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Primary Indirect Inguinal Hernioplasty: Results in 2595 Operations
Primary Indirect Inguinal Hernioplasty: Results in 2595 Operations From the Department of Surgery, Veterans Administration Hospital, Des Moines, Iowa
LOUIS T. PALUMBO, M.D., WENDELL S. SHARPE, M.D., R. D. HUNTER, M.D.,
AND
R. S. BERARDI, M.D.*
INTRODUCTION
INDIRECT inguinal hernia in the adult male is the most common type of hernia and continues to be the most troublesome. In recent years several new refinements in anatomically sound surgical procedures have aided in the reduction of recurrence rates. Continued improvement in this regard can be expected by the universal adoption and careful duplication of the techniques which have proved to be most effective in control of this disabling defect. It is apparent that general agreement has been reached by most authorities in this field that surgical repair should be performed early. Any delay results in a larger defect with an associated weakening of the structures of the abdominal wall in this region, thereby diminishing the chances for solid repair and a resultant low recurrence rate. The hazards of nonoperative treatment are known to all. The morbidity, mortality and disablement from nonsurgical treatment far exceed in practically all age groups that associated with surgery. A survey of the literature indicates a recurrence rate that is much too high even today. This actually does not represent a true index of countrywide results of hernioplasty. It is our opinion that such a survey would reveal a recurrence rate of 15 to 25 per cent. A recurrence rate in excess of 3 per cent for simple primary hernioplasty indicates that the surgeon should re-evaluate his own ability and/or the technique which he is using. The basic anatomy and rationale of certain procedures advocated in
* And other full-time and resident staff members.
1439
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PALUMBO, SHARPE, HUNTER, BERARDI
the past appear logical. Some of these basic concepts are sound but cannot be applied in toto in the adult. The removal of the hernial sac and the partial fortification of the internal ring alone, in our opinion, may be the correct approach to the problem in infants and early childhood. However, in the adult the problem is different. The major difference is that the hernial defect and/or weakness has been present for a long period of time. This weakness, plus the associated weakness of the abdominal wall, including the sphincteric mechanism at the internal ring as described by some, has made it impossible to retain a true hernia or prevent the development of one. Since these structures in the adult are no longer capable of providing the necessary support to prevent herniation and since many adults have or will develop direct inguinal hernias, too, a surgical repair which provides fortification or strengthening of the weak points should result in a strong repair which will allow the least possible chance for recurrence. It seems illogical to suppose that the removal of the hernia sac and reinforcing or tightening the inferior border of the internal ring alone is an adequate operation in the adult. During the past 25 years we have employed the same basic technique for the repair of all types of inguinal hernia in the adult. It is our opinion, even though the basic concepts are different in direct and indirect inguinal hernias, that the hernia repair should be of a type which both takes care of the original hernia and also prevents the recurrence of a direct or indirect type, as the case may be. In at least 25 per cent of the patients beyond 35 years of age a direct hernia coexists or will develop later in life. It is upon this premise that we have utilized the same technique throughout all of our series. Purpose of Report
We are reporting the results of our method of repair!" 18 in 2595 primary indirect inguinal hernioplasties performed upon 2286 patients during a 16-year period beginning in 1944. These were in adult males, a consecutive and unselected group of patients. Table 1.
Age Incidence at Time of Surgery
AGE
NUMBER
Under 20 20-29 30-39 40-49 50-59 60-69 Over 70 Totals
256 376 422 640 520 64 2286
8
PER CENT
0.3 11.2 16.5 18.5 28.0 22.7 2.8 100.0
1441
Primary I ndirect Inguinal H ernioplasty Table 2.
