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Purse-string suture repair of indirect inguinal hernia
Purse-string \/VILLIAM
Suture Inguinal
Repair Hernia
MCDOUGAL,
Grand Rapids,
M.D.,
lbfichigan
the internal ring must be stretched apart in order for an indirect inguinai hernia to form. (3) The internal oblique muscle is an important “second line of defense,” but only when it is physiologically capable of contractmg strongly so as to stretch tightIy across the inguinal canal floor in the internal ring area. (4)The external oblique fascia in its normal position in relation to the spermatic cord has little or no barrier effect against the formation of an inguinai hernia. From the foregoing facts, the following principles in surgical treatment can be stated: (I) The ligation of the hernial sac at the internal ring is only important from the standpoint of presenting a smooth peritoneal lining to the intra-abdominal contents. (2) To prevent a recurrence of an indirect inguinal hernia the transversalis fascia must be approximated about the spermatic cord in a circular fashion \vhich itiio\vs only enough room for the cord structures to emerge through it. If the transversaiis fascial ring is unbroachable, an indirect hernia cannot recur. (3) The internal oblique muscle must not be damaged or displaced permanentlyfrom its normal position if its muscle fibers appear to be in a good functional state. If the muscle edge is atrophic or infiltrated \vith fat, it has lost its effectiveness as a barrier to the formation of a hernia. In such instances its substance should be replaced by a fascial hap, metal mesh or other suitable substitutes. (4) From the standpoint of the prevention of hernia recurrence, the external ohiique fascia can he used to much more advantage by, suturing its flaps across the floor of the ingurnal canal rather than using it as a “ roof” to cover the spermatic cord. The most important principle in repairing an indirect inguinai hernia is to make certain the structures about the internal inguinal ring are suffrcientiy tight to prevent the first “ tongue ” of peritonea1 sac from extending through the internal ring. This Ivouid seem to
the past t\venty years numerous improvements and refinements of surgical technic in the repair of inguinal hernias have been made. Most of these have been directed toward a more satisfactory repair of the floor of the inguinai canal medial to the inferior epigastric vessels (Hesselbach’s triangle). The apparent result to most surgeons is a lowered incidence of “recurrent” direct hernias. During the period of popularity of the Bassini type of repair, in which the lower border of the internal oblique muscle was sutured to the edge of Poupart’s ligament, it was common to note the appearance of a direct hernia some months or years following the repair of an indirect inguinai hernia. With the currently popular method of suturing the transversalis fascia either to Poupart’s or Cooper’s ligament, the formation of new or recurrent direct hernias has become less frequent. The recurrence of an indirect hernia, however, is still frequently seen, and the percentage of recurrence does not seem to have been lowered in recent years as much as the recurrence rate of direct hernias. The purpose of this paper is to describe a method of repair of the internal ring which, in my experience, has markedly lowered the recurrence rate of indirect inguinai hernias. In planning the repair of an inguinal hernia, one must be able to adjust his technical steps to the variations of anatomy and pathology encountered in the groins of different patients. However, certain basic principles hold true in every variation of indirect inguinai hernia: (I) The peritoneum alone is no barrier to the intra-abdominal pressure, being very easily stretched and poorly attached to the overlying transversalis fascia which allows it to slide and “pouch” readily through any defect in the adjacent fascia. (2) The transversalis fascia is the “first line of defense” and the most important barrier to the formation of a hernia. Its fibers form the edges of the internal inguinai ring. The edges of the transversalis fascia at
D
of Indirect
WRING
227
American
Journal
oJ Surgery.
Volume
or,
Fe‘ehruar~,
1~56
McDougaI be an unnecessary statement, but it has been my observation that many surgeons, when operating for indirect inguinal hernia, seem to lose sight of the fact that the hernia is at the internal ring and they concern themselves chiefly with reinforcing the tissues through
noticed that the transversalis fascia is acutely angled across beneath the spermatic cord and there is usually some tension, as the most IateraI suture is placed, to puI1 the medial transversalis fascia to the edge of Poupart’s ligament. Later, when the patient coughs or strains, the constriction of the transversalis muscle causes tension and pull on the sutures anchoring this obliquely displaced fascia. The mechanics of this stress is illustrated diagrammatically in Figure I. I feel certain that many recurrences are due to the most laterally placed sutures tearing through the tissue early in the postoperative period. In order to prevent any shifting of the internal ring and to offer more complete support to the fascia about the exit of the spermatic cord from the internal inguinal ring, a heavy purse-string suture of silk is inserted through the transversaIis fascia and the edge of the inguinal ligament, which completely encircles the spermatic cord. This may be done as a single-purse string suture, or two or more may be placed in concentric circles around the internal ring. The suture is tied tightly enough so that just enough room is left around the cord to allow circulation to and from the testicIe. This suture not onIy pulls in firm fascial support around the internal inguinal ring but also gives a firm, non-distensible edge to the entire circumference of the internal ring.
