.B. Saunders Company INDEX WORDS: Inguinal hernia, indirect, recurrence.
ROM 1976 through 1984, 1,280 boys (under 15
F years of age) with indirect inguinal hernia were treated in our hospital (JRCMC). Five patients had
recurrence, which necessitated reoperation. To elucidate possible causes of recurrence and to improve surgical techniques, a thorough review was undertaken of the operative records of both the initial and the second repairs. MATERIALS AND METHODS
and then enter the inguinal canal. Within the canal, these three structures are enclosed within a tough, thin, Sleeve-like extension of the transversalis fascia, the internal spermatic fascia (ISF) (Fig
I). In light of the anatomy of the indirect inguinal hernia and the findings from the operative notes, we speculate that recurrence of the hernia represents a de novo protrusion of peritoneum proximal to the high ligation of the original sac, originating from peritoneum denuded or exposed from the original sac proximal to the ligation, through a defect in the ISF when the ISF is moved up to the level of the internal ring, inevitably widening the ring (Fig 2). Based on this assumption we have used a modification of the Marcy repair 2 since 1.985. With this procedure, great emphasis is placed on preservation of the ISF around the hernia sac, uSing it tO reduce the size at the level of the internal inguinal ring by including the ISF as a tough sheath around the peritoneal sac. Through the inguinal approach, ~che outer surface of the ISF, which encases the cord structures and the hernia, is exposed by separating cremasteric muscle fibers. As the hernia sac is separated from the cord structures, the thin but tough layer of ISF (transversalis fascia) can be identified encircling the cord. The ISF is incised with scissors, longitudinally and laterally, just as it passes around the cord, up to the internal ring. The cord structures are dissected off the sac, preserving as much of the ISF as possible, and the sac is transected (Fig 3). Now the hernia sac is covered by a layer of the ISF in most parts, except for the denuded area between the two edges of the fascial mantle (Fig 4). Both edges of the internal spermatic fascia at the level of the internal ring are then approximated above the retroperitoneal cord structures, with great care taken to not Penetrate the wall of tile sac (Fig 5). The suture is then used for high ligation, via a stay suture placed on the transversal is fascia at the other cephalad side of the ring. This serves to narrow the internal ring back to a size that just accommodates the cord, because the ligation now closes off the peritoneal sac as well as most of the transversalis (internal spermatic) fascial sleeve.
Review of Operative Records
DISCUSSION
Ligation of the hernia sac at the level of the internal inguinal ring without opening the external inguinal ring, after Pons' procedure, 1 has been our standard operation. A review of the records of the initial surgery in five recurrent cases disclosed that two had a large, dilated internal inguinal ring ( > 115 cm in diameter) and that the hernia sac was doubly ligated at the level of the internal inguinal ring, with silk sutures in three cases and absorbable sutures in two. The distal portion of the sac was removed in each case. Common findings from the surgical records for second repairs included (1) residual suture material and/or scar tissue, presumably from ligation of the hernia sac at the time of the initial operation, evident at the level of the internal inguinal ring and (2) a very thin and friable hernia sac.
Surgical Technique In boys with indirect inguinal hernias, the spermatic vessels, vas deferens, and hernia sac join together at the internal inguinal ring
Journa/ofPed/atric Surgery,Vo130, No 1 (January),
1995: pp 97-100
To allow adequate
high ligation, most textbooks of
pediatric surgery recommend thorough dissection of the hernia sac from the cord structures and the areolar tissues, until the preperitoneal pad of fat is seen at the neck of the s a c Y However, because the From the Department of Pediatric Surgery, Japanese Red Cross Medical Center, and the Department of Pediatric Surgery, Universityof Tokyo Hospital, Tokyo, Japan. Date accepted:January 12, I994. Address reprint requests to Kinji Yokomori, MD, Department of Pediatric Surgery; Universityof Tokyo Hospital, 7-3-1, Hongo, Bunkyoku, Tokyo 113, Japan. Copyright © 1995 by W.B. Saunders Company 0022-3468/95/3001-0025503.00/0
97
Fig 1, Schematic illustration of indirect inguinal hernia in the male infant. The internal spermatic fascia, a sleeve-like continuation of the transversalis fascia, covers the hernia sac, vas deferens, and the testicular vessels within the inguinal canal.