Location of Hernia
SIDE
NUMBER
PER CENT
Right Left Bilateral* Total
1086 777 366* -2229 366* -2595
41.9 29.9 14.1 100.0
In 94 per cent of cases silk sutures were used; in the remaining 6 per cent cotton was the suture material. These procedures were performed by 70 members of our full-time and house staff, most by the latter. Only in recent years have bilateral hernias been repaired at the same time. Age Incidence
The patients' ages at the time of hernioplasty ranged from 18 to 85 years. The largest number were 50 to 59 years of age. Over 31 per cent were 60 years of age or older. (Table 1.) Location and Types of Hernia
This report includes elective as well as emergency operations. There were 99 (3.9 per cent) sliding hernias, 69 (2.7 per cent) incarcerated hernias and only seven (0.27 per cent) strangulated hernias. There were 35 femoral hernias. Bilateral hernia was present in 366 (14.1 per cent) cases. Over 41 per cent of defects were on the right side (Table 2). Additional Surgical Procedures
Two hundred seventy-five additional procedures were performed at the time of hernioplasty (Table 3). Table 3.
Operations Performed at Time of Hernioplasty TYPE
NUMBER
Appendectomy Epigastric hernioplasty Femoral Hydrocelectomy Lipoma, cord (excision) Orchiectomy Spermatocelectomy Spigelian Umbilical hernioplasty Varicocelectomy
29 15 35 42 86 18 5 2
Total
25 18 275
1442
PALUMBO, SHARPE, HUNTER, BERARDI
OPERATIVE TECHNIQUE
The method of repair has been reported and depicted by drawings in previous publications.F: 18 A thorough and complete dissection of the hernial sac high into the internal inguinal ring, and fortifying and reducing the size of the internal ring are two of the basic principles of our technique. In addition, we provide support to Hesselbach's triangle since in many instances this has been weakened by a large indirect hernia and since it may become a potentially weaker area later in life, resulting in a direct hernia. In order to prevent this possibility and to aid in providing additional support inferior to the new internal inguinal ring, the area of Hesselbach's triangle is reinforced by imbricating the transversalis fascia, suturing the internal oblique aponeurosis to the shelving edge of the inguinal ligament inferior and superior to the internal inguinal ring. To complete the repair, the cut leaves of the external oblique aponeurosis are imbricated beneath the cord. This provides a four-layer repair in this area. The external inguinal ring is formed a half-inch inferior to the internal ring. The sutures are placed without tension and are tied so as not to cause constriction and necrosis. Muscle is not used in this repair. It is primarily a fascia and an aponeurotic layer-by-layer repair. RESULTS
There were no deaths in this series of 2595 operations. One-year to 16-year follow-ups were obtained in 91.3 per cent of the cases. The data assembled were from a combined survey consisting of a questionnaire, recall examination at this hospital, examination by local physicians or examination at places of employment. In the event of any doubt concerning a patient, he was recalled for further examination. For those who had recurrences repaired elsewhere, the information was requested from the surgeons, including reports of the operative procedures and findings. Recurrences
There were 26 recurrences, a recurrence rate of only 1 per cent. The recurrences developed in three cases within one year, in three within two to three years, and in 20 after three years; 77 per cent of the recurrences occurred after the third year. A number of those recurrences were due to associated diseases or to the uncooperation of the patient. Those causes or conditions mentioned here are frequently beyond the control of the surgeon. Several patients had disabling rheumatoid arthritis and silicosis; others had advanced pulmonary changes with a chronic cough. One of this group had epilepsy and developed a grand mal seizure during the fifth postoperative day. Several returned to heavy work on the eighth to tenth day.
Primary I ndirect Inguinal H ernioplasty Table 4.