A _ -Pubis
FIG. I. A, Xustrates normaI positions (A) and (B) before sutures are pIaced for tightening interna ring in the common method of repair. B, after suturing points (A) and (B) together, tightening of the transversahs muscIe during straining puts an oblique puI1 on point (A) away from point (B).
TECHNIC
The indirect hernial sac is completely isolated from the spermatic cord and is closed at the internal ring in the usual manner. To accurately place the purse-string suture of heavy braided silk around the internal inguinal ring and spermatic cord, the entire circumference of the transversalis fascia about the cord must be exposed to view. This is accomplished on the medial and inferior border of the internal ring quite easiIy by simpIy eIevating the spermatic cord from the floor of the inguinal canal. The superior portion can be exposed by retracting the edge of the interna oblique muscle. The lateral and superioIatera1 edges can best be exposed by cIamping and cutting the cremaster muscle fibers as they cross from the internal obIique muscIe onto the spermatic cord (Fig. 2) and then retracting the margin of the arching fibers of the interna oblique muscIe IateraIIy. When the entire fascia1 circumference about the cord at the internal ring is exposed and cIear,
which a direct hernia occurs. The usua1 method for diminishing the size of the internal ring by suturing the transversalis fascia to itself or to the shelving edge of the inguinal ligament just medial to the exit of the spermatic cord from the internal inguinal ring has certain disadvantages. First, onIy a portion of the fascia1 borders of the interna ring is reinforced-the medial and superiomedia1 sides. If the cord can be shifted graduaIIy Iateralward and inferiorly away from the repaired area by repeated stress from increased intra-abdominal pressure, a recurrent hernia can occur between the repaired area and the shifted cord. Second, in pIacing sutures across the inguina1 cana floor just medial to the interna ring, it can be 228
Repair
of Indirect
Inguinai
Hernia
3
2
FIG. 2. The
cremaseter muscle fibers are clamped, cut and tied just 1:rteraI to the inter& ring, where they are reflected from the internal obIique muscle onto the spermatic cord. The indirect hernia sac stump is demonstrated by upward retraction of the internal oblique muscIe. The ileoinguinal nerve is preserved. FIG. 3. The heavy purse-string suture of silk has been placed in the transversalis fascia hernia sac and exit of the sDermatic cord from the internal inguinal ring, and is anchored Poupart’s ligament below.
a No. 3 or No. 4 braided silk suture on a short round needle is started in the transversahs fascia superior to the neck of the previousIy ligated hernial sac and carried in and out of this fascia Iateral to the spermatic cord, then through two portions of the shelving edge of the inguinal ligament, the second bite of the needIe being about 3 mm. from the first one placed in the ligament, thence mediaIIy aIong the edge of the dilated interna ring back to the starting point. The suture must be accurately placed in the edge of the diIated interna ring, making a complete circIe around the spermatic cord and neck of the hernia1 sac (Fig. 3) in order for the encIosed fascia to be pulIed up snugly around the cord. The suture bites are placed about 5 mm. apart, and if they are accurately pIaced in the edges of the diIated interna ring, there wiI1 be no tension when it is snugly tied. I believe that tying the pursestring suture tightly enough is extremeIy important in this technic. The resident surgeons learning this technic are instructed to tighten the suture until they think it is too tight around the spermatic cord, and then tighten it just a little more. An opening through the pursestring suture, about 5 mm. in diameter, is sufficient to ahow unimpaired circulation to and from the testicIe.
