Primary Inguinal Hernioplasty in the Adult

Symposium on Surgery of Hernia

Primary Inguinal Hernioplasty in the Adult

Louis T. Palumbo, MD.,* and Wendell S. Sharpe, MD.**

Inguinal hernia repair is the most frequent major surgical procedure performed in the United States. The incidence of this congenital or acquired defect in men is 10 per cent. It poses an important socioeconomic problem for several reasons: loss of time from gainful employment, inability to meet physical requirements for employment, and limitation of activities because of the hazards of the herniation. There are very few contraindications to surgical treatment today in the average group. Many advances in patient care, refinement of surgical techniques in recent years with a resultant high cure rate, and low morbidity and mortality far outweigh the higher risks of nonoperative treatment. It has been reported in a recent U.S. Department of Public Health survey that the complications and mortality rates are higher in non surgically treated patients. In fact, the yearly mortality in the United States in the above group is between 8,000 and 10,000; most of these deaths are due to incarceration or strangulation or both. It is difficult to obtain accurate nationwide statistics on the recurrence rates associated with primary repair in the adult. The senior author estimates this rate to be between 10 and 15 per cent. During World War II, examination of 5834 young male inductees who had had a primary repair prior to induction revealed a recurrence rate of 8.3 per cent. We recently completed a 10 year survey of male patients admitted to our hospital for repair of an inguinal hernia. There were 1597 patients, ranging in age from 18 to 85 years. The incidence of a primary hernia was 91.4 per cent with the highest rate in patients in the 40 to 50 year age group. Of this group, 138t (8.6 per cent) were admitted for a recurrent hernia. In recent years the recurrence rates following primary and recurrent *Chief, Surgical Service, Veterans Administration Hospital, Des Moines; Clinical Professor of Surgery, University of Iowa College of Medicine, Iowa City, Iowa ,,* Assistant Chief, Surgical Service, Veterans Administration Hospital, Des Moines; Clinical Associate Professor of Surgery, University of Iowa College of Medicine, Iowa City, Iowa tThese were patients operated upon elsewhere.

Surgical Clinics of North America- Vol. 51, No.6, December 1971

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hernioplasties have declined to a more acceptable level. This has come about by the adoption of one of the several sound anatomic and physiologic techniques developed and perfected in the past 20 years by a number of surgeons. Much of this favorable progress in our country has been due to the persistent efforts and through the publications of a number of well qualified surgeons with a broad experience in this field. Because of their repeated reports, with stress on the basic anatomy and sound principles of hernia repair, the well-trained surgeons of the current generation have been able to apply these basic tenets effectively and have succeeded in lowering recurrence rates. In elective surgery of this type in a primary repair a recurrence rate exceeding 2 per cent should alert the surgeon to re-evaluate his technical capabilities or the hernia repair he performs. There are a number of excellent techniques which result in a high cure rate when properly performed. It is our opinion that a surgeon performing only an average number of hernia repairs a year should adopt one of the currently acceptable techniques and the one which is easiest and safest for him to perform. In this way he can become profiCient with one instead of attempting to be a master of all techniques. A careful review and analysis of the current and past literature on this subject, including our 30 years of experience, leads us to this conclusion: A reported series of consecutive and unselected cases of less than 250 to 300 patients followed for less than 3 years is of limited value, particularly in reference to recurrence rates. A repeated and long followup of our 3572 primary operations revealed that 75 per cent of recurrences occurred after the third year.

Sutures and Foreign Prosthetics With all the advances made in surgery, the use of nonabsorbable sutures in hernia repair was and is a milestone. This type of suture has played a significant role in lowering the recurrence rates. The proper selection and use of sutures can be of great value in providing the basic needs in tissue reparative processes, in minimizing the degree of tissue reaction, and at the same time providing the required tensile strength to maintain tissue in apposition during the critical periods of wound healing. Many of these induce the minimal degree of fibrosis, which is the primary aim in any wound healing, and this is most important in the inguinal region. The selection of a foreign or nonabsorbable suture is dependent upon the experience and personal preference of the surgeon well versed in hernia repairs. Our experience during the past 30 years in 5000 inguinal hernioplasties has brought us back to the use of black silk as the suture of choice. We conducted a survey about 12 years ago on the recurrence rates following the use of silk and cotton versus chromic catgut. The recurrence rate was twice as great in those patients in whom absorbable sutures were used. We do not use fine wire in the inguinal area because it usually fragments in about 6 months, resulting in sharp broken ends which may result in pain on movement. We realize that, on rare occasions, a prosthetic synthetic mesh,