1443
Recurrence Rate and Age Incidence
AGE
NUMBER OF OPERATIONS
RECURRENCES
PER CENT
Under 20 20-29 30-39 40-49 50-59 60-69 Over 70 Totals
10 313 429 464 721 592 66 -2595
0 2 6 6 9 3 0 26
0 0.6 1.4 1.3 1.2 0.5 0 1.0
The recurrence rate was fairly equal throughout all decades (Table 4). Effects of Early and Late Ambulation
At the inception of this study, a carefully controlled program was instituted to determine the effects of early and late ambulation upon the postoperative complication and recurrence rates. In all groups (Table 5) the patients were unselected and consecutive. In Group A there were 163 patients (187 hernioplasties), ambulatory after the tenth postoperative day. There were 18 (9.6 per cent) complications and a recurrence rate of 1.6 per cent with a follow-up period of six months to 14 years and a 91.9 per cent follow-up. In Group B there were 446 patients (516 hernioplasties), ambulatory on the 3rd to 9th day. There were 45 (8.7 per cent) complications and a recurrence rate of 1.5 per cent with a follow-up period of six months to 14 years and a 93.3 per cent follow-up. In Group C there were 1677 patients (1892 hernioplasties), ambulatory from the day of operation to the second postoperative day. There were 103 (5.4 per cent) complications and a recurrence rate of 0.7 per cent with a follow-up of six months to 16 years and a 88.3 per cent follow-up. Table 5.
Group A Group B Group C Totals
Early and Late Ambulation-Results
NUMBER OF OPERATIONS
PER
PERIOD
NUMBER OF PATIENTS
CENT FOLLOW-
OF FOLLOW-
PER CENT COMPLI-
UP
UP
CATIONS
PER CENT RECURRENCE
163 446 1677 -2286
187 516 ]892 -2595
91.9 93.3 88.3 91.3
6 mo.-14 yrs. 6 mo.-14 yrs. 6 mo.-16 yrs.
9.6 8.7 5.4 6.4
1.6 1.5 0.7 -1.0
Group A: Ambulatory after 10th postoperative day. Group B: Ambulatory 3rd to 9th postoperative day. Group C: Ambulatory day of surgery to 2nd postoperative day.
1444
PALUMBO, SHARPE, HUNTER, BERARDI
Table 6.
Early and Late Ambulation-Complications GROUP A
GROUP B
GROUP C
(187
(516
(1892
OPERATIONS)
OPERATIONS)
OPERATIONS)
TYPE
Pulmonary 'Vound Miscellaneous Totals
10 5 3 18
(5.3%) (2.7%) (1.6%) (9.6%)
10 13 22 45
(1.9%) (2.5%) (4.3%) (8.7%)
40 34 29 103
(2.1 %) (1.8%) (1.5%) (5.4%)
PER CENT COMPLICATIONS
60 52 54 166
(2.3%) (2.0%) (2.1 %) (6.4%)
Group A: Ambulatory after 10th postoperative day. Group B: Ambulatory 3rd to 9th postoperative day. Group C: Ambulatory day of surgery to 2nd postoperative day.
Early ambulation resulted in about a 50 per cent reduction in the complication rate (Table 6), but did not increase the recurrence rate. Our patients are instructed to refrain from heavy lifting, straining and athletics for a period of four to six weeks postoperatively. They were permitted to return to sedentary work at the end of ten to 14 days, moderately heavy work in about 30 days and heavy work in about six weeks. Inguinal Hernias in Geriatric Patients
The age ranged from 60 to 85 years. There were 584 patients in this group; 658 operations were performed, 92 (14 per cent) bilateral. There were no deaths. Fifty-six complications (8.5 per cent) developed. In the early ambulatory group the complication rate was 6.2 per cent compared to 16.9 per cent in the late ambulatory group. There were only three (0.5 per cent) recurrences. Recurrences in Bilateral Hernioplasty
Bilateral hernias were present in 366 (14.1 per cent) patients. In only 32 (8.7 per cent) patients was bilateral hernioplasty performed at the same time. One (1.5 per cent) recurrence occurred in this group. The other 668 operations performed upon 334 patients were accomplished separately at intervals of six to ten days in most instances. In this group, there were four (0.6 per cent) recurrences. SUMMARY AND CONCLUSIONS
A review is presented of the results obtained in 2595 primary indirect inguinal hernioplasties performed upon 2286 unselected and consecutive adult male patients with a follow-up of one to 16 years in 91.3 per cent of this series.