about the neck of the to the shelving edge of
RESULTS
AI1 cases included in this series were operated upon before 1952. The known recurrences in a series repaired by the purse-string suture technic are compared with another series repaired by the Edmund Andrews principle. Of 274 cases in which the purse-string suture technic was used, there was one known recurrence of an indirect hernia. Of 248 cases in which the Edmund Andrews type of repair was used, there were eIeven known recurrences. AI1 of these recurrences were confirmed by reoperation as recurrent indirect hernias. The percentage of cases Iost to fohow-up study was essentiahy the same in the two series (29 and 33 per cent, respectively). COMMENTS
Reoperation was necessary for the one recurrence in the series in which purse-string suture technic was used. The recurrent hernia developed through a purse-string opening I cm. in diameter. Obviously the suture had not been tied down tightly enough around the spermatic cord. It was interesting to note that the transversalis fascia around the edge of the internal ring and adjacent to the siIk purse-string suture was exceptionally thick and strong-several 229
McDougaI times as thick as the norma transversahs fascia in that area usuaIIy is. Apparently there is enough reaction around the suture at the internal ring to cause proIiferation of fibrobIasts adjacent to it with consequent thickening and strengthening of the fascia. This same thickening around the purse-string suture at the interna ring was aIso observed to be quite marked in another man undergoing reoperation for a direct hernia one year after an indirect hernia was repaired.
SUMMARY
A technic is presented which can contribute to a firm repair of the internal ring in patients with indirect inguina1 hernia. Objections to the commonIy used methods of repairing the diIated internal inguinal ring are mentioned. In my experience, the purse-string suture technic of repair has markedly reduced the recurrences of indirect inguinal hernia.
/Ve recommend:
CounseIing in MedicaI Genetics. By Sheldon C. Reed. 268 pages. PhiladeIphia, 1955. W. B. Saunders Co. Price $4.00. Man in a Cold Environment (Monographs of the PhysioIogicaI Society, Number 2. Editors: L. E. Bayliss, W. FeIdberg, A. L. Hodgkin). PhysioIogicaI and PathoIogicaI Effects of Exposure to Low Temperatures. By AIan C. Burton, PH.D. and Otto G. Edholm, B.S., hm. 273 pages, illustrated. Balitmore, 1955. WiIIiams & Wilkins Co. Price $6.75. Current Therapy, 1955. Latest Approved Methods of Treatment for the Practicing Physician. Edited by Howard F. Conn, M.D. ConsuIting Editors: M. Edward Davis, Vincent J. Derbes, Garfield G. Duncan, Hugh J. Jewett, WiIIiam Kerr, Perrin H. Long, H. Houstan Merritt, PauI A. O’Leary, Waiter L. PaImer, Hobart A. Reisman, Cyrus C. Sturgis, Robert H. WiIIiams. (Active ingredients in commonIy used products.) 692 pages. Philadelphia, 1955. W. B. Saunders Co.
230
Suture Inguinal
Repair Hernia
MCDOUGAL,
Grand Rapids,
M.D.,
lbfichigan
the internal ring must be stretched apart in order for an indirect inguinai hernia to form. (3) The internal oblique muscle is an important “second line of defense,” but only when it is physiologically capable of contractmg strongly so as to stretch tightIy across the inguinal canal floor in the internal ring area. (4)The external oblique fascia in its normal position in relation to the spermatic cord has little or no barrier effect against the formation of an inguinai hernia. From the foregoing facts, the following principles in surgical treatment can be stated: (I) The ligation of the hernial sac at the internal ring is only important from the standpoint of presenting a smooth peritoneal lining to the intra-abdominal contents. (2) To prevent a recurrence of an indirect inguinal hernia the transversalis fascia must be approximated about the spermatic cord in a circular fashion \vhich itiio\vs only enough room for the cord structures to emerge through it. If the transversaiis fascial ring is unbroachable, an indirect hernia cannot recur. (3) The internal oblique muscle must not be damaged or displaced permanentlyfrom its normal position if its muscle fibers appear to be in a good functional state. If the muscle edge is atrophic or infiltrated \vith fat, it has lost its effectiveness as a barrier to the formation of a hernia. In such instances its substance should be replaced by a fascial hap, metal mesh or other suitable substitutes. (4) From the standpoint of the prevention of hernia recurrence, the external ohiique fascia can he used to much more advantage by, suturing its flaps across the floor of the ingurnal canal rather than using it as a “ roof” to cover the spermatic cord. The most important principle in repairing an indirect inguinai hernia is to make certain the structures about the internal inguinal ring are suffrcientiy tight to prevent the first “ tongue ” of peritonea1 sac from extending through the internal ring. This Ivouid seem to
the past t\venty years numerous improvements and refinements of surgical technic in the repair of inguinal hernias have been made. Most of these have been directed toward a more satisfactory repair of the floor of the inguinai canal medial to the inferior epigastric vessels (Hesselbach’s triangle). The apparent result to most surgeons is a lowered incidence of “recurrent” direct hernias. During the period of popularity of the Bassini type of repair, in which the lower border of the internal oblique muscle was sutured to the edge of Poupart’s ligament, it was common to note the appearance of a direct hernia some months or years following the repair of an indirect inguinai hernia. With the currently popular method of suturing the transversalis fascia either to Poupart’s or Cooper’s ligament, the formation of new or recurrent direct hernias has become less frequent. The recurrence of an indirect hernia, however, is still frequently seen, and the percentage of recurrence does not seem to have been lowered in recent years as much as the recurrence rate of direct hernias. The purpose of this paper is to describe a method of repair of the internal ring which, in my experience, has markedly lowered the recurrence rate of indirect inguinai hernias. In planning the repair of an inguinal hernia, one must be able to adjust his technical steps to the variations of anatomy and pathology encountered in the groins of different patients. However, certain basic principles hold true in every variation of indirect inguinai hernia: (I) The peritoneum alone is no barrier to the intra-abdominal pressure, being very easily stretched and poorly attached to the overlying transversalis fascia which allows it to slide and “pouch” readily through any defect in the adjacent fascia. (2) The transversalis fascia is the “first line of defense” and the most important barrier to the formation of a hernia. Its fibers form the edges of the internal inguinai ring. The edges of the transversalis fascia at
D
of Indirect
WRING
227
American
Journal
oJ Surgery.