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such as Marlex, tantalum, or nylon net, may be required to provide support or bridge a gap in a large direct inguinal hernial defect, and particularly in recurrent hernia repairs. We have removed a number of these and have not found it necessary to use these prosthetic sheaths or devices during the past 10 years. We have been able to develop and restore the normal anatomic layers in Hesselbach's triangle in direct recurrent, as well as large primary hernias by providing a normal repair without tension. Our recurrence rate has been lower in direct hernias than in indirect. This high rate of cure is a result of the application of the basic principles and tenets of our technique which will be described and shown as part of this presentation. Certain recurrences are beyond the control of the surgeon. These most frequently follow emergency surgery, usually in patients with chronic pulmonary disease or patients with Marie-Strumpell disease of the spine who develop postoperative pulmonary complications, or the young energetic patient who returns to heavy work within 7 to 10 days after surgery. Early Ambulation Early ambulation is now commonly encouraged and has been since World War II for a variety of surgical procedures, even for the most major and complex ones. For many years prior to 1941, surgeons were reluctant to allow early ambulation following inguinal hernioplasty for fear of a high recurrence rate. The studies of many, including ours, carried out in the late 1940's, dispelled this fear. We will show the results of our randomized studies conducted from 1947 to 1949. During the past 5 years a number of surgeons have advocated and practiced immediate postsurgical ambulation. In these instances the herniorrhaphy is performed under local and block anesthesia. The patient is permitted to walk back to his room from the operating room almost immediately after the completion of the repair. It is difficult to obtain an accurate interpretation of the reports concerning the recurrence rate following this method. It is my (L TP) opinion that it will be high (8 to 10 per cent). The only word of caution I (LTP) have to offer is that if early ambulation is encouraged, the patient should not be allowed to get up until the local effects of the anesthetic have completely disappeared and he has regained normal pain sensation and the normal protective muscular and tissue spasm in the operative area. Both of these are strong protective mechanisms and may play an important role in redUCing the recurrence rate. Recent Progress in Results It is evident that definite progress has been made during the past 15 years. The lower morbidity, mortality, and incidence of recurrences within a reasonable range have been reported by several groups well qualified in this field. However, these favorable results are not common to all who perform this type of surgery. Unfortunately, this is one aspect of surgery which has been neglected in many communities from the standpoint of providing excellent, well supervised training by those best

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qualified in this field. The responsibility for a progressive and definite plan in a teaching program is frequently delegated to individuals capable neither by experience or training to cope with such a problem. This is due to the attitude of many physicians and surgeons that inguinal hernioplasty is a simple operation. A careful analysis of the literature quickly dispels this concept, for it is readily apparent that the recurrence rate in most series varies from 3 to 20 per cent for a primary repair. In the hands of the occasional inexperienced operator, the recurrence rate is much higher. Even in well established and organized surgical services in a number of hospitals the recurrence rate varies from 1.2 to 18 per cent.

REPORT OF STUDY Purpose of Study We shall present a survey of our results in 3572 primary inguinal hernioplasties, performed on a consecutive and un selected group of adult patients. We have performed this same basic technique with only a few more recent modifications and additions since 1940 in over 5000 patients. This study represents 3155 patients; of this number, 417 (13 per cent) had bilateral inguinal hernias. In all cases nonabsorbable sutures, cotton or silk (94 per cent were silk), were used. The operations were performed by 70 members of our full-time and house staff, principally by the latter. In recent years bilateral hernias were and are repaired at the same time.