Fig 2. Hypothetical schema illustrating the process of recurrent hernia after simple herniorrhaphy for indirect inguinal hernia in the male infant. A de novo protrusion of the hernia originates from the thin portion of the original hernia sac, through a defect of the internal spermatic fascia.
Fig 3. Schema showing dissection of the cord structures from the hernia sac. The internal spermatic fascia is incised longitudinally with scissors. Care must be taken to preserve, intact, as much of the fascial tissues covering the sac as possible.
MODIFIED MARCY REPAIR OF INDIRECT INGUINAL HERNIA
99
Fig 4. Schema showing the hernia sac after dissection of the cord structures. Note that the longitudinal facial defect forms a narrow slit, with almost the entire portion of the internal spermatic fascia preserved unharmed.
preperitoneal adipose tissues lie beneath the transversalis fascia, direct exposure of the fat tissues simply implies that the integrity of the internal spermatic fascial sleeve has been breached, effectively widening the internal ring. This may well predispose to a de novo protrusion of the hernia sac, from increased abdominal pressure, in cases having an enlarged internal ring, especially when the hernia sac and adjacent peritoneum are particularly flimsy. Marcy is credited as being the first surgeon to describe transversalis fascia repair of the internal inguinal ring with interrupted sutures of catgut, in 1871~2 In his procedure, the ISF, an evagination of the transversalis fascia, is incised circumferentially at the
Fig 5. Schema showing the approximation of two edges of the facial defect, under the sac and above the cord structures. Care must be taken to ensure that the needle never catches the wall of the sac and penetrates it.
internal ring for its closure with interrupted sutures. However, with our procedure, attention is paid to preserving intact as much of the ISF tissue as possible; the hernia sac is ligated together with the ISF, as a tougher monolayer, effectively narrowing the internal ring by tightening the neck of the "sleeve" (Figs 5 and 6). Therefore, the technique is best for premature babies, whose internal rings often are widened and whose sacs are composed of thin, friable peritoneal tissue. It also may be useful for some older patients who have large hernias and widely dilated internal rings. Additionally, it can be used in female cases without sliding components. In these cases, the ISF sleeve can be used to truly close the internal ring. Since the introduction of this policy in 1985, there have been no recurrences, to our knowledge, among the 945 boys with indirect inguinal hernia.
Fig 6. Schematic illustration of high ligation of the hernia sac at the internal inguinal ring. After closure of the fascial defect {left), the same suture is used for high ligation, by passing it through the ISF on the other side of the neck, to establish complete closure of the hernia sac and reduction in the size of internal inguinal ring (right).
100
YOKOMORI ET AL
REFERENCES
1. Potts WJ, Riker WL, Lewis JE: The treatment of inguinal hernia in infants and children. Ann Surg 132:566-576, 1950 2. Griffith CA: The Marcy repair of indirect inguinal hernia, in Nyhus LM, Condon RE (eds): Hernia (ed 2). Philadelphia, PA, Lippincott, 1964, pp 137-152 (chap 5) 3. Tam PKH: Inguinal hernia, in Lister J, Irving IM (eds): Neonatal Surgery (ed 3). Austin, TX, Butterworth, 1990, pp 367-375 (chap 26)
4. Idriss FS: Inguinal hernia, hydroceles, undescended testicle, and torsion of testicle, in Swenson O (ed): pediatric Surgery (ed 3). Norwalk, CT, Appleton-Century-Crofts, 1969, pp 559-579 (chap 33) 5. Rowe MI, Lloyd DA: Inguinal hernia, in Welch KJ, Randolph JG, Ravitch MM, et al (eds): Pediatric Surgery (ed 4). Chicago, IL, Year Book Medical, 1986, pp 779-793 (chap 78)