Volume
or,
Fe‘ehruar~,
1~56
McDougaI be an unnecessary statement, but it has been my observation that many surgeons, when operating for indirect inguinal hernia, seem to lose sight of the fact that the hernia is at the internal ring and they concern themselves chiefly with reinforcing the tissues through
noticed that the transversalis fascia is acutely angled across beneath the spermatic cord and there is usually some tension, as the most IateraI suture is placed, to puI1 the medial transversalis fascia to the edge of Poupart’s ligament. Later, when the patient coughs or strains, the constriction of the transversalis muscle causes tension and pull on the sutures anchoring this obliquely displaced fascia. The mechanics of this stress is illustrated diagrammatically in Figure I. I feel certain that many recurrences are due to the most laterally placed sutures tearing through the tissue early in the postoperative period. In order to prevent any shifting of the internal ring and to offer more complete support to the fascia about the exit of the spermatic cord from the internal inguinal ring, a heavy purse-string suture of silk is inserted through the transversaIis fascia and the edge of the inguinal ligament, which completely encircles the spermatic cord. This may be done as a single-purse string suture, or two or more may be placed in concentric circles around the internal ring. The suture is tied tightly enough so that just enough room is left around the cord to allow circulation to and from the testicIe. This suture not onIy pulls in firm fascial support around the internal inguinal ring but also gives a firm, non-distensible edge to the entire circumference of the internal ring.
A _ -Pubis
FIG. I. A, Xustrates normaI positions (A) and (B) before sutures are pIaced for tightening interna ring in the common method of repair. B, after suturing points (A) and (B) together, tightening of the transversahs muscIe during straining puts an oblique puI1 on point (A) away from point (B).
TECHNIC
The indirect hernial sac is completely isolated from the spermatic cord and is closed at the internal ring in the usual manner. To accurately place the purse-string suture of heavy braided silk around the internal inguinal ring and spermatic cord, the entire circumference of the transversalis fascia about the cord must be exposed to view. This is accomplished on the medial and inferior border of the internal ring quite easiIy by simpIy eIevating the spermatic cord from the floor of the inguinal canal. The superior portion can be exposed by retracting the edge of the interna oblique muscle. The lateral and superioIatera1 edges can best be exposed by cIamping and cutting the cremaster muscle fibers as they cross from the internal obIique muscIe onto the spermatic cord (Fig. 2) and then retracting the margin of the arching fibers of the interna oblique muscIe IateraIIy. When the entire fascia1 circumference about the cord at the internal ring is exposed and cIear,
which a direct hernia occurs. The usua1 method for diminishing the size of the internal ring by suturing the transversalis fascia to itself or to the shelving edge of the inguinal ligament just medial to the exit of the spermatic cord from the internal inguinal ring has certain disadvantages. First, onIy a portion of the fascia1 borders of the interna ring is reinforced-the medial and superiomedia1 sides. If the cord can be shifted graduaIIy Iateralward and inferiorly away from the repaired area by repeated stress from increased intra-abdominal pressure, a recurrent hernia can occur between the repaired area and the shifted cord. Second, in pIacing sutures across the inguina1 cana floor just medial to the interna ring, it can be 228
Repair
of Indirect
Inguinai
Hernia
3
2
FIG. 2. The
cremaseter muscle fibers are clamped, cut and tied just 1:rteraI to the inter& ring, where they are reflected from the internal obIique muscle onto the spermatic cord. The indirect hernia sac stump is demonstrated by upward retraction of the internal oblique muscIe. The ileoinguinal nerve is preserved. FIG. 3. The heavy purse-string suture of silk has been placed in the transversalis fascia hernia sac and exit of the sDermatic cord from the internal inguinal ring, and is anchored Poupart’s ligament below.