Age Distribution The patients ranged in age from 18 to 85 years; more than half were between 50 and 69; more than 26 per cent were over 60 years old. The greatest incidence was in the 50 to 59 year age group (27.4 per cent) (Fig. 1).

10

No. of Patients

.3:1:

Figure 1.

Inguinal hernia. Age distribution among 3572 patients.

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Location and Type of Hernia All types of inguinal hernia are included in this study, elective and all emergency cases. This also includes femoral hernias (52 cases), and sliding, incarcerated, and strangulated hernias. The incidence of sliding hernia was 2.8 per cent; femoral 1.4 per cent; incarcerated 2.2 per cent; and strangulated 0.2 per cent (Fig. 2). In unilateral cases, the hernia occurred most frequently in the right side. In 64.5 per cent it was indirect, in 19.2 per cent direct, and combined types in 16.3 per cent (Fig. 2).

Concurrent Operations In 285 patients (7.9 per cent), 411 additional surgical procedures were performed at time of hernioplasty (Fig. 3). Operative Technique This basic technique with our modifications and improvements over the past 30 years has been used in all cases of adult primary inguinal hernioplasties including indirect, direct, and combined types. It resulted from the utilization of the most basic and important features of the original operations of Bassini, Halsted, and Andrews. A multilayer repair is performed using transversalis fascia imbrication, aponeurosis to

INDIRECT

2304 64.5~

FEMORAL

SLIDING

INCARCERATED

STRANGULATED 2

3

.

Figure 2. Location and type of hernia. Top, The usual side distribution was noted, with bilateral occurrence in 13.2 per cent. Bottom, Femoral and sliding hernias included. Eightysix incarcerated and strangulated hernias (2.4 per cent) were operated upon as emergencies.

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Femoral hernioplosty Appendectomy

Voriococeledomy and spermatoceledomy

Figure 3. Concurrent Operations. 411 additional surgical procedures were performed in 285 patients at the time of hernioplasty.

inguinal ligament, and aponeurosis-to-aponeurosis layers. The sutures are placed without tension and tied so as not to cause constriction or strangulation of tissues. The salient features include: complete dissection of hernial sacs, high ligation of sac at the internal inguinal ring, reinforcement of Hesselbach's triangle, elimination of the naturally weak area superior to the pubic spine, division of the external oblique aponeurosis along the medial side of the spermatic cord to provide an additional aponeurotic layer in Hesselbach's triangle, formation of a new, snug internal inguinal ring, and provision of four separate tissue layers in Hesselbach's triangle. In 3361 patients (94 per cent) hernioplasty was performed with the patient under spinal anesthesia; 211 (6 per cent) had general anesthesia. In 94 per cent silk was the suture material; in 6 per cent cotton was used. We use an oblique or transverse skin incision. In a bilateral repair, we may use a single suprapubic elliptical incision or two separate oblique incisions. If we use the former, the patient is told preoperatively that temporary edema of the scrotum and suprapubic soft tissues may occur. The oblique skin incision extends from the pubic spine upward and about 5 cm. medially to the antero-superior iliac spine. The external oblique aponeurosis is split in the direction of its fibers along the medial side of the cord (Fig. 4). The cord and associated structures are displaced laterally from their bed. The indirect sac, if present, is dissected from the cord structures high up to the internal ring. If an associated direct weakness or sac is present, it is dissected from the surrounding structures and from the urinary bladder. This maneuver converts the two hernial sacs into one common sac. If an indirect sac is not present, the direct sac is approached at the upper part of Hesselbach's triangle. It is our opinion that a careful and complete dissection of the sacs is extremely important. In our patients a combined type of hernia often exists (Fig. 5). The excess portion of the sac is excised and the neck of the sac is closed with a purse-string suture of 000 silk. In less than 30 per cent of the cases the sac is transplanted and anchored to the abdominal wall medially and superior to the

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External inguinal ring Figure 4. Dotted line represents line of incision in the direction of the external obliqu e aponeurotic fibers along the medial side of the cord.

Internal oblique m. and aponeurosis

sselbach's triangle

Deep inferior epigastric vv.