Primary I ndirect Inguinal Hernioplasty
1445
Recurrence rate was only 1 per cent, 26 recurrences. Early ambulation resulted in almost a 50 per cent reduction in the complication rates in all age groups without increasing, the recurrence rate; in fact the recurrence rate in the early ambulatory group was only 0.7 per cent. Early ambulation contributed substantially to a more rapid rehabilitation of the patients and resulted in great economic savings. Our same basic technique, a combined modification of a Bassini, Halsted II and Andrews operation coupled with many of our own refinements, has been employed in all types of primary inguinal hernias in adult males for the past 25 years with a recurrence rate consistently under 2 per cent. This multilayered fascia-aponeurosis-inguinal ligament repair has proved to be the most effective method of cure for inguinal hernia in adults. REFERENCES 1. Andreasen, A. T. : Twenty years' experience with midline extraperitoneal approach to hernias of the inguinofemoral region. J. Internat. ColI. Surge 35:713, 1961. 2. Andrews, E.: A method of herniotomy utilizing only white fascia. Ann. Surge 80:225, 1924. 3. Burton, C. E.: Collective review: Hernias of the supravesical, inguinal and lateral pelvic fossae: Their diagnosis, classification and relationship. Internat. Abstr. Surge 91: 1, 1950; in Surge Gynec. & Obst., July, 1950. 4. Burton, C. C.: A suggested terminology for ligaments of the groin; their clinical and surgical application in repair of hernias. Surgery 31:562, 1952. 5. Estes, W. L., Jr.: Five year end-results in treatment of inguinal hernia. West. J. Surg.68:269, 1960. 6. Estes, W. L., Jr.: Surgical treatment of inguinal hernia. Postgrad. Med. 7:313, 1950. 7. Halsted, W. S.: The radical cure of inguinal hernia in the male. Bull. Johns Hopkins Hosp. 4:17, 1893. 8. Harkins, H. N.: Repair of groin hernias: Progress in past decade. S. CLIN. NORTH AMERICA 29: 1457, 1949. 9. Koontz, A. R. : Personal technique and results in inguinal hernia repair. J.A.M.A. 164: 29, 1957. 10. Lamphier, T. A., et al.: Inguinal hernia-survey of 977 cases. J. Internat. CoIl. Surge 35: 451, 1961. 11. Levy, A. H., Wren, R. S. and Friedman, M. N.: Complications and recurrences following inguinal hernia repair. Ann. Surge 133: 533, 1951. 12. McVay, C. B. and Anson, B. J.: A fundamental error in current methods of inguinal herniorrhaphy. Surg., Gynec. & Obsta 74: 746, 1942. . 13. McVay, C. B. and Anson, B. J.: Inguinal and femoral hernioplasty. Surg., Gynec., and Obsta 88: 473, 1949. 14. McVay, C. B. and Chapp, J. D.: Inguinal and femoral hernioplasty, The evaluation of a basic concept. Ann. Surge 148: 499, 1958. 15. Marsden, A. J.: Inguinal hernia: Three-year review of one thousand cases. Brit. J. Surge 46: 234, 1958. 16. Nyhus, L. M., Condon, R. E. and Harkins, H. N.: Clinical experiences with preperitoneal hernial repair for all types of hernia of groin, with particular reference to the importance of transversalis fascia analogues. Amer. J. Surge 100: 234, 1960. 17. Palumbo, L. T., Paul, R. E. and Emery, F. B.: Results of primary inguinal hernioplasty. A.M.A. Arch. Surge 64-: 384, 1952.
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PALUMBO, SHARPE, HUNTER, BERARDI
18. Palumbo, L. T., Paul, R. E. and Mighell, S. J.: Primary inguinal hernioplasty: A study of 1375 cases. S. CLIN. NORTH AMERICA 34: 567, 1954. 19. Skinner, H. L. and Duncan, R. D.: Inguinal hernia: Report of 1,126 cases. S. CLIN. NORTH AMERICA 25: 219, 1945. 20. Summers, J. E.: Classical herniorrhaphies of Bassini, Halsted and Ferguson. Amer. J. Surge 73: 87, 1947. 21. Telle, L. D.: Inguinal and femoral hernia. A review of 1694 cases. Amer. J. Surge 93: 433, 1957. 22. Zimmerman, L. M.: Recent advances in surgery of inguinal hernia. S. CLIN NORTH AMERICA 32: 135, 1952.