a No. 3 or No. 4 braided silk suture on a short round needle is started in the transversahs fascia superior to the neck of the previousIy ligated hernial sac and carried in and out of this fascia Iateral to the spermatic cord, then through two portions of the shelving edge of the inguinal ligament, the second bite of the needIe being about 3 mm. from the first one placed in the ligament, thence mediaIIy aIong the edge of the dilated interna ring back to the starting point. The suture must be accurately placed in the edge of the diIated interna ring, making a complete circIe around the spermatic cord and neck of the hernia1 sac (Fig. 3) in order for the encIosed fascia to be pulIed up snugly around the cord. The suture bites are placed about 5 mm. apart, and if they are accurately pIaced in the edges of the diIated interna ring, there wiI1 be no tension when it is snugly tied. I believe that tying the pursestring suture tightly enough is extremeIy important in this technic. The resident surgeons learning this technic are instructed to tighten the suture until they think it is too tight around the spermatic cord, and then tighten it just a little more. An opening through the pursestring suture, about 5 mm. in diameter, is sufficient to ahow unimpaired circulation to and from the testicIe.
about the neck of the to the shelving edge of
RESULTS
AI1 cases included in this series were operated upon before 1952. The known recurrences in a series repaired by the purse-string suture technic are compared with another series repaired by the Edmund Andrews principle. Of 274 cases in which the purse-string suture technic was used, there was one known recurrence of an indirect hernia. Of 248 cases in which the Edmund Andrews type of repair was used, there were eIeven known recurrences. AI1 of these recurrences were confirmed by reoperation as recurrent indirect hernias. The percentage of cases Iost to fohow-up study was essentiahy the same in the two series (29 and 33 per cent, respectively). COMMENTS
Reoperation was necessary for the one recurrence in the series in which purse-string suture technic was used. The recurrent hernia developed through a purse-string opening I cm. in diameter. Obviously the suture had not been tied down tightly enough around the spermatic cord. It was interesting to note that the transversalis fascia around the edge of the internal ring and adjacent to the siIk purse-string suture was exceptionally thick and strong-several 229
McDougaI times as thick as the norma transversahs fascia in that area usuaIIy is. Apparently there is enough reaction around the suture at the internal ring to cause proIiferation of fibrobIasts adjacent to it with consequent thickening and strengthening of the fascia. This same thickening around the purse-string suture at the interna ring was aIso observed to be quite marked in another man undergoing reoperation for a direct hernia one year after an indirect hernia was repaired.
SUMMARY
A technic is presented which can contribute to a firm repair of the internal ring in patients with indirect inguina1 hernia. Objections to the commonIy used methods of repairing the diIated internal inguinal ring are mentioned. In my experience, the purse-string suture technic of repair has markedly reduced the recurrences of indirect inguinal hernia.
/Ve recommend:
CounseIing in MedicaI Genetics. By Sheldon C. Reed. 268 pages. PhiladeIphia, 1955. W. B. Saunders Co. Price $4.00. Man in a Cold Environment (Monographs of the PhysioIogicaI Society, Number 2. Editors: L. E. Bayliss, W. FeIdberg, A. L. Hodgkin). PhysioIogicaI and PathoIogicaI Effects of Exposure to Low Temperatures. By AIan C. Burton, PH.D. and Otto G. Edholm, B.S., hm. 273 pages, illustrated. Balitmore, 1955. WiIIiams & Wilkins Co. Price $6.75. Current Therapy, 1955. Latest Approved Methods of Treatment for the Practicing Physician. Edited by Howard F. Conn, M.D. ConsuIting Editors: M. Edward Davis, Vincent J. Derbes, Garfield G. Duncan, Hugh J. Jewett, WiIIiam Kerr, Perrin H. Long, H. Houstan Merritt, PauI A. O’Leary, Waiter L. PaImer, Hobart A. Reisman, Cyrus C. Sturgis, Robert H. WiIIiams. (Active ingredients in commonIy used products.) 692 pages. Philadelphia, 1955. W. B. Saunders Co.
230