Medial leaf external oblique aponeurosis Indired sac

Figure 5. External oblique aponeurosis has been divide d and cord displaced from its bed. Indirect sac has been dissected completely from th e cord structures. Tip of index finger is within the direct sac, revealing direct weakness in Hesselbach 's triangle.

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internal inguinal ring. This maneuver can be hazardous and may result in accidental needle puncture or tear of small or large bowel. In all cases, whether or not there is a direct hernia or weakness in Hesselbach's triangle, interrupted imbricating sutures of 000 silk are taken in the transversalis fascia. It is our opinion that this is the first line of defense, and removing this relaxation from this structure helps to form a solid foundation for the hernia repair. Usually 3 sutures in this area are sufficient (Fig. 6). In order to prevent a recurrence immediately superior to the pubic spine area, which represents a normally weak point and a frequent point for direct recurrences, steps are taken to fortify this area. An 00 silk suture is used as a pulley or figure-of-eight stitch approximating the internal oblique aponeurosis to the lacunar (Gimbernat's) and inguinal ligaments. The suturing is begun by passing the needle through the medial aspect of the internal oblique aponeurosis above the pubic spine. The next step is to pass the needle through the inguinal ligament at the point where it attaches to the pubic spine without placing the suture through the periosteum. The same suture is then continued as a parallel stitch, being brought up and through the internal oblique aponeurosis close to the first one. The final step of this 4-way stitch is to sweep upward behind the area of the pubic spine, the suture being placed through the lacunar ligament and coming out at the free margin of the inguinal ligament close to the suture taken above the pubic spine (Fig. 6). As this is tied, it approximates these structures superior to and over the pubic spine area, closing off this weak angle (Fig. 7).

Figure 6. First layer of the basic repair is shown with imbrication of the transversalis fascia with 000 silk. A figure-of-eight or pulley stitch of 00 silk is in place over the pubic spine area to obliterate the weak area at this point. Lower border of the internal inguinal ring is formed by a horizontal mattress of 00 silk approximating internal oblique aponeurosis to the shelving edge of the inguinal ligament.

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Figure 7. Second layer of basic repair is completed. Internal oblique aponeurosis is sutured to the inguinal ligament using 00 silk. New internal inguinal ring is small, admitting the back end of a small thumb forceps.

The lower border of the internal inguinal ring is formed by a horizontal mattress suture of 00 silk approximating the free rolled edge of the internal oblique aponeurosis to the shelving edge of the inguinal (Poupart's) ligament (Figs. 6 and 7). The upper border of this ring is then formed by suturing the same two structures with the s,ame size suture. The size of the ring is made according to the size of the cord and its structures and not to the size of the index finger of the surgeon. In none of our cases was the size of the ring large enough to admit the tip of the little finger. It is our opinion that the ring should be small. We feel that it is adequate in size if it will admit the blunt end of an ordinary sized thumb forceps (Fig. 7). The second layer of the basic repair is then completed by approximating the rolled edge of the internal oblique aponeurosis to the shelving edge of the inguinal ligament superior and inferior to the internal ring, using interrupted 00 silk sutures (Figs. 6 and 7). The lateral leaf of the external oblique aponeurosis is divided at right angles to its fibers down to the inguinal ligament about half an inch (1.25 cm.) below the lower border of the newly formed internal ring (Fig. 8). The divided medial and lateral leaves of the external oblique aponeurosis inferior to the internal ring are now imbricated and sutured to the newly formed floor in Hesselbach's triangle using interrupted 000 silk (Figs. 8 and 9). This step completes a 4-layer repair in Hesselbach's area. The new external inguinal ring is then formed half an inch (1.25 cm.) inferior to the internal ring by suturing the divided leaves of the external oblique aponeurosis above the cord. The operation is completed by reapproximating the cut leaves superior to the cord, using 000 silk (Fig. 9). The superficial fascia is closed with 4-0 silk and the skin with mattress and interrupted sutures of 000 silk.