LOUIS T. PALUMBO, M.D., WENDELL S. SHARPE, M.D., R. D. HUNTER, M.D.,
AND
R. S. BERARDI, M.D.*
INTRODUCTION
INDIRECT inguinal hernia in the adult male is the most common type of hernia and continues to be the most troublesome. In recent years several new refinements in anatomically sound surgical procedures have aided in the reduction of recurrence rates. Continued improvement in this regard can be expected by the universal adoption and careful duplication of the techniques which have proved to be most effective in control of this disabling defect. It is apparent that general agreement has been reached by most authorities in this field that surgical repair should be performed early. Any delay results in a larger defect with an associated weakening of the structures of the abdominal wall in this region, thereby diminishing the chances for solid repair and a resultant low recurrence rate. The hazards of nonoperative treatment are known to all. The morbidity, mortality and disablement from nonsurgical treatment far exceed in practically all age groups that associated with surgery. A survey of the literature indicates a recurrence rate that is much too high even today. This actually does not represent a true index of countrywide results of hernioplasty. It is our opinion that such a survey would reveal a recurrence rate of 15 to 25 per cent. A recurrence rate in excess of 3 per cent for simple primary hernioplasty indicates that the surgeon should re-evaluate his own ability and/or the technique which he is using. The basic anatomy and rationale of certain procedures advocated in
* And other full-time and resident staff members.
1439
1440
PALUMBO, SHARPE, HUNTER, BERARDI
the past appear logical. Some of these basic concepts are sound but cannot be applied in toto in the adult. The removal of the hernial sac and the partial fortification of the internal ring alone, in our opinion, may be the correct approach to the problem in infants and early childhood. However, in the adult the problem is different. The major difference is that the hernial defect and/or weakness has been present for a long period of time. This weakness, plus the associated weakness of the abdominal wall, including the sphincteric mechanism at the internal ring as described by some, has made it impossible to retain a true hernia or prevent the development of one. Since these structures in the adult are no longer capable of providing the necessary support to prevent herniation and since many adults have or will develop direct inguinal hernias, too, a surgical repair which provides fortification or strengthening of the weak points should result in a strong repair which will allow the least possible chance for recurrence. It seems illogical to suppose that the removal of the hernia sac and reinforcing or tightening the inferior border of the internal ring alone is an adequate operation in the adult. During the past 25 years we have employed the same basic technique for the repair of all types of inguinal hernia in the adult. It is our opinion, even though the basic concepts are different in direct and indirect inguinal hernias, that the hernia repair should be of a type which both takes care of the original hernia and also prevents the recurrence of a direct or indirect type, as the case may be. In at least 25 per cent of the patients beyond 35 years of age a direct hernia coexists or will develop later in life. It is upon this premise that we have utilized the same technique throughout all of our series. Purpose of Report
We are reporting the results of our method of repair!" 18 in 2595 primary indirect inguinal hernioplasties performed upon 2286 patients during a 16-year period beginning in 1944. These were in adult males, a consecutive and unselected group of patients. Table 1.
Age Incidence at Time of Surgery
AGE
NUMBER
Under 20 20-29 30-39 40-49 50-59 60-69 Over 70 Totals
256 376 422 640 520 64 2286
8
PER CENT
0.3 11.2 16.5 18.5 28.0 22.7 2.8 100.0
1441
Primary I ndirect Inguinal H ernioplasty Table 2.