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Medial leaf of external oblique sutured to floor of Hesselbach's triangle

New internal inguinal ring Figure 8. Medial leaf of external oblique aponeurosis is sutured with 000 silk to newly formed floor inferior to the cord. Lateral leaf of external oblique has been cut toward the inguinal ligament 1/2 inch (1.25 em.) inferior to internal inguinal ring.

Deaths There were two postoperative deaths, a mortality of 0.05 per cent. The first death occurred on the tenth day in a 42 year old man as a result of peritonitis secondary to perforation of the ascending colon. The second death occurred in a 71 year old man during the eighth day, from acute coronary occlusion.

Lateral leaf of external oblique aponeurosis sutured deep to cord Figure 9. Lateral leaf of external oblique aponeurosis is sutured beneath the cord with interrupted 000 silk. New external inguinal ring is formed 1/ 2 inch (1.25 em.) inferior to internal ring. External oblique is approximated superior to cord.

External oblique aponeurosis

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RESULTS

A 1 to 16 year follow-up was obtained in 91.2 per cent of the patients. Over 85 per cent of the patients were followed for 3 or more years. The data assembled were from a combined survey consisting of a questionnaire, recall examination at this hospital, examination by local physicians, or results of examination at place of employment. In the event of any doubt concerning the patient, he was recalled for further examination. In those instances of recurrence repaired elsewhere, information was requested from the surgeon, including a copy of the operative report. Recurrences There were only 37 recurrences-a 1 per cent I~currence rate. Seventy-five per cent of the recurrences occurred after the third year. Patients in the 30 to 39 and 50 to 59 year ago groups had the highest recurrence rate, 1.5 per cent (Fig. 10). A number of those recurrences were due to associated diseases or to the lack of cooperation from the patient. The causes or conditions listed 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. Another of this group had epilepsy and developed a grand mal seizure on the fifth postoperative day. Several returned to heavy work too soon-a truck driver on the tenth day, a laborer on the seventh day, a machine operator on the seventh day, and a painter on the eighth day. In 13 (35 per cent) of the 37 patients described above who developed recurrences, the hernia repair most likely could have remained intact under more favorable circumstances. Of the 70 surgeons performing those operations, 24 (34 per cent)· experienced 1 or 2 recurrences in their series. The recurrence rate occurred equally throughout all decades (Fig. 10). No recurrences have occurred in 110 patients 70 years or older. Of the 37 recurrences, 21 were indirect, and 3 were direct, and in 13 the type was not classified.

1.5

110 Undor 20

20 - 29

30 - 39

40-49

50-59

60-69

Ovor 70

Figure 10. Recurrence rate vs. age distribution. The highest recurrence rates were in the 30 to 39 and 50 to 59 age groups. There were no recurrences in the youngest or the oldest age groups. Seventy-five per cent of the recurrences developed after the third year.

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Effects of Early and Late Ambulation A carefully controlled program was instituted at the inception of this study to determine the effects of early and late ambulation upon the postoperative complication and recurrence rates. In all groups (randomized) the patients were consecutive and unselected. Group A consisted of 208 patients (239 hernioplasties) who were ambulatory after the tenth postoperative day. There were 24 (10.2 per cent) complications and a recurrence rate of 1. 7 per cent with follow-up to 14 years. Group B consisted of 508 patients (590 hernioplasties) who were ambulatory from the third to ninth postoperative day. There were 57 (9.8 per cent) complications and a recurrence rate of 1. 7 per cent with follow-up to 14 years. In Group C were 2439 patients (2743 hernioplasties) who were ambulatory on the day of operation or the first postoperative day. There were 151 (5.5 per cent) complications and a recurrence rate of 0.8 per cent with a follow-up of 16 years (Fig. 11). The recurrence rate was low in all three groups. Early ambulation effected a marked reduction (50 per cent) in the postoperative complication rate. It did not increase the recurrence rate; the slight difference in rates was not statistically significant (Fig. 11).

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4r--------------r-------------+--------,---~

3j----:;;;4---t---2r---~~----t_-~~.~~---t_-~~--~

1-2

3-10t

1-2 3-10. 1-2 Post-operative days of, ambulation

3-10 +

RECURRENCE

.".1.7 0.8\11:

I

I

COMPLICATIONS

5.5\11:

o

2

9.8

10 Per cent

Figure 11. Recurrence and complications rates vs. ambulation. Early ambulation was a significant factor in the reduction of all types of postoperative complications and contributed materially to the low recurrence rate.

PRIMARY INGUINAL HERNIOPLASTY IN THE ADULT

6

1-----------

4

f-----------

2

f--------.--::,......,,----

CONCURRENT REPAIR

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SEPARATED REPAIR

Figure 12. Recurrence rate in patients with bilateral hernia. The recurrence rate was five times greater when bilateral hernias were repaired simultaneously.

Our patients were instructed to refrain from heavy lifting, straining, or athletics for a period of 4 to 6 weeks postoperatively. They were permitted to return to sedentary work at the end of 7 to 14 days; moderately heavy work in 25 to 30 days; and heavy work in about 40 to 45 days. These periods were made flexible depending upon the individual and his reliability. Prior to engaging in moderate to heavy work or activities, the patient was placed through a regime of graded activities so as to prepare him for his regular type of duties. Recurrences in Bilateral Hernioplasties Bilateral hernias were present in 417 (11.8 per cent) patients. During the past 10 years bilateral inguinal hernias were repaired simultaneously. This was accomplished in 78 operations. Two (2.5 per cent) recurrences' occurred in this group. The remaining 756 hernioplasties performed upon 378 patients were accomplished separately at intervals of 6 to 10 days. In this group there were only 4 (0.5 per cent) recurrences; this was 5 times less frequent than in the group in whom both hernias were repaired at the same time. We continue to perform both hernia repairs simultaneously. Since our unilateral recurrence rate is low and the ultimate recurrence rate for a bilateral repair is in an extremely low and acceptable range, the risk of 2 separate operations, second anesthetics, and longer hospital stay are all factors which favor simultaneous repair (Fig. 12).

SUMMARY AND CONCLUSIONS There are a number of sound anatomic and physiologic repairs for primary inguinal hernioplasty in the adult. Those currently employed have progressed favorably by a slow process of evolution from the original concepts of Bassini, Halsted, and Andrews. To these basic and original principles have been added many improvements and refinements, contributed by many well qualified surgeons. With all these advancements we have noted a most favorable decline in recurrence in

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recent years to a readily desirable and acceptable rate. It is our considered opinion that in elective and consecutive primary repairs in the adult, the rate of recurrence should not exceed 2 per cent. With adherence to sound basic surgical principles, coupled with the application of the currently known tenets of surgery for these congenital and acquired defects, the proper use of nonabsorbable sutures, and restoration of the anatomy to normal physiologic function, the well qualified surgeon can be assured of a very high cure rate. In most all cases there will be no need for supportive prosthetic sheaths or meshes. We have employed the technique described herein in 5000 operations during the past 30 years (including new modifications since 1946) with an overall recurrence rate of only 1 per cent. The salient features of this repair and those reported by others using a similar or modified technique are: complete dissection of hernial sacs, high ligation at the internal inguinal ring, reinforcement of Hesselbach's triangle, elimination of naturally weak area superior to pubic spine, division of external oblique aponeurosis along medial side of cord so both medial and lateral leaves can be imbricated beneath the cord in Hesselbach's triangle, and formation of a new and snug internal inguinal ring.