Location of Hernia
SIDE
NUMBER
PER CENT
Right Left Bilateral* Total
1086 777 366* -2229 366* -2595
41.9 29.9 14.1 100.0
In 94 per cent of cases silk sutures were used; in the remaining 6 per cent cotton was the suture material. These procedures were performed by 70 members of our full-time and house staff, most by the latter. Only in recent years have bilateral hernias been repaired at the same time. Age Incidence
The patients' ages at the time of hernioplasty ranged from 18 to 85 years. The largest number were 50 to 59 years of age. Over 31 per cent were 60 years of age or older. (Table 1.) Location and Types of Hernia
This report includes elective as well as emergency operations. There were 99 (3.9 per cent) sliding hernias, 69 (2.7 per cent) incarcerated hernias and only seven (0.27 per cent) strangulated hernias. There were 35 femoral hernias. Bilateral hernia was present in 366 (14.1 per cent) cases. Over 41 per cent of defects were on the right side (Table 2). Additional Surgical Procedures
Two hundred seventy-five additional procedures were performed at the time of hernioplasty (Table 3). Table 3.
Operations Performed at Time of Hernioplasty TYPE
NUMBER
Appendectomy Epigastric hernioplasty Femoral Hydrocelectomy Lipoma, cord (excision) Orchiectomy Spermatocelectomy Spigelian Umbilical hernioplasty Varicocelectomy
29 15 35 42 86 18 5 2
Total
25 18 275
1442
PALUMBO, SHARPE, HUNTER, BERARDI
OPERATIVE TECHNIQUE
The method of repair has been reported and depicted by drawings in previous publications.F: 18 A thorough and complete dissection of the hernial sac high into the internal inguinal ring, and fortifying and reducing the size of the internal ring are two of the basic principles of our technique. In addition, we provide support to Hesselbach's triangle since in many instances this has been weakened by a large indirect hernia and since it may become a potentially weaker area later in life, resulting in a direct hernia. In order to prevent this possibility and to aid in providing additional support inferior to the new internal inguinal ring, the area of Hesselbach's triangle is reinforced by imbricating the transversalis fascia, suturing the internal oblique aponeurosis to the shelving edge of the inguinal ligament inferior and superior to the internal inguinal ring. To complete the repair, the cut leaves of the external oblique aponeurosis are imbricated beneath the cord. This provides a four-layer repair in this area. The external inguinal ring is formed a half-inch inferior to the internal ring. The sutures are placed without tension and are tied so as not to cause constriction and necrosis. Muscle is not used in this repair. It is primarily a fascia and an aponeurotic layer-by-layer repair. RESULTS
There were no deaths in this series of 2595 operations. One-year to 16-year follow-ups were obtained in 91.3 per cent of the cases. The data assembled were from a combined survey consisting of a questionnaire, recall examination at this hospital, examination by local physicians or examination at places of employment. In the event of any doubt concerning a patient, he was recalled for further examination. For those who had recurrences repaired elsewhere, the information was requested from the surgeons, including reports of the operative procedures and findings. Recurrences
There were 26 recurrences, a recurrence rate of only 1 per cent. The recurrences developed in three cases within one year, in three within two to three years, and in 20 after three years; 77 per cent of the recurrences occurred after the third year. A number of those recurrences were due to associated diseases or to the uncooperation of the patient. Those causes or conditions mentioned here are frequently beyond the control of the surgeon. Several patients had disabling rheumatoid arthritis and silicosis; others had advanced pulmonary changes with a chronic cough. One of this group had epilepsy and developed a grand mal seizure during the fifth postoperative day. Several returned to heavy work on the eighth to tenth day.
Primary I ndirect Inguinal H ernioplasty Table 4.
1443
Recurrence Rate and Age Incidence
AGE
NUMBER OF OPERATIONS
RECURRENCES
PER CENT
Under 20 20-29 30-39 40-49 50-59 60-69 Over 70 Totals
10 313 429 464 721 592 66 -2595
0 2 6 6 9 3 0 26
0 0.6 1.4 1.3 1.2 0.5 0 1.0
The recurrence rate was fairly equal throughout all decades (Table 4). Effects of Early and Late Ambulation
At the inception of this study, a carefully controlled program was instituted to determine the effects of early and late ambulation upon the postoperative complication and recurrence rates. In all groups (Table 5) the patients were unselected and consecutive. In Group A there were 163 patients (187 hernioplasties), ambulatory after the tenth postoperative day. There were 18 (9.6 per cent) complications and a recurrence rate of 1.6 per cent with a follow-up period of six months to 14 years and a 91.9 per cent follow-up. In Group B there were 446 patients (516 hernioplasties), ambulatory on the 3rd to 9th day. There were 45 (8.7 per cent) complications and a recurrence rate of 1.5 per cent with a follow-up period of six months to 14 years and a 93.3 per cent follow-up. In Group C there were 1677 patients (1892 hernioplasties), ambulatory from the day of operation to the second postoperative day. There were 103 (5.4 per cent) complications and a recurrence rate of 0.7 per cent with a follow-up of six months to 16 years and a 88.3 per cent follow-up. Table 5.
Group A Group B Group C Totals
Early and Late Ambulation-Results
NUMBER OF OPERATIONS
PER
PERIOD
NUMBER OF PATIENTS
CENT FOLLOW-
OF FOLLOW-
PER CENT COMPLI-
UP
UP
CATIONS
PER CENT RECURRENCE
163 446 1677 -2286
187 516 ]892 -2595
91.9 93.3 88.3 91.3
6 mo.-14 yrs. 6 mo.-14 yrs. 6 mo.-16 yrs.
9.6 8.7 5.4 6.4
1.6 1.5 0.7 -1.0
Group A: Ambulatory after 10th postoperative day. Group B: Ambulatory 3rd to 9th postoperative day. Group C: Ambulatory day of surgery to 2nd postoperative day.
1444
PALUMBO, SHARPE, HUNTER, BERARDI
Table 6.
Early and Late Ambulation-Complications GROUP A
GROUP B
GROUP C
(187
(516
(1892
OPERATIONS)
OPERATIONS)
OPERATIONS)
TYPE
Pulmonary 'Vound Miscellaneous Totals
10 5 3 18
(5.3%) (2.7%) (1.6%) (9.6%)
10 13 22 45
(1.9%) (2.5%) (4.3%) (8.7%)
40 34 29 103
(2.1 %) (1.8%) (1.5%) (5.4%)
PER CENT COMPLICATIONS
60 52 54 166
(2.3%) (2.0%) (2.1 %) (6.4%)
Group A: Ambulatory after 10th postoperative day. Group B: Ambulatory 3rd to 9th postoperative day. Group C: Ambulatory day of surgery to 2nd postoperative day.
Early ambulation resulted in about a 50 per cent reduction in the complication rate (Table 6), but did not increase the recurrence rate. Our patients are instructed to refrain from heavy lifting, straining and athletics for a period of four to six weeks postoperatively. They were permitted to return to sedentary work at the end of ten to 14 days, moderately heavy work in about 30 days and heavy work in about six weeks. Inguinal Hernias in Geriatric Patients
The age ranged from 60 to 85 years. There were 584 patients in this group; 658 operations were performed, 92 (14 per cent) bilateral. There were no deaths. Fifty-six complications (8.5 per cent) developed. In the early ambulatory group the complication rate was 6.2 per cent compared to 16.9 per cent in the late ambulatory group. There were only three (0.5 per cent) recurrences. Recurrences in Bilateral Hernioplasty
Bilateral hernias were present in 366 (14.1 per cent) patients. In only 32 (8.7 per cent) patients was bilateral hernioplasty performed at the same time. One (1.5 per cent) recurrence occurred in this group. The other 668 operations performed upon 334 patients were accomplished separately at intervals of six to ten days in most instances. In this group, there were four (0.6 per cent) recurrences. SUMMARY AND CONCLUSIONS
A review is presented of the results obtained in 2595 primary indirect inguinal hernioplasties performed upon 2286 unselected and consecutive adult male patients with a follow-up of one to 16 years in 91.3 per cent of this series.