REFERENCES Andrews, E.: A method of herniotomy utilizing only white fascia. Ann. Surg., 80:225,1924. Belenger, J. et al.: Summary of 14 years of hernia cures. Acta Chir. Belg., 66:283-292,1967. Bellis, C. J.: Inguinal herniorrhaphy: Immediate return to unrestricted work. Surgical techniques using local anesthesia and results in 5903 personal cases. Industr. Med. Surg. 33:721-725,1964. Brandon, W. J.: Inguinal hernia- The sling operation. Brit. J. Surg., 56:408-413,1969. Burton, C. C.: A suggested terminology for ligaments of the groin; their clinical and surgical application in repair of hernias. Surgery, 31 :562, 1952. Burton, C. E.: Collective review: Hernias of the supravesical, inguinal and lateral pelvic fossae: Their diagnosis, classification and relationship. Surg. Gynec. Obstet., 91: 1, July 1950. Conkling, R. W.: Surgical treatment of inguinal hernia (Review of the literature). Surgical Staff Meeting BulL, Veterans Hospital, Des Moines, Iowa. 3(No. 11):1,1951Estes, W. L., Jr.: Five year end results in treatment of inguinal hernia. Western J. Surg., 68:269,1960. Gumrich, H.: [Results of research on 5199 inguinal and femoral hernia operations in an interval of 20 years (I).] Med. Welt., 48:2448-2455, 1968, published in German. Halsted, W. S.: The radical care of inguinal hernia in the male. Bull. Johns Hopkins Hosp., 4:17,1893. Katz, L A.: Early ambulation in the management of surgical patient (review of the literature). Surgical Staff Meeting Bull., Veterans Hospital, Des Moines, Iowa, 4:1, 1951Koontz, A. R.: Some common fallacies and confusions with regard to repair of inguinal hernia. J.A.M.A., 141 :336, 1949. Leithauser, D. J., and Bergo, H. L.: Early rising and ambulatory activity after operation: A means of preventing complications. Arch. Surg., 42:1086,1941Lichtenstein, I. L.: Local anesthesia for hernioplasty. Immediate ambulation and return to work: A preliminary report. Calif. Med., 100:106-109, 1964. Lund, J., et aL: Inguinal and femoral hernioplasty. Five-year follow-up of 284 cases of McVay repair. Acta Chir. Scand., 131 :72-80,1966. McVay, C. B.: Inguinal and femoral hernioplasty. Surgery, 57:615-625, 1965. McVay, C. B., et al.: Inguinal hernia. Curro ProbL Surg., 1 :50,1967. McVay, C. B., and Anson, B. J.: A fundamental error in current methods of inguinal herniorrhaphy. Surg. Gynec. Obstet., 74:746, 1942. McVay, C. B., and Chapp, J. D.: Inguinal and femoral hernioplasty. The evaluation of a basic concept. Ann. Surg., 148:499, 1958.

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Morris, D., et a!.: Early discharge after hernia repair. Lancet, 1 :681-685,1968. Palumbo, L. T., et al.: Primary inguinal hernioplasty. Postgrad. Med., 42:505-512, 1967. Palumbo, L. T., et a!.: Primary direct inguinal hernioplasty: Sixteen year study of 686 operations. Amer. J. Surg., 108:815-819, 1964. Ponka, J. L.: The relaxing incision in hernia repair. Amer. J. Surg., 115:552-557, 1968. Rostad, H.: Inguinal hernia in adults. Recurrence rate related to suture material, recumbency period and anesthesia. Acta Chir. Scand., 134:49-54, 1968. Shearburn, E. W., et al.: Shouldice repair for inguinal hernia. Surgery, 66:450-459, 1969. Speir, E. B.: Symposium on use and abuse of bed-rest: Surgery. Western J. Surg., 54:328, 1946. Summers, J. E.: Classical herniorrhaphies of Bassini, Halsted, and Ferguson. Amer. J. Surg., 73:87, 1947. Todorov, T.: [Complete reconstruction of the inguinal area as a surgical method in the treatment of inguinofemoral hernia.] Khirurgiia (Sofiia), 22:121-5,1969. Usher, F. C.: Marlex mesh in the repair of direct inguinal hernias. Med. Rec. Ann. (Houston), 56:208-209, 1963. U sov, D. V.: [The causes of recurrence of inguinal hernia and some methods for its prevention.] Klin. Khir. (Kiev), 9:46-51, 1968. Zimmerman, L. M.: Recent advances in surgery of inguinal hernia. SURG. CLIN. N. AMER., 32:135,1952. Department of Surgery Veterans Administration Hospital Des Moines, Iowa 50308