Primary I ndirect Inguinal Hernioplasty
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Recurrence rate was only 1 per cent, 26 recurrences. Early ambulation resulted in almost a 50 per cent reduction in the complication rates in all age groups without increasing, the recurrence rate; in fact the recurrence rate in the early ambulatory group was only 0.7 per cent. Early ambulation contributed substantially to a more rapid rehabilitation of the patients and resulted in great economic savings. Our same basic technique, a combined modification of a Bassini, Halsted II and Andrews operation coupled with many of our own refinements, has been employed in all types of primary inguinal hernias in adult males for the past 25 years with a recurrence rate consistently under 2 per cent. This multilayered fascia-aponeurosis-inguinal ligament repair has proved to be the most effective method of cure for inguinal hernia in adults. REFERENCES 1. Andreasen, A. T. : Twenty years' experience with midline extraperitoneal approach to hernias of the inguinofemoral region. J. Internat. ColI. Surge 35:713, 1961. 2. Andrews, E.: A method of herniotomy utilizing only white fascia. Ann. Surge 80:225, 1924. 3. Burton, C. E.: Collective review: Hernias of the supravesical, inguinal and lateral pelvic fossae: Their diagnosis, classification and relationship. Internat. Abstr. Surge 91: 1, 1950; in Surge Gynec. & Obst., July, 1950. 4. Burton, C. C.: A suggested terminology for ligaments of the groin; their clinical and surgical application in repair of hernias. Surgery 31:562, 1952. 5. Estes, W. L., Jr.: Five year end-results in treatment of inguinal hernia. West. J. Surg.68:269, 1960. 6. Estes, W. L., Jr.: Surgical treatment of inguinal hernia. Postgrad. Med. 7:313, 1950. 7. Halsted, W. S.: The radical cure of inguinal hernia in the male. Bull. Johns Hopkins Hosp. 4:17, 1893. 8. Harkins, H. N.: Repair of groin hernias: Progress in past decade. S. CLIN. NORTH AMERICA 29: 1457, 1949. 9. Koontz, A. R. : Personal technique and results in inguinal hernia repair. J.A.M.A. 164: 29, 1957. 10. Lamphier, T. A., et al.: Inguinal hernia-survey of 977 cases. J. Internat. CoIl. Surge 35: 451, 1961. 11. Levy, A. H., Wren, R. S. and Friedman, M. N.: Complications and recurrences following inguinal hernia repair. Ann. Surge 133: 533, 1951. 12. McVay, C. B. and Anson, B. J.: A fundamental error in current methods of inguinal herniorrhaphy. Surg., Gynec. & Obsta 74: 746, 1942. . 13. McVay, C. B. and Anson, B. J.: Inguinal and femoral hernioplasty. Surg., Gynec., and Obsta 88: 473, 1949. 14. McVay, C. B. and Chapp, J. D.: Inguinal and femoral hernioplasty, The evaluation of a basic concept. Ann. Surge 148: 499, 1958. 15. Marsden, A. J.: Inguinal hernia: Three-year review of one thousand cases. Brit. J. Surge 46: 234, 1958. 16. Nyhus, L. M., Condon, R. E. and Harkins, H. N.: Clinical experiences with preperitoneal hernial repair for all types of hernia of groin, with particular reference to the importance of transversalis fascia analogues. Amer. J. Surge 100: 234, 1960. 17. Palumbo, L. T., Paul, R. E. and Emery, F. B.: Results of primary inguinal hernioplasty. A.M.A. Arch. Surge 64-: 384, 1952.
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18. Palumbo, L. T., Paul, R. E. and Mighell, S. J.: Primary inguinal hernioplasty: A study of 1375 cases. S. CLIN. NORTH AMERICA 34: 567, 1954. 19. Skinner, H. L. and Duncan, R. D.: Inguinal hernia: Report of 1,126 cases. S. CLIN. NORTH AMERICA 25: 219, 1945. 20. Summers, J. E.: Classical herniorrhaphies of Bassini, Halsted and Ferguson. Amer. J. Surge 73: 87, 1947. 21. Telle, L. D.: Inguinal and femoral hernia. A review of 1694 cases. Amer. J. Surge 93: 433, 1957. 22. Zimmerman, L. M.: Recent advances in surgery of inguinal hernia. S. CLIN NORTH AMERICA 32: 135, 